Indiana State Department of Health


Division of Long Term Care

 

CONSUMER REPORT

 

WATERS OF CLIFTY FALLS, THE

 

NURSING HOME


SKILLED NURSING FACILITY / NURSING FACILITY DUALLY CERTIFIED

Created on: 07/25/2025

 
Posted to the Web on: 08/06/2025
 
 






Basic Information


FACILITY CONTACT INFORMATION:
Address: 950 CROSS AVE
City: MADISON
Telephone: (812) 273-4640
Web Site:  
 
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
 
LICENSE INFORMATION:
  License number: 25-000116-1
  License effective date: 05/01/2025
  License expiration date: 04/30/2026
 




Administration and Staff


Administrator: MELINDA ALCORN
  Start date: 04/15/2024
 
Director of Nursing: ANNESTACIA MATRIX
  Start date: 05/12/2025
 
Medical director: Federico Salcedo
  Start date:   /  /  
 
Wound care specialist:  
  Start date:   /  /  
 
Infection preventionist:  
  Start date:   /  /  
 




Ownership


CURENT OWNERSHIP:
 
Owning corporation: MAJOR HOSPITAL
2451 INTELLPLEX DR
SHELBYVILLE IN 46176
 
Ownership type:  OTHER
 
Officer(s): DANA CALDWELL
            JEFF BEATY
            JOHN COFFIN
            JAN SANDMAN
            SHERRI TANDY
            PAULA GUSTAFSON
            GENE JONES
            RALPH MERCURI
            LINDA WESSIC
            ROB KINDER
            RYAN CLAXTON
            MELANIE STEVENS
            PHILP MATTHEW HAEHL
            ALEXANDER ISAKOVAN
 
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: THE WATERS OF CLIFTY FALLS LLC
Date of last change of ownership: 05/19/2014
 




Bed Counts and Census


COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF):                     0
Number of Medicare beds (SNF):                    0
Number of Medicare/Medicaid beds (SNF/NF):        138
Number of non-certified comprehensive care beds (State Licensed only):     0
Total number of comprehensive care beds:     138
 
RESIDENTIAL CARE BEDS:
 
Total number of residential beds:            0
 
Total number of beds in facility:            138
 
CENSUS:
Facility census:  100
As reported by the facility on: 04/16/2025
 
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 04/16/2025
 
Residential care beds occupied:  0
As reported by the facility on: 04/16/2025
 
Alzheimer Beds:  32
Alzheimer Beds Occupied:  18
As reported by the facility on:   /  /  
 
Ventilator Beds:  0
Ventilator Beds Occupied:  0
As reported by the facility on:   /  /  
 




Sprinklers and Smoke Detectors


This facility is: FULLY SPRINKLERED
 
Number of comprehensive care resident rooms: 74
Number of comprehensive care resident rooms with battery 
                    operated smoke detectors: 74
Number of comprehensive care resident rooms 
             with hard wired and/or wireless smoke detectors: 0
 
Person completing form - SHAWN COLWELL
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. MAINTENANCE DIRECTOR
Date form completed - 06/11/2025
 




Nurse Aide Training


NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 03/10/2017
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2025
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 07/18/2025
 
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites: 
     SOUTHEASTERN CAREER CENTER
         Approved: 08/26/2016
         Terminated: 07/19/2023
     HEALTH AIDE TRAINING INC
         Approved: 10/19/1998
         Terminated: 01/09/2006
     WATERS OF CLIFTY FALLS, THE
         Approved: 03/10/2017
         Terminated: 07/19/2023
     TRI-STATE HEALTH CARE TRAINING CENTER, LLC
         Approved: 11/17/2014
         Terminated: 06/20/2014
     IVY TECH COMMUNITY COLLEGE
         Approved: 08/17/2020
         Terminated: 07/19/2023
     INDIANA HEALTH CAREERS VOCATIONAL TRAINING &  TEST
         Approved: 06/18/2018
         Terminated: 06/11/2021
     KAISER HEALTHCARE CERTIFICATION LLC
         Approved: 09/21/2021
         Terminated: 07/19/2023
     ALORA COLLEGE OF HEALTH SCIENCES
         Approved: 02/07/2023
         Terminated: 07/19/2023
     IVY TECH COMMUNITY COLLEGE
         Approved: 03/20/2024
         Terminated: 07/19/2023
     WATERS OF DILLSBORO-ROSS MANOR, THE
         Approved: 05/01/2025
         Terminated: N/A
 




Complaints



NUMBER OF SUBSTANTIATED COMPLAINTS: 
 
  Current year:  1
  Previous year:  0
  2 years previous:  0


 




Facility Report Card






 




 
03/01/2020 Current QTR
12/01/2019 Previous QTR
09/01/2019 Previous QTR
06/01/2019 Previous QTR




Report Card Score
290
293
236
242




Rank of Score
73
73
84
84




Average Score
302
296
295
296





 
*Facility report card scores have not been updated since March 1, 2020 due to changes in the survey process during the ongoing COVID-19 pandemic. 
The facility report card score is calculated four times per calendar year 
for the two most recent nursing home health surveys.  The facility report card score 
also includes all complaint surveys, life safety code surveys, emergency preparedness surveys, 
and any follow-up surveys that occur within the two most recent nursing home health surveys. 
The facility report card score ranges from 500 to 0, with 500 being the best score possible. 
 
