D69

WATERS OF CLIFTY FALLS, THE

Grade D 69/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

138

Ownership

For profit - Limited Liability company

Total Fines

None

Last Survey

N/A

950 CROSS AVE, MADISON, IN 47250
8122734640

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.24h
LPN
0.49h
CNA
1.36h
Total
2.09h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

MAJOR HOSPITAL

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince May 2014

100%

THE WATERS OF CLIFTY FALLS, LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince May 2014

HANDY, SHAYNE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2014

HORNER, JOHN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2014

JONES, KATHY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince May 2014

HORNER, JOHN

IndividualCORPORATE OFFICERSince May 2014

HANDY, SHAYNE

IndividualCONTRACTED MANAGING EMPLOYEESince May 2014

JONES, KATHY

IndividualCONTRACTED MANAGING EMPLOYEESince May 2014

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (51)

November 18, 2025Health2 deficiencies1 severe
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Nov 25, 2025
0908DMinimal harm, Isolated

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Nov 25, 2025
October 20, 2025Health1 deficiency
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Oct 24, 2025
July 14, 2025Health2 deficiencies
0740DMinimal harm, Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies

Corrected Jul 25, 2025
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Jul 25, 2025
June 4, 2025Health15 deficiencies
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Jul 3, 2025
0583EMinimal harm, Pattern

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Jul 3, 2025
0640DMinimal harm, Isolated

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 3, 2025
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 3, 2025
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jul 3, 2025
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jul 3, 2025
0688DMinimal harm, Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Jul 3, 2025
0732CNo harm, Widespread

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Jul 3, 2025
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Jul 3, 2025
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Jul 3, 2025
0770DMinimal harm, Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies

Corrected Jul 3, 2025
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jul 3, 2025
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Jul 3, 2025
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jul 3, 2025
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Jul 3, 2025
February 25, 2025Health2 deficiencies
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Jan 23, 2025
0919EMinimal harm, Pattern

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Corrected Mar 20, 2025
August 30, 2024Health2 deficiencies
0602DMinimal harm, Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Sep 19, 2024
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Sep 19, 2024
July 17, 2024Health2 deficiencies
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 14, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 14, 2024
June 24, 2024Health7 deficiencies
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jul 17, 2024
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Jul 17, 2024
0693DMinimal harm, Isolated

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies

Corrected Jul 17, 2024
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Jul 17, 2024
0758DMinimal harm, Isolated

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected Jul 17, 2024
0761EMinimal harm, Pattern

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Jul 17, 2024
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jul 17, 2024
April 4, 2024Health2 deficiencies
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Apr 29, 2024
0842EMinimal harm, Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 29, 2024
February 27, 2024Health2 deficiencies
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Mar 8, 2024
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Mar 8, 2024
September 28, 2023Health4 deficiencies
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Oct 27, 2023
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Oct 27, 2023
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Oct 27, 2023
0744DMinimal harm, Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

Corrected Oct 27, 2023
July 26, 2023Health2 deficiencies
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Aug 11, 2023
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Aug 11, 2023
April 4, 2023Health8 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Apr 22, 2023
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 22, 2023
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Apr 22, 2023
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Apr 22, 2023
0758DMinimal harm, Isolated

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected Apr 22, 2023
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 22, 2023
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Apr 22, 2023
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Apr 22, 2023

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Frequently Asked Questions

What is the CareGrader rating for WATERS OF CLIFTY FALLS, THE?

WATERS OF CLIFTY FALLS, THE in MADISON, Indiana has a CareGrader grade of D (Below Average), with a composite score of 69.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WATERS OF CLIFTY FALLS, THE?

WATERS OF CLIFTY FALLS, THE has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WATERS OF CLIFTY FALLS, THE have?

WATERS OF CLIFTY FALLS, THE has 51 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does WATERS OF CLIFTY FALLS, THE have?

WATERS OF CLIFTY FALLS, THE has 138 certified beds with approximately 101 current residents (73% occupancy). The facility is located at 950 CROSS AVE, MADISON, Indiana 47250. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.