Waters of Clifty Falls: Wheelchair Injury Violation - IN
The cause was a wheelchair.
Federal inspectors arrived at the Madison facility on November 18, 2025, following a complaint. What they found was straightforward and documented in the facility's own paperwork: the home had a policy requiring staff to check wheelchairs for proper operation and needed repairs. The policy had no date on it. The administrator handed it over at 1:21 in the afternoon on the day of the inspection.
The policy existed. The inspection that should have caught a dangerous wheelchair, by the facility's own standard, had not prevented a resident from being cut badly enough to require a trip to the emergency room.
A progress note from August 23 recorded the resident's return from the hospital. The note listed the injuries: glue on the skin tears of the right calf, six sutures and skin glue on the wound to the left calf. New orders were written to cleanse the wounds daily and watch for redness, discharge, fever, or any sign the injuries were getting worse. The resident's family was present at bedside.
The wounds themselves tell the story of what a malfunctioning wheelchair can do. The 5-centimeter laceration on the left lower leg was deep enough that it required a local anesthetic before anyone could irrigate it. The circumferential laceration on the right lower leg wrapped around the limb. The five smaller tears, each roughly 2 centimeters, were spread across the right leg. None of those injuries happen without significant contact between skin and a hard surface, the kind of contact that comes from a piece of equipment that isn't working the way it should.
Inspectors cited the facility under F0908, which covers the physical environment and the maintenance of equipment. The level of harm was recorded as minimal harm or potential for actual harm. Few residents were noted as affected.
That classification, minimal harm, sits uneasily next to the specifics: lidocaine, high-pressure irrigation, sutures placed in a running fashion to approximate wound edges, a resident transported to a hospital and returned the same day with new wound care orders. The federal harm scale has room for definitions. What it doesn't change is that someone went to a hospital and came back with six stitches in their leg.
The facility's wheelchair inspection policy, the one the administrator produced on the afternoon of the inspection visit, says to check all wheelchairs for proper operation and needed repairs. It does not say how often. It does not say who is responsible. The copy provided to inspectors carried no date, meaning there is no record of when the policy was last reviewed or whether staff had been trained on it recently.
Waters of Clifty Falls is a nursing facility in Madison, a small city in Jefferson County in southeastern Indiana, near the Ohio River. The inspection on November 18 was a complaint investigation, meaning someone, a resident, a family member, or a staff member, had contacted regulators before inspectors walked through the door.
The resident who was injured returned from the hospital on August 23. Their family was at bedside. The new wound care orders called for daily cleaning and monitoring for the signs that would mean the wounds were not healing: redness, discharge, fever, worsening condition. Whether those wounds healed cleanly, the inspection report does not say.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 31, 2026 · Our methodology
WATERS OF CLIFTY FALLS, THE in MADISON, IN was cited for violations during a health inspection on November 18, 2025.
Federal inspectors arrived at the Madison facility on November 18, 2025, following a complaint.
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.