View the Scope and Severity grid
 
View the scoring methodology
 






Overview of Survey findings








 
 The Most Recent Set
 2ND Most Recent Set
 3RD Most Recent Set


Immediate Jeopardy
No
No
No




 Substandard Quality of Care 
No
No
No




Administrator Change
No
Yes
Yes




Owner Change
No
No
No




Number of Substantiated Complaints With Deficiencies
0
0
0




Deficiency Free Standard Health Survey
No
No
No





 
    The term 'Recent Set' referenced above relates to the referenced annual survey,
    and any other surveys performed between it and the previous annual survey.
 


 




Enforcement Actions


 
Federal Certification Actions Imposed
     Directed Plan of Correction
     Date Imposed: 10/08/2022  Date Ended: 10/18/2022
     Civil Money Penalty
     Date Imposed: 09/12/2022  Date Ended: 09/12/2022
     Amount proposed per day: 
 
Date terminated from Medicare/Medicaid: N/A
 




Survey History




    The survey report is not posted until the report has been provided to the facility and their plan of correction submitted and approved.
    The survey report therefore will likely not be posted until four to six weeks after the exit date.
        
    In the grid below click on an event ID that is underlined to see the survey report for that event.




 
Event ID
Survey Type
Exit Date


YJOB21
Recertification, Life Safety Code
06/18/2025




YJOB11
Recertification, State Licensure
06/04/2025




XSPD11
Complaint
04/22/2025




O79J12
Complaint, Follow Up
04/14/2025




XP5P22
Complaint, Follow Up, Life Safety Code
03/05/2025




O79J11
Complaint
02/25/2025




XP5P21
Complaint, Life Safety Code
01/21/2025




5CTN11
Complaint
01/15/2025




17IN11
Complaint
12/17/2024




QG9Z11
Complaint
11/07/2024




R5BX12
Complaint, Follow Up
10/04/2024




R5BX11
Complaint
08/30/2024




JS2M12
Recertification, Follow Up, State Licensure
08/15/2024




8DB812
Complaint, Follow Up
08/15/2024




JS2M22
Follow Up, Life Safety Code, Recertification
08/14/2024




8DB811
Complaint
07/17/2024




JS2M21
Recertification, Life Safety Code
07/09/2024




JS2M11
Recertification, Complaint, State Licensure
06/24/2024




DXZK12
Complaint, Follow Up
05/29/2024




DXZK11
Complaint
04/04/2024




837W12
Complaint, Follow Up
03/14/2024




837W11
Complaint
02/27/2024




O52G11
Complaint
01/30/2024




RGKH12
Complaint, Follow Up
11/09/2023




508311
Complaint
10/26/2023




RGKH11
Complaint
09/28/2023




WXUG12
Complaint, Follow Up
09/15/2023




WXUG11
Complaint
07/26/2023




7IVU22
Recertification, Follow Up, Life Safety Code
06/27/2023




O5C111
Complaint
06/20/2023




KO0011
Complaint
05/23/2023




7IVU12
Recertification, Follow Up, State Licensure
05/15/2023




7IVU21
Recertification, Life Safety Code
04/17/2023




7IVU11
Recertification, State Licensure
04/04/2023




WFKI11
Complaint
02/28/2023




3QWE11
Complaint
02/07/2023




OZ5O11
Complaint
01/09/2023




T1KL11
Complaint
12/08/2022




SX7912
Complaint, Follow Up
11/13/2022




093V12
Complaint, Follow Up
11/13/2022




093V11
Complaint
10/17/2022




SX7911
Complaint
09/12/2022




HNQ522
Recertification, Follow Up, Life Safety Code
08/11/2022




GQDM12
Complaint, Follow Up
08/05/2022




HNQ512
Recertification, Complaint, Follow Up, State Licensure
08/05/2022





 
 




Links and Resources


 
CMS nursing home compare page 
 
    In addition to the information provided on this 
    web site, the Centers for Medicare & Medicaid Services (CMS) has a web site 
    which contains information on every Medicare and Medicaid certified nursing 
    home in the country. The CMS nursing home survey results contain summary information 
    about a facility's noncompliance of regulations regarding the care of residents 
    found in the nursing homes. You can locate nursing homes in your area and find 
    information about compliance with federal regulations.
 
Resources and links to other organizations
 
Choosing a Nursing Home
 
Overview of the Survey Process
 
State Wide Grouping of all Scores
   
Overview of current comprehensive facility scores
   
Spreadsheet of current comprehensive facility names and scores
   
Legal Disclaimer for Long Term Care Reports.