Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Timbercrest Church Of The Brethren Home during CMS and state inspections, most recent first.
Dietary staff were not competent in dishwasher operation or three-compartment sink sanitation testing. The Exec Chef and Dietary Aide were unsure of the dishwasher type, required temperatures, and sanitizer use, and test strips repeatedly showed no sanitizer in the sink until sanitizer was added without measuring. Dishes were treated as clean even when sanitizer was not detected, and logs showed multiple missed entries for required dishwasher and sink checks.
Unsafe glove use and food handling during meal service. A dietary employee repeatedly failed to perform hand hygiene and change gloves after touching non-serving items such as a phone, meal tickets, and kitchen handles while assembling resident meal trays. He also handled cooked chicken and buns with gloved hands, and a second dietary server placed a bag of buns on clean meal trays during tray assembly. Staff interviews and facility policy confirmed that gloves were expected to be changed and hands washed between tasks.
Dignified Dining Experience Not Maintained: Two residents with severe cognitive impairment were observed during meals while CNAs carried on personal conversations, did not engage the residents, and used abrupt or dismissive communication. One resident was startled when food and drinks were placed abruptly in front of him, repeatedly redirected in a gruff manner, and had items moved away from him, while the other resident’s questions were ignored and staff talked over her during the meal.
A resident with GERD, CKD, hyponatremia, and type 2 DM was receiving both famotidine and omeprazole, and the pharmacist repeatedly noted that one of the therapies may not have been necessary. The record lacked documentation that the physician was notified of the earlier pharmacy recommendations or that a rationale was provided for declining them until a later order discontinued omeprazole. Facility policy required the consultant pharmacist’s medication irregularities to be communicated to the DON, attending physician, and Medical Director, with physician responses documented.
A resident with a DNR order was given CPR despite having a POST form indicating no resuscitation if found without a pulse. The facility's staff initiated CPR due to conflicting information in the resident's records, and the code status was not updated as required by the facility's policy.
A facility failed to allow a resident, who was cognitively intact and capable of making decisions, to formulate an advance directive. Despite being alert and oriented, the resident's family member signed a DNR form upon admission. The facility's policy to assist residents in formulating advance directives was not followed, as the Admissions Coordinator relied on personal judgment rather than the resident's capacity. The Administrator confirmed the resident's competence to sign the directive.
The facility failed to label medications in two medication carts with resident identifiers and directions. Unlabeled bottles of supplements and medications were found in the Hall 100 and Hall 400 medication carts. Staff confirmed that all medications should have labels with resident information and usage instructions, but the facility's policy lacked guidance on labeling.
The facility failed to ensure proper PPE usage in areas requiring transmission-based precautions. Observations revealed that a CNA entered a resident's room without the required face shield or goggles, despite signage indicating their necessity. Interviews indicated a misunderstanding of PPE protocols, with staff wearing both a surgical mask and an N95 mask, contrary to facility guidelines.
The facility failed to follow physician orders to call the physician for low blood pressure readings for a resident at risk for falls. Despite the resident's blood pressure falling below the specified threshold on two occasions, the physician was not called, and nursing interventions were performed instead. Interviews revealed a misunderstanding or miscommunication regarding the notification protocol.
The facility failed to provide adequate supervision and implement personalized interventions to prevent falls for a resident with a history of repeated falls and severe cognitive impairment. Despite various care plan interventions, these measures were frequently discontinued after one day, leading to multiple falls. Staff interviews revealed inconsistencies in maintaining fall prevention measures, contrary to the facility's policy.
