Timbercrest Church Of The Brethren Home

Based on observation, interview, and record review the facility failed to ensure dietary employees were competent in both dishwasher and three compartment sink sanitation testing. This deficient practice had the potential to impact 60 of 60 residents who received meals prepared in the facility kitchen.Findings include:1.During an observation of dishwasher operations in the main kitchen, on 8/19/25 at 11:24 a.m., the following was observed:The dishwasher ran through the wash and rinse cycles three times. The temperature gauges did not fluctuate before, during, or after the cycles were completed. The Executive Chef indicated that she was unsure if the temperature gauges were working and she did not know if the dishwasher was a low or high temperature machine. She was unsure of the specifics of the dishwasher, including what the desired temperatures should be and what, if any, chemicals were used.2.During an observation of dishwasher operations in the main kitchen, on 8/20/25 at 10:15 a.m., the following was observed:The dishwasher ran through the wash and rinse cycles three times. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure food was prepared and served in a safe and sanitary manner regarding food handling and hand hygiene. This deficient practice had the potential to impact 60 of 60 residents who received their meals from the kitchen.Findings include:During a continuous lunch service observation, on 8/22/25 from 12:12 p.m. to 1:05p.m., the following food handling and food service concerns were observed: After preparing meal trays, [NAME] 5 exited the kitchen, walked into the dining area, turned around, and approached the meal window where the prepared meal trays sat. He removed his gloves and placed the used gloves in his front right pant pocket. [NAME] 5 delivered three resident meal trays. [NAME] 5 re-entered the kitchen and applied a new pair of gloves without performing hand hygiene. DC 5 touched several dietary meal tickets that were placed on meal trays. After he reviewed the meal tickets, he picked up the telephone and made a call. Wearing the same gloves, DC 5 reached into a plastic bag and retrieved a hotdog bun.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents received a dignified dining experience for 2 of 16 residents during random dining observations. (Residents 54 and 45)Findings include:1.Resident 54's clinical record was reviewed on 8/21/25 at 2:03 p.m. Diagnoses included unspecified dementia (severe, with psychotic disturbance), generalized anxiety disorder, insomnia, impulse disorder, chronic kidney disease, and benign prostatic hyperplasia (enlarged prostate).Current physician orders included buspirone 10 milligrams (mg) three times a day for anxiety, donepezil 10 mg once a day for dementia, sertraline 25 mg once a day for anxiety, and trazodone 50 mg at bedtime for insomnia. A quarterly Minimum Data Set (MDS) assessment, dated 7/8/25, indicated Resident 54 was severely cognitively impaired, able to eat independently, and required substantial/maximal assistance for oral hygiene, toileting hygiene, showering/bathing, and dressing. A current care plan, initiated on 10/14/24 and revised on 8/21/25, indicated Resident 54 was at nutritional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the physician reviewed and addressed pharmacy recommendations in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 1). Finding includes:Resident 1's clinical record was reviewed on 8/21/25 at 12:26 p.m. Diagnoses included gastro-esophageal reflux disease (GERD) without esophagitis, folate deficiency, Vitamin D deficiency, constipation, chronic kidney disease, hypo-osmolality (lower-than-normal concentration of dissolved particles, such as sodium, in blood), hyponatremia (having too little sodium in the blood), and type 2 diabetes mellitus with polyneuropathy (damage to peripheral nerves). Current orders included famotidine 40 milligrams (mg) daily (7/25/24). Pharmacy recommendations on 11/11/24, 1/13/25, and 3/10/25, provided by the DON on 8/22/25 at 9:30 a.m., indicated the pharmacist indicated the resident received a proton pump inhibitor (PPI - treats disorders of the stomach), omeprazole 40 mg once daily, in addition to another gastroprotective therapy famotidine 40 mg once…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow an Indiana Physician Order for Scope of Treatment (POST) form indicating do not attempt resuscitation/DNR for a resident that received cardiopulmonary resuscitation (CPR) for 1 of 3 residents reviewed for Advanced Directives. (Resident 61) Findings include: Resident 61's clinical record was reviewed on [DATE] at 11:49 a.m. Diagnoses included unspecified systolic (congestive) heart failure, obstructive sleep apnea, dysphagia, oropharyngeal phase, and other pneumonia, unspecified organism. Current orders indicated the resident was a full code, pending POST form completion, dated [DATE]. An Indiana Physician Order for Scope of Treatment (POST) form dated [DATE], and signed [DATE], indicated in section A that Resident 61 requested a do not attempt resuscitation (DNR) if he had no pulse and was not breathing. A progress note, dated [DATE] at 3:30 a.m., indicated resident had no pulse, was not breathing, and had no chest rising. Code status was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to allow a resident with the ability to make their own decisions to formulate an advance directive. (Resident 50) Findings include: On 9/26/24 at 8:55 a.m., Resident 50's clinical record was reviewed. Diagnoses included essential hypertension, heart failure, acute kidney failure, and Type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment, dated 6/30/24, did not include a BIMS (Brief Interview for Mental Status) assessment to evaluate cognition. On 6/27/24, Resident 