Core Of Dale

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

office registered them on the sexual offender registry. There were restrictions to follow with the residents currently on probation and those residents were visited by the probation officers monthly, and once a resident was no longer on probation, they have no restrictions to enforce. They just have to abide by the laws in Indiana. She indicated they kept files on all the sexual offenders in the building at the office that included the resident specific restrictions to follow and these restrictions were on the resident care plans. If

a resident was on probation, they were not allowed to go into the community without someone with them.

She indicated staff were informed of behaviors, whether the resident was on probation, and the restrictions

they had to enforce. During an interview on 9/25/25 at 9:10 A.M., Registered Nurse (RN) 8 indicated the staff communicate through verbal nurse to nurse report if there were any behavioral flare-ups to closely monitor. They were trained to de-escalate and separate residents if they were combative with each other but not on what to expect dealing with sexual offenders or personal safety. She indicated the facility was particular on which male residents they put on the East Hall (women's hall). Kids that come to the facility have to be supervised at all times. She indicated Resident B was not allowed to go to the East Hall for any reason. They were not notified which residents were sex offenders. Most of the time, they found out on their own from other staff and it was verbally understood who can and can't do things. They monitor all residents for behaviors.On 9/25/25 at 9:53 the DON indicated all the residents were treated the same regardless of why they were in the facility. She indicated they were a behavioral health facility, not a typical nursing home, and all their residents have behaviors of some sort. She wasn't sure how staff was supposed to know the specific restrictions for the residents that were sexual offenders. For Resident F, they did not know at that time that he was not allowed to have electronics until they were notified by cops. They have not incorporated the restrictions (if known) into resident specific interventions for the residents. During an

interview on 9/25/25 at 1:40 P.M., the Administrator indicated after the nearby school closed a few years ago, they started admitting sexual offenders. They work closely with the parole officers who let the facility know what the residents can and can not do. On 9/25/25 at 8:30 A.M., a current Care Plan Revision Policy, last revised 8/27/24, was provided by the DON and indicated, The purpose of this procedure is to provide a consistent process for reviewing and revising the resident specific care plan . The comprehensive care plan will be reviewed, and revised as necessary . The MDS Coordinator or appropriate staff member, will review and update the resident's care plan and intervention(s) as needed . On 9/25/25 at 1:55 P.M., a current Facility Safety Plan for Offenders Policy/Procedure, dated 9/25/25, was provided by the DON and indicated,

It is the policy of this facility to maintain the safety of the residents, staff, visitors, and the community in the presence of residents with a history of a violent/sexual offense.This citation relates to Intake 2609464.3.1-35(d)(2)(B)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Core of Dale

510 W Medcalf Road Dale, IN 47523

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

cup was not increased after the 7/12/25 visit. She also had no visit notes from the dietician in August or September. She indicated that the weights not being in the clinical record would have caused the dietitian to miss seeing him, and the MD not being notified.On 9/25/25 at 12:06 P.M., a current Nutritional Risk Program Policy, last revised 9/10/13, was provided by the DON and indicated, It is the policy of this facility to monitor the weight status of each resident and that appropriate interventions be initiated should weight decline or incline unplanned . This citation relates to Intake 26070813.1-46(a)(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Core of Dale

510 W Medcalf Road Dale, IN 47523

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of food and nutrition services. The Dietary Manager lacked appropriate certification. Finding includes: On 9/16/25 at 8:05 A.M., the current Dietary Manager indicated

she started in that role on 9/5/25 and lacked a current certification and was working to become re-certified.

On 9/25/25 at 9:48 A.M., the Director of Nursing (DON) provided a current, undated, Dietary Manager job description as their policy that indicated, Required Qualifications Minimum requirements include one of the following: Certification as a dietary manager. Certification as a food service manager .Must also meet State requirements for food service managers or dietary managers . This Federal tag relates to Intake 2607081.3.1-20(h)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Core of Dale

