Indiana ›Madison

Waters of Clifty Falls, the

950 Cross Ave, Madison, IN 47250 · Jefferson County · 138 certified beds · avg 97 residents/day · certified since Jan 20, 1983

Part of chain: INFINITY HEALTHCARE CONSULTING (69 facilities, chain avg rating 2.0★)

1/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
2.16
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Nov 18, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 25, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (55)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
May 14, 2026D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
May 14, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Apr 8, 2026D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Apr 8, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jan 22, 2026D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 22, 2026D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Nov 18, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 18, 2025D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint
Oct 20, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Jul 14, 2025D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Jul 14, 2025D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Jun 4, 2025E · Potential for harm, repeatedThe facility did not keep residents' personal and medical information private and confidential.
Jun 4, 2025E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 4, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 4, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 4, 2025D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Jun 4, 2025D · Potential for harm, one-offThe facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
Jun 4, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jun 4, 2025D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jun 4, 2025D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jun 4, 2025D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jun 4, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jun 4, 2025D · Potential for harm, one-offThe facility did not provide timely, quality laboratory tests to meet residents' needs.
Jun 4, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jun 4, 2025D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Jun 4, 2025C · Minimal risk, facility-wideThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Feb 25, 2025E · Potential for harm, repeatedThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Feb 25, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Aug 30, 2024D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Aug 30, 2024D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Jul 17, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jul 17, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jun 24, 2024E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jun 24, 2024E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 24, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jun 24, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jun 24, 2024D · Potential for harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Jun 24, 2024D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jun 24, 2024D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Apr 4, 2024E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Apr 4, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Feb 27, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Feb 27, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 28, 2023E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Sep 28, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 28, 2023D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Sep 28, 2023D · Potential for harm, one-offThe facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint
Apr 4, 2023E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 4, 2023D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Apr 4, 2023D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 4, 2023D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Apr 4, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 4, 2023D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Apr 4, 2023D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Apr 4, 2023D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (7 → 15).

YearCitationsSerious (G–L)Worst severity that year
2023120E
2024150E
2025221G ▲
202660D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityIndiana avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)2.163.423.95bottom 1% in Indiana; bottom 1% in the U.S.
Registered Nurse hours0.250.620.69bottom 2% in Indiana; bottom 6% in the U.S.
Weekend total nurse staffing2.023.013.50bottom 1% in Indiana; bottom 2% in the U.S.
Weekend RN hours (not acuity-adjusted)0.280.470.48bottom 20% in Indiana; bottom 29% in the U.S.
Total nursing staff turnover (%)44.145.945.8top 43% in Indiana; top 48% in the U.S.
RN turnover (%)37.540.442.9top 44% in Indiana; top 42% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.88, RN 0.34, weekend 2.70. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Handy, ShayneIndividualContracted Managing EmployeeNOT APPLICABLE05/19/2014
Handy, ShayneIndividualOperational/Managerial ControlNOT APPLICABLE05/19/2014
Horner, JohnIndividualCorporate OfficerNOT APPLICABLE05/19/2014
Horner, JohnIndividualOperational/Managerial ControlNOT APPLICABLE05/19/2014
Jones, KathyIndividualContracted Managing EmployeeNOT APPLICABLE05/19/2014
Jones, KathyIndividualOperational/Managerial ControlNOT APPLICABLE05/19/2014
The Waters of Clifty Falls, LLCOrganizationOperational/Managerial ControlNOT APPLICABLE05/19/2014

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Hickory Creek at Madison0.5 miMadison, IN★★★★☆4/5
River Terrace Health Campus2.3 miMadison, IN★★★☆☆3/5
Thornton Terrace Health Campus4.8 miHanover, IN★★★★★4/5
Aperion Care Hanover5.3 miHanover, IN★☆☆☆☆1/5
Bedford Springs Health and Rehabilitation13.4 miBedford, KY★★★★★5/5
Signature Healthcare of Carrollton Rehab & Wellnes14.5 miCarrollton, KY★★★★☆4/5
Swiss Villa Nursing and Rehabilitation17.8 miVevay, IN★★★★☆4/5

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Facility data as of CMS processing date 2026-08-01. CCN 155209.