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WATERS OF CLIFTY FALLS, THE

Open-data reference.

WATERS OF CLIFTY FALLS, THE is a for profit - limited liability company facility in MADISON, IN with 138 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file.

950 CROSS AVE, MADISON, IN 47250

Phone: 8122734640

Overall Rating

1/5

Health Inspection

1/5

Staffing

2/5

Quality Measures

3/5

Long-Stay Quality

5/5

Facility Information

Provider Number
155209
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
Beds
138
Residents
101
In Hospital
No
County
Jefferson
Last Inspection
Jun 4, 2025

Staffing Data

RN Hours
0.32 (nat'l avg: 0.68)
LPN Hours
0.65
CNA Hours
1.80
Total Nursing Hours
2.76 (nat'l avg: 3.89)
PT Hours
0.01
Nursing Turnover
31.0%
RN Turnover
14.3%

What the CMS Record Reveals About WATERS OF CLIFTY FALLS, THE

WATERS OF CLIFTY FALLS, THE operates 138 certified beds in MADISON, IN with approximately 101 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 50 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 2.76 total nursing hours per resident day (national average 3.89), with RN coverage at 0.32 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, WATERS OF CLIFTY FALLS, THE falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 31.0%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (50 most recent)

D — Isolated - Minimal harm Nov 18, 2025 Tag: 0908

Keep all essential equipment working safely.

Category: Environmental Deficiencies

Corrected: Nov 25, 2025

G — Isolated - Actual harm Nov 18, 2025 Tag: 0689

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

Category: Quality of Life and Care Deficiencies

Corrected: Nov 25, 2025

D — Isolated - Minimal harm Oct 20, 2025 Tag: 0550

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

Category: Resident Rights Deficiencies

Corrected: Oct 24, 2025

D — Isolated - Minimal harm Jul 14, 2025 Tag: 0760

Ensure that residents are free from significant medication errors.

Category: Pharmacy Service Deficiencies

Corrected: Jul 25, 2025

D — Isolated - Minimal harm Jul 14, 2025 Tag: 0740

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

Category: Quality of Life and Care Deficiencies

Corrected: Jul 25, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0921

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

Category: Environmental Deficiencies

Corrected: Jul 3, 2025

E — Pattern - Minimal harm Jun 4, 2025 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0842

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jul 3, 2025

E — Pattern - Minimal harm Jun 4, 2025 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0770

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

Category: Administration Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0756

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

Category: Pharmacy Service Deficiencies

Corrected: Jul 3, 2025

C — Widespread - No harm Jun 4, 2025 Tag: 0732

Post nurse staffing information every day.

Category: Nursing and Physician Services Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0688

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.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0686

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

Category: Quality of Life and Care Deficiencies

Corrected: Jul 3, 2025

E — Pattern - Minimal harm Jun 4, 2025 Tag: 0684

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

Category: Quality of Life and Care Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0657

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0640

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jul 3, 2025

E — Pattern - Minimal harm Jun 4, 2025 Tag: 0583

Keep residents' personal and medical records private and confidential.

Category: Resident Rights Deficiencies

Corrected: Jul 3, 2025

D — Isolated - Minimal harm Jun 4, 2025 Tag: 0554

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

Category: Resident Rights Deficiencies

Corrected: Jul 3, 2025

E — Pattern - Minimal harm Feb 25, 2025 Tag: 0919

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

Category: Environmental Deficiencies

Corrected: Mar 20, 2025

D — Isolated - Minimal harm Feb 25, 2025 Tag: 0550

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

Category: Resident Rights Deficiencies

Corrected: Jan 23, 2025

D — Isolated - Minimal harm Aug 30, 2024 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Sep 19, 2024

D — Isolated - Minimal harm Aug 30, 2024 Tag: 0602

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

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Sep 19, 2024

D — Isolated - Minimal harm Jul 17, 2024 Tag: 0610

Respond appropriately to all alleged violations.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Aug 14, 2024

D — Isolated - Minimal harm Jul 17, 2024 Tag: 0609

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

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Aug 14, 2024

E — Pattern - Minimal harm Jun 24, 2024 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: Jul 17, 2024

E — Pattern - Minimal harm Jun 24, 2024 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Jul 17, 2024

D — Isolated - Minimal harm Jun 24, 2024 Tag: 0758

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.

Category: Pharmacy Service Deficiencies

Corrected: Jul 17, 2024

D — Isolated - Minimal harm Jun 24, 2024 Tag: 0698

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

Category: Quality of Life and Care Deficiencies

Corrected: Jul 17, 2024

D — Isolated - Minimal harm Jun 24, 2024 Tag: 0693

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.