510 W Medcalf Road Dale, IN 47523

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Based on observation, interview, and record review, the facility failed to appropriately test the dishwasher to verify it was functioning correctly. Staff lacked knowledge of the test strips used to test the sanitation chemicals in 1 of 2 observations of dishwasher use. Finding includes: On 9/16/25 at 8:05 A.M., the Dietary Manager indicated she was unsure of what kind of dishwasher the facility had, and that staff checked to make sure the temperature reached 120 degrees Fahrenheit. At that time, she indicated that the staff failed to test the dishwasher with chlorine strips and was unable to find strips.During an observation on 9/16/25 at 8:18 A.M., Maintenance 11 indicated the dishwasher is a low-temperature dishwasher, and he verified the temperature reached 120 degrees Fahrenheit daily. At that time, he indicated he was not a dietary employee, so he did not check the chemicals on the dishwasher.During an interview on 9/16/25 at 9:45 A.M., the Maintenance Supervisor indicated the dishwasher should be tested with a chlorine strip every shift. At that time, she located a container of strips and tested the dishwasher. The strip showed 10 parts per million (ppm). The Maintenance Supervisor indicated it should be at 100 ppm.During an interview on 9/16/25 at 10:30 A.M., the Director of Nursing (DON) indicated kitchen staff should notify maintenance of any problems. At that time, she indicated they were not aware of the problem, and a call had been placed to

the manufacturer of the dishwasher.On 9/16/25 at 9:45 A.M., the Maintenance Supervisor provided a current manual as a policy, dated 10/29/07, that indicated chlorine levels should be between 50-100 ppm.This Federal tag relates to Intake 2607081.3.1-21(i)(3)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Core of Dale

510 W Medcalf Road Dale, IN 47523

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure a homelike environment for 6 of 15 resident rooms reviewed for the environment. Rooms and a hall had a strong urine odor, peri-cleanser and cream (used for incontinence care) were found in a resident refrigerator, call light strings in the bathrooms were soiled, and grab bars and the toilet seat were loose. (East Hall, [NAME] Hall, Resident rooms and or shared bathrooms, Rooms 101, 102, 103/105, 108/110, 207/209, 204/206)Findings include:1. On 9/16/25 12:33 P.M., room [ROOM NUMBER] and the private bathroom was observed with a strong urine odor.On 9/24/25 at 9:10 A.M., the same was observed. 2. On 9/16/25 at 12:35 P.M., room [ROOM NUMBER], there was cream in an open clear cup and a bottle of peri-cleanser observed in Resident 8's refrigerator with three cans of soda.On 9/24/25 at 9:11 A.M., the same was observed.On 9/24/25 at 9:23 A.M., Certified Nurse Aide (CNA) 22 indicated those shouldn't be stored there, took them out, and discarded them in the trash can. 3. On 9/16/25 12:38 P.M., room [ROOM NUMBER]'s bathroom (shared with room [ROOM NUMBER]) was observed with a strong urine odor.On 9/24/25 at 9:08 A.M., the same was observed. 4. On 9/16/25 at 12:46 P.M., room [ROOM NUMBER] and bathroom (shared with 110) was observed with a strong urine odor, the handle bars and the toilet seat they were connected to were loose, and the call light cord was brown.On 9/24/25 at 9:06 A.M., the same was observed. 5. On 9/16/25 at 12:48 P.M., room [ROOM NUMBER]'s bathroom (shared with room [ROOM NUMBER]) was observed with a brown call light cord that was wrapped around a grab bar.On 9/24/25 at 9:04 A.M., the same was observed. 6. On 9/16/25 at 12:57 A.M., room [ROOM NUMBER]'s bathroom (shared with room [ROOM NUMBER]) was observed with a brown call light cord and a strong urine odor.On 9/24/25 at 9:02 A.M., the same was observed.

During an interview on 9/24/25 at 9:25 A.M., Housekeeper 5 indicated they do have rooms that smell because the residents forget to flush or did't hold the handle down long enough. At that time, she indicated staff located the source and used bio enzymatic odor eliminator spray. They cleaned the rooms and bathrooms daily and as needed. If the call light cord was brown, it would need to be changed by maintenance. The housekeeper was responsible for taking the resident refrigerator temperatures daily and when they looked inside at thermometer, if there was something in it that shouldn't be, they would discard it.

On 9/25/25 at 9:29 A.M., the Director of Nursing (DON) indicated the facility didn't really have a policy for

the environment but they would follow the regulations. This citation relates to Intake 2607081. 3.1-19(f)

Event ID:

Facility ID:

If continuation sheet