50's family member signed a Do Not Resuscitate (DNR) form. A progress note, on 6/27/24 at 8:47 p.m., indicated Resident 50 was alert and oriented. A POST form (a physician's order for scope of treatment based on the resident's medical conditions and preferences),dated 7/5/24, indicated the resident had a DNR code status. During an interview with the Admissions Coordinator (AC) on 9/27/24 at 9:45 a.m., she indicated the resident's family member had completed the admission paperwork. At the time of admission, Resident 50 had come from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure medications stored in the medication carts were labeled with resident identifiers and directions for 2 of 3 medication carts reviewed. (Hall 100 Medication Cart and Hall 400 Medication Cart). Findings include: During an observation of the Hall 100 medication cart on 9/26/24 at 3:30 p.m., accompanied by QMA 6, the bottom drawer contained an unlabeled bottle of Vanadium Complex (a supplement used to support blood glucose levels), an unlabeled bottle of Stasis Liver Detox (a liver supplement), and an unlabeled bottle of Thytrophin PMG (a thyroid supplement). QMA 6 indicated all supplements belonged to one resident and each should have a label with resident identifiers. During an observation of the Hall 400 medication cart on 9/26/24 at 3:42 p.m., accompanied by QMA 8, an unlabeled bottle of acetaminophen 500 mg tablets and an unlabeled bottle of Juice Plus Fruit & Vegetable Blend supplement were in the cart. QMA 8 indicated both should be labeled. During an interview with RN 9 on 9/26/24 at 3:57 p.m., she indicated all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by not wearing appropriate personal protective equipment (PPE) in areas requiring transmission-based precautions (TBP) during random observations on the 300 Hall. Findings include: During a random observation, on 9/24/24 at 10:59 a.m., CNA 14 entered room [ROOM NUMBER] while wearing gloves, an N95 mask placed over a surgical mask, and a gown. No face shield and/or eye protection was worn before entering the resident's room. Signage on the door indicated the resident was in transmission-based precautions, and required a gown, gloves, N95 mask and a face shield/goggles before entering the room. During a random observation, on 9/24/24 at 11:05 a.m., CNA 14 was wearing a gown, gloves, and an N95 mask overtop of a surgical mask while entering room [ROOM NUMBER]. During an interview, on 9/24/24 at 12:12 p.m., CNA 14 indicated she only wore gloves, a gown, and placed an N95 mask over a surgical mask. No…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow physician orders to call the physician for low blood pressure readings for 1 of 3 residents reviewed at risk for falls. (Resident B) Findings include: Resident B's clinical record was reviewed on 3/13/24 at 10:35 a.m. Diagnoses included hypertension, amnesia (memory loss), unsteadiness on feet, muscle weakness, and other lack of coordination. Current physician orders included calling the physician when the resident's blood pressure was below 80/50 and with signs/symptoms of hypotension (low blood pressure). A progress note, dated 2/18/24 at 5:50 p.m., indicated the resident had a low blood pressure of 71/53 with symptoms including shortness of breath and lethargy (lack of energy/ motivation). He was reclined to 30 degrees in his recliner. The resident representative was notified and was to be called if he experienced further symptoms. A note was sent to the physician. A progress note, dated 2/24/24 at 10:33 a.m., indicated the resident had a low blood pressure of 77/47 with symptoms of shortness of breath. He was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide supervision and implement personalized interventions to prevent falls for 1 of 3 residents reviewed for falls (Resident C). Findings include: During an observation, on 3/13/24 at 3:07 p.m., Resident C sat in a recliner in her room. She wore stockings, with her shoes laying beside her feet. During an observation, on 3/14/24 at 11:41 a.m., the resident was assisted out of her room in a wheelchair. The resident's clinical record was reviewed on 3/13/24 at 11:30 a.m. Diagnoses included heart failure, hypertension (high blood pressure), repeated falls, pain, disorientation, syncope (fainting) and collapse, difficulty in walking, generalized muscle weakness, history of falling, unsteadiness on feet, and fatigue. Current physician orders included diltiazem (for blood pressure) 240 mg extended release daily started 9/28/23, tramadol (opiate for pain) 50 mg three times a day started 12/29/23, and oxygen at 2-5 liters per minute per nasal cannula for dyspnea (difficulty breathing) started 11/27/23. A significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident did not receive psychotropic medications when continuation of the medication was not indicated for 1 of 5 residents reviewed for unnecessary medications (Resident 5). Findings include: During an observation on 8/7/23 at 10:25 a.m., Resident 5 was observed sleeping in a recliner near the nurses station. On 8/8/23 at 9:50 a.m., the resident was observed sleeping in his wheelchair sitting at the nurses station. On 8/8/2023 at 3:38 p.m., the resident was observed sleeping in a recliner near the nurses station. On 8/10/2023 at 11:00 a.m., the resident was observed to be sleeping intermittently during the resident council meeting. When awake, the resident appeared confused. On 8/10/23 at 4:08 p.m., the resident was asleep in the recliner near the nurses station. On 8/11/23 at 9:00 a.m., the resident was asleep in his wheelchair in the television room. Resident 5's clinical record was reviewed, on 8/9/2023 at 10:19 a.m., and indicated an active, 10/22/20, diagnosis of major depressive disorder,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.