Category: Quality of Life and Care Deficiencies

Corrected: Jul 17, 2024

D — Isolated - Minimal harm Jun 24, 2024 Tag: 0690

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

Category: Quality of Life and Care Deficiencies

Corrected: Jul 17, 2024

D — Isolated - Minimal harm Jun 24, 2024 Tag: 0686

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

Category: Quality of Life and Care Deficiencies

Corrected: Jul 17, 2024

E — Pattern - Minimal harm Apr 4, 2024 Tag: 0842

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Apr 29, 2024

D — Isolated - Minimal harm Apr 4, 2024 Tag: 0755

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

Category: Pharmacy Service Deficiencies

Corrected: Apr 29, 2024

D — Isolated - Minimal harm Feb 27, 2024 Tag: 0689

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 8, 2024

D — Isolated - Minimal harm Feb 27, 2024 Tag: 0580

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

Category: Resident Rights Deficiencies

Corrected: Mar 8, 2024

D — Isolated - Minimal harm Sep 28, 2023 Tag: 0744

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

Category: Quality of Life and Care Deficiencies

Corrected: Oct 27, 2023

D — Isolated - Minimal harm Sep 28, 2023 Tag: 0686

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

Category: Quality of Life and Care Deficiencies

Corrected: Oct 27, 2023

D — Isolated - Minimal harm Sep 28, 2023 Tag: 0684

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

Category: Quality of Life and Care Deficiencies

Corrected: Oct 27, 2023

E — Pattern - Minimal harm Sep 28, 2023 Tag: 0677

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

Category: Quality of Life and Care Deficiencies

Corrected: Oct 27, 2023

E — Pattern - Minimal harm Jul 26, 2023 Tag: 0725

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

Category: Nursing and Physician Services Deficiencies

Corrected: Aug 11, 2023

D — Isolated - Minimal harm Jul 26, 2023 Tag: 0677

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

Category: Quality of Life and Care Deficiencies

Corrected: Aug 11, 2023

E — Pattern - Minimal harm Apr 4, 2023 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: Apr 22, 2023

D — Isolated - Minimal harm Apr 4, 2023 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Apr 22, 2023

D — Isolated - Minimal harm Apr 4, 2023 Tag: 0760

Ensure that residents are free from significant medication errors.

Category: Pharmacy Service Deficiencies

Corrected: Apr 22, 2023

D — Isolated - Minimal harm Apr 4, 2023 Tag: 0758

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.

Category: Pharmacy Service Deficiencies

Corrected: Apr 22, 2023

D — Isolated - Minimal harm Apr 4, 2023 Tag: 0689

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

Category: Quality of Life and Care Deficiencies

Corrected: Apr 22, 2023

D — Isolated - Minimal harm Apr 4, 2023 Tag: 0686

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

Category: Quality of Life and Care Deficiencies

Corrected: Apr 22, 2023

D — Isolated - Minimal harm Apr 4, 2023 Tag: 0641

Ensure each resident receives an accurate assessment.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Apr 22, 2023

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 9.0% Yes
Percentage of long-stay residents who lose too much weight Long Stay 5.8% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.7% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 2.2% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 84.1% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 4.7% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 95.8% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 87.1% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 8.5% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 12.6% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 30.7% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 97.9% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 92.4% No
Percentage of long-stay residents with pressure ulcers Long Stay 4.5% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 25.1% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 15.1% Yes

Penalty History

No penalties on record.

Frequently Asked Questions

What is the overall CMS rating for WATERS OF CLIFTY FALLS, THE?
WATERS OF CLIFTY FALLS, THE has an overall CMS rating of 1 out of 5 stars. This rating combines health inspection results (1★), staffing levels (2★), and quality measures (3★).
What are the staffing levels at WATERS OF CLIFTY FALLS, THE?
WATERS OF CLIFTY FALLS, THE reports 2.76 total nursing hours per resident day (national average: 3.89). RN hours are 0.32 per resident day (national average: 0.68). Nursing staff turnover is 31.0%.
How many beds does WATERS OF CLIFTY FALLS, THE have?
WATERS OF CLIFTY FALLS, THE has 138 certified beds with approximately 101 residents. The facility is located at 950 CROSS AVE, MADISON, IN 47250.
Does WATERS OF CLIFTY FALLS, THE have any deficiencies on record?
Yes, WATERS OF CLIFTY FALLS, THE has 50 deficiencies on record from recent inspections. Of these, 1 are classified as causing actual harm or jeopardy.
Has WATERS OF CLIFTY FALLS, THE received any fines or penalties?
No, WATERS OF CLIFTY FALLS, THE has no fines or penalties on record.
Who owns WATERS OF CLIFTY FALLS, THE?
WATERS OF CLIFTY FALLS, THE is classified as "For profit - Limited Liability company" ownership. The facility type is "Medicare and Medicaid".
When was WATERS OF CLIFTY FALLS, THE last inspected?
The most recent health inspection for WATERS OF CLIFTY FALLS, THE was on Jun 4, 2025. The facility received a health inspection rating of 1 out of 5 stars.
What quality measures are tracked for WATERS OF CLIFTY FALLS, THE?
WATERS OF CLIFTY FALLS, THE is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial