Waters of Clifty Falls: Wheelchair Injury Requires Sutures - IN
The injuries were extensive. The resident came back from the hospital with a 5-centimeter circumferential laceration on the left lower leg that had been numbed with lidocaine, flushed with high-pressure irrigation, and closed with six sutures placed in a running pattern. The right lower leg had four separate skin tears, each roughly 2 centimeters long, sealed with Dermabond, a medical-grade skin adhesive. A progress note from August 23, 2025 recorded the resident's return and listed new orders: cleanse the wounds daily, watch for redness, discharge, fever, or any sign of worsening.
Family members were at the bedside.
Four days later, wound assessments told a fuller picture of the damage. The left lower posterior leg wound measured 6.5 centimeters by 4.2 centimeters. The right lower posterior leg wound measured 10.1 centimeters by 2.5 centimeters. Both still had sutures in place.
The wounds healed. A wound assessment from September 17, 2025 documented that the skin tears on both legs had closed. But the healing of the wounds did not resolve the underlying question inspectors were examining: whether the facility had done what it was supposed to do when a resident is injured by equipment in its care.
Federal inspectors who visited the facility on November 18, 2025 rated the deficiency as causing actual harm, the designation CMS uses when an inspection finding goes beyond a risk of injury and reaches a resident who was genuinely hurt. The citation fell under F0689, the federal tag covering accidents and the environment a nursing home is responsible for keeping safe.
The facility's own accident and incident policy, signed and dated June 30, 2023, and handed to the administrator on the day of inspection, stated that the facility would ensure incidents involving residents are identified, reported, and resolved. The inspection record does not indicate those steps were completed in a way that satisfied inspectors.
Waters of Clifty Falls sits at 950 Cross Ave in Madison, a small city in southeastern Indiana on the Ohio River. The inspection was triggered by a complaint, not a routine survey cycle, meaning someone had flagged the incident before federal investigators arrived.
The inspection report does not identify the resident by name, does not describe which part of the wheelchair caused the injuries, and does not say whether the wheelchair was the resident's own equipment or a facility-owned device. It does not say whether the sharp component was identified and addressed after the incident, or whether any other residents used the same chair.
What it does say is that a person in the facility's care went to a hospital, was sutured and glued back together, returned to a room where family waited, and spent the following weeks having wounds measured and monitored while the facility logged dimensions and watched for infection.
The sutures came out. The wounds closed by mid-September. The resident recovered.
The citation remained.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Clifty Falls, The from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
WATERS OF CLIFTY FALLS, THE in MADISON, IN was cited for violations during a health inspection on November 18, 2025.
The right lower leg had four separate skin tears, each roughly 2 centimeters long, sealed with Dermabond, a medical-grade skin adhesive.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.