Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.