Dietary Staff Lacked Competency in Dishwasher and Sink Sanitization
Penalty
Summary
The facility failed to ensure dietary employees were competent in dishwasher operations and three-compartment sink sanitation testing. During an observation of the main kitchen dishwasher, the Executive Chef was unsure whether the machine was low- or high-temperature, did not know the desired temperatures, and did not know what chemicals were used. The temperature gauges did not fluctuate during repeated wash and rinse cycles, and the Regional Support later stated he did not know much about the dishwasher and was unsure whether the gauge behavior was normal. During a separate observation, the Executive Chef washed blender blades in the three-compartment sink and attempted to test the sanitizer using the wrong test strips before obtaining another brand. Neither strip initially registered sanitizer in the sink. Dietary Aide 8 then identified the correct strips, but the sanitizer still did not register until he drained the sink, added pink sanitizer without measuring the amount, and refilled it. The test strip then showed 400 parts per million, while the Executive Chef was unsure of the desired range and thought it should be around 200 parts per million. Dietary Aide 8 stated 400 parts per million was a good range, and the blender blades remained in the drying rack without being rewashed later that morning. On another observation, Dietary Aide 8 was washing dishes in the three-compartment sink and stated the dishwasher had not been used since the previous Sunday because detergent was unavailable, so all dishes were being washed in the sink. Test strips again showed no sanitizer in the sink, yet dishes that had already been washed were considered clean and sanitized and were put away. The Dietary Manager later stated the sanitizer readings were incorrect because the automatic dispenser above the sink was out of calibration, that staff were not using the pink sanitizer in the plastic jug, and that the dishwasher was rented and he could not identify whether it was low- or high-temperature. Logs for the dishwasher and three-compartment sink showed multiple missed entries, and the facility policy required sanitizer at 200 ppm and titration and temperature checks three times daily.
Unsafe glove use and food handling during meal service
Penalty
Summary
The facility failed to ensure food was prepared and served in a safe and sanitary manner during a continuous lunch service observation. During the meal service, a dietary employee removed gloves, placed the used gloves in a pocket, returned to the kitchen, and applied a new pair of gloves without performing hand hygiene. The same employee touched meal tickets, handled the telephone, reached into a plastic bag to retrieve a hotdog bun, opened the bun with gloved hands, placed a hotdog in the bun, and continued dishing food onto resident meal trays. He also handled meal trays, dietary slips, serving utensils, and a food container while moving between tasks, and at one point diced cooked chicken breast by holding the chicken with one hand and using a knife with the other, then wiped his gloved hands on his apron and used his hands to pull chicken apart and rearrange it on a plate. A second dietary server assisted with meal tray assembly and also handled a hotdog bun from a plastic bag, then placed the bag containing the buns on a stack of clean meal trays. During interview, the dietary employee stated he was to change gloves after touching items not used during serving, such as knobs, the phone, and refrigerator and freezer handles, and after touching food. The Executive Chef and Dietary Manager stated staff were expected to change gloves after touching items not used for serving, especially the phone or cooked chicken, and that staff dishing meal trays should change gloves anytime they touched an item not used to serve meal items. The facility policy stated hands must be washed before putting on and after removing disposable gloves, and gloves must be changed and hands washed when moving from one task to another.
Dignified Dining Experience Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience for 2 of 16 residents observed during meals. Resident 54 had diagnoses including severe dementia with psychotic disturbance, anxiety, insomnia, impulse disorder, chronic kidney disease, and BPH. His record showed he was severely cognitively impaired, could eat independently, and required supervision, cueing, and redirection at meals because he wandered and was at risk of eating non-food items. Resident 45 had Alzheimer's disease, anxiety, hypertension, and osteoporosis, and her care plan noted she talked loudly to herself at times and had exit-seeking behaviors. During one lunch observation, two CNAs assisted Resident 54 and Resident 45 while carrying on a personal conversation about one CNA's cat. Neither CNA conversed with the residents, and the residents were not included in the discussion. In another observation, a CNA reached in front of Resident 54, removed an item from his hand, and said, "We don't do that!" During a later meal observation, Resident 54 was asleep at the table and was startled awake when a CNA abruptly placed a drink in front of him. The CNA repeatedly placed food and drink close to his face, spoke to him only when offering items, told him, "One more little drink," after he indicated he did not want more, and moved his meal ticket away when he reached for it. Resident 45 was observed using a dining chair to ambulate from her walker to the table, and staff did not intervene. When she pushed her chair away and asked why staff were asking where she was going, staff did not answer her questions. While she continued talking, the CNAs talked over her head about the cat and did not engage her in conversation. One CNA interrupted her by announcing, "Here's your soup!" and then, "Here's your crackers!" The DON stated staff should not have personal conversations while assisting residents during mealtimes, and the facility policy required person-centered care that maximized dignity, autonomy, privacy, socialization, independence, choice, and safety.
Failure to Timely Address Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure the physician reviewed and addressed pharmacy recommendations in a timely manner for a resident with GERD without esophagitis, folate deficiency, Vitamin D deficiency, constipation, chronic kidney disease, hypo-osmolality, hyponatremia, and type 2 diabetes mellitus with polyneuropathy. The resident’s current medication orders included famotidine 40 mg daily, and the record also reflected omeprazole 40 mg daily had been used in addition to famotidine. Pharmacy recommendations dated 11/11/24, 1/13/25, and 3/10/25 indicated the pharmacist identified that the resident was receiving both a PPI and famotidine and that one of the therapies may not have been necessary; discontinuation of one medication was recommended. The resident’s record did not contain physician notification or a documented rationale for declining the pharmacist’s recommendations for the 11/11/24, 1/13/25, and 3/12/25 recommendations prior to 4/18/25. A nursing progress note on 4/18/25 documented a new order to discontinue omeprazole due to multiple therapies. Interviews with the ADON and DON indicated the pharmacy recommendations were sent to the physician or given to nurses to send, but additional information could not be located showing communication with the physician or the rationale for declination of the earlier recommendations. The facility policy stated that findings and recommendations were to be reported to the DON, attending physician, and Medical Director, and that the physician must be notified of all medication irregularities and provide an explanation when disagreeing.
Failure to Follow DNR Orders for a Resident
Penalty
Summary
The facility failed to adhere to an Indiana Physician Order for Scope of Treatment (POST) form for a resident who had requested a do not attempt resuscitation (DNR) status. Despite the POST form indicating that the resident did not want CPR if found without a pulse and not breathing, the staff initiated CPR and called emergency services when the resident was found in such a condition. The resident's clinical record showed conflicting information, with current orders indicating a full code status pending POST form completion, while the POST form itself, signed and dated, clearly stated the resident's DNR wishes. Interviews with the Director of Nursing (DON) and Social Services revealed confusion regarding the resident's code status, as they indicated the resident wanted to be a DNR but with full interventions. The DON acknowledged that the code status was not updated in the system despite the POST form being completed and in the chart. Staff members were found to verify a resident's code status through the electronic clinical record, but discrepancies were noted between the face sheet and the POST form. The facility's Advanced Directive Policy required updates to state-specific documents and communication of changes to staff, which was not followed in this case.
Failure to Allow Resident to Formulate Advance Directive
Penalty
Summary
The facility failed to honor a resident's right to formulate an advance directive, despite the resident being capable of making their own decisions. Resident 50, who had diagnoses including essential hypertension, heart failure, acute kidney failure, and Type 2 diabetes mellitus, was admitted to the facility from the hospital. At the time of admission, the resident's family member signed a Do Not Resuscitate (DNR) form, although a progress note indicated that the resident was alert and oriented. The facility's Minimum Data Set (MDS) assessment did not include a Brief Interview for Mental Status (BIMS) assessment to evaluate cognition at that time. Subsequent documentation showed that Resident 50 had a BIMS score of 14, indicating cognitive intactness and the ability to make reasonable and consistent decisions. Despite this, the Admissions Coordinator assessed the resident's ability to sign advance directives based on her own judgment and family dynamics, rather than the resident's actual capacity. The facility's policy required identifying if a resident had an advance directive and assisting them in formulating one if they wished, but this was not followed. The Administrator later confirmed that the resident would have been competent enough to sign the Advance Directive at admission.
Medication Labeling Deficiency in Medication Carts
Penalty
Summary
The facility failed to ensure that medications stored in the medication carts were properly labeled with resident identifiers and directions. During an observation of the Hall 100 medication cart, it was found that the bottom drawer contained unlabeled bottles of Vanadium Complex, Stasis Liver Detox, and Thytrophin PMG, which were indicated by QMA 6 to belong to one resident and should have been labeled with resident identifiers. Similarly, the Hall 400 medication cart contained an unlabeled bottle of acetaminophen 500 mg tablets and an unlabeled bottle of Juice Plus Fruit & Vegetable Blend supplement, which QMA 8 confirmed should have been labeled. In an interview, RN 9 stated that all bottles and containers in the medication carts should have labels containing the resident's name, date of birth, instructions for use, and the provider's name. The Assistant Director of Nursing (ADON) also indicated that medications in the carts should have a resident name, physician name, an open date, and directions for use on the bottle. However, the facility's current policy on Storage and Expiration Dating of Medications and Biologicals did not include information regarding the labeling of medications.
