Cycle 1
Health 2025-08-26 · Fire 2025-08-26
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
North Manchester, IN
Timbercrest Church Of The Brethren Home
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2201 East St, North Manchester, IN
(260) 982-2118
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
61
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-09-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.28
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.16
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
3.18
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
1.04
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.59
CMS adjusted RN staffing hours
Adjusted total hours
5.74
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,614
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9965
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.65% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.53
Baseline 47.95% · Performance 41.10% · Measure score 5.53 · Achievement 5.53 · Improvement 2.47
Adjusted total nurse staffing
7.53
Baseline 6.04 hours · Performance 5.22 hours · Measure score 7.53 · Achievement 7.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.17% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 12.77% · Lower 95% interval 7.62% |
| Discharge to community | 56.25% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 50% · Lower 95% interval 44.09% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 60.87% |
95.27%
34.4 pts worse
|
Numerator 14 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 15.44% |
8.2%
7.2 pts better
|
Numerator 21 · Denominator 136 |
| Staff flu vaccination coverage | 53.8% |
42%
11.8 pts better
|
Numerator 92 · Denominator 171 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.6
0.6 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.4 |
1.5
2.9 pts worse
|
1.8
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.4 · Observed 3.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
93.6%
0.6 pts better
|
93.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 89.5% · Q3 94.6% · Q4 96.5% · 4Q avg 94.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
95.4%
1.3 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.8%
2 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 3.6% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
24.6%
23.2 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.9% · Q4 1.8% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.6%
1.7 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 2.0% · Q3 0.0% · Q4 6.7% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
23.5%
6.7 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.3% · Q3 18.6% · Q4 17.8% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
14.8%
1.4 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 15.4% · Q3 13.5% · Q4 10.3% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.7% |
13.3%
6.4 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 41.4% · Q3 14.1% · Q4 6.6% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.1% |
11.7%
8.4 pts worse
|
14.9%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 42.9% · Q3 13.5% · Q4 9.8% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.2%
0.1 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
24.2%
2.4 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 27.2% · Q3 24.6% · Q4 27.2% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.1%
1.7 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.4% · Q3 0.0% · Q4 2.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.8% |
81.6%
10.8 pts worse
|
81.7%
10.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 72.7% · Q3 58.3% · 4Q avg 70.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
10.5%
7.5 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 16.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.3%
0.6 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.3% |
79.0%
0.7 pts worse
|
79.7%
1.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.9% |
22.4%
12.5 pts better
|
23.9%
14 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 8.3% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-30 · Fire 2024-09-30
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-08-14 · Fire 2023-08-14
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-08-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-08-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-11-21
F · Potential for more than minimal harm
2024-09-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-09-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-09-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-09-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-09-30
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-09-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-09-30
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-09-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-09-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-09-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-20
C · Minimal harm
2024-09-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-20
F · Potential for more than minimal harm
2023-08-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-14
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-08-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-20
C · Minimal harm
2023-08-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-26
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-08-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-09-19
D · Potential for more than minimal harm
2024-09-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-30
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-10
D · Potential for more than minimal harm
2023-08-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-01
Penalties and ownership
What sits behind the stars
Ownership
Woodlawn Hospital
5% Or Greater Direct Ownership Interest · Organization
Baumann, Jeff
Operational/Managerial Control · Individual
Boyer, Kevin
Operational/Managerial Control · Individual
Brubaker, Sally
Operational/Managerial Control · Individual
Chinworth, James
Operational/Managerial Control · Individual
Church Of The Brethren Home Inc
Operational/Managerial Control · Organization
Church Of The Brethren Home Inc
5% Or Greater Security Interest · Organization
Culp, Eunice
Operational/Managerial Control · Individual
Eastis, Todd
Operational/Managerial Control · Individual
Fisher, Alan
Operational/Managerial Control · Individual
Fisher, Alan
Corporate Officer · Individual
Hammer, Steve
Operational/Managerial Control · Individual
Heyde, Alison
Corporate Director · Individual
Higgins, Pamela
Operational/Managerial Control · Individual
Hollenberg, Rebecca
Operational/Managerial Control · Individual
Huiras, Christine
Operational/Managerial Control · Individual
Johnson, Terri
Corporate Director · Individual
Mellinger, Gregory
Corporate Director · Individual
Merryman, George
Operational/Managerial Control · Individual
Sarber, Megan
Operational/Managerial Control · Individual
Smith, Byron
Operational/Managerial Control · Individual
Thomas, Sabine
Operational/Managerial Control · Individual
Troyer, Angela
Operational/Managerial Control · Individual
Wenger, John
Operational/Managerial Control · Individual
Wysong, David
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Peabody Retirement Community
North Manchester, IN
3-star overall rating with 2-star inspections with $33,518 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Grace Village Health Care Facility