Inadequate PPE Usage in Transmission-Based Precaution Areas
Penalty
Summary
The facility failed to properly implement its infection prevention and control program by not ensuring that staff adhered to the required personal protective equipment (PPE) protocols in areas under transmission-based precautions. During observations, it was noted that a Certified Nursing Assistant (CNA) entered a resident's room wearing gloves, an N95 mask over a surgical mask, and a gown, but without the required face shield or goggles, despite signage indicating the necessity for these items. This occurred on multiple occasions, with the CNA consistently failing to wear the appropriate eye protection as mandated by the facility's policy. Interviews with the CNAs revealed a misunderstanding or lack of adherence to the PPE requirements, as one CNA admitted to wearing both a surgical mask and an N95 mask, which was not in line with the facility's guidelines. The Assistant Director of Nursing (ADON) confirmed that staff should not be wearing both types of masks simultaneously when entering rooms under transmission-based precautions. The facility's policy clearly stated the need for a NIOSH-approved particulate respirator, gown, gloves, and eye protection when entering the room of a resident with suspected or confirmed SARS-CoV-2 infection, highlighting a gap between policy and practice.
Failure to Follow Physician Orders for Low Blood Pressure Notification
Penalty
Summary
The facility failed to follow physician orders to call the physician for low blood pressure readings for Resident B, who was at risk for falls. Resident B had diagnoses including hypertension, amnesia, unsteadiness on feet, muscle weakness, and lack of coordination. The physician's orders required notifying the physician if the resident's blood pressure fell below 80/50. On two occasions, the resident's blood pressure readings were below this threshold, and the physician was not called. Instead, notes were sent to the physician, and nursing interventions such as encouraging fluid intake and elevating the resident's feet were performed. Interviews with the nursing staff and administration revealed a misunderstanding or miscommunication regarding the physician's notification protocol. LPN 5 admitted to not calling the physician for the low blood pressure reading, while RN 4 indicated that she would only call the physician if symptoms did not improve with interventions. The ADON and DON also provided conflicting information about when to notify the physician, with the DON stating that it was not emergent to call the physician since the resident's condition improved with nursing interventions. The facility's policy on physician notification was not followed, leading to the deficiency.
Failure to Provide Adequate Fall Prevention for Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement personalized interventions to prevent falls for Resident C, who was reviewed for falls. Resident C had a history of repeated falls and multiple diagnoses, including heart failure, hypertension, and severe cognitive impairment. Despite being at high risk for falls, the facility did not maintain consistent and effective fall prevention interventions. Observations showed that Resident C was often found without proper footwear and had fallen multiple times, with interventions being frequently discontinued after one day without resolving the underlying issues. The resident's care plans indicated various interventions, such as purposeful routine rounding, keeping personal items within reach, and using a gait belt with one assist during transfers and ambulation. However, these interventions were not consistently implemented or maintained. For instance, after falls on several occasions, new interventions were introduced but then discontinued the following day, leaving the resident vulnerable to further falls. The facility's staff, including CNAs, RNs, and the ADON, acknowledged the inconsistency in maintaining fall prevention measures and were uncertain why interventions were being discontinued prematurely. Interviews with staff revealed that there was a lack of adherence to the facility's policy on fall prevention and follow-up. The DON and ADON both expressed uncertainty about why the interventions were not sustained. The facility's policy aimed to prevent as many falls as possible, but the repeated discontinuation of interventions after one day indicated a failure to provide the necessary supervision and personalized care to prevent Resident C's falls. This deficiency was highlighted by the resident's 17 falls from December 4, 2023, through March 6, 2024.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Manchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peabody Retirement Community | 1.4 mi | ★★★★★ | 5 | 0 |
| Grace Village Health Care Facility | 14 mi | ★★★★★ | 0 | 0 |
| Miller's Merry Manor | 14.3 mi | ★★★★★ | 0 | 0 |
| Wellbrooke Of Wabash | 14.4 mi | ★★★★★ | 12 | 0 |
| Waters Of Wabash Skilled Nursing Facility East The | 14.4 mi | ★★★★★ | 5 | 0 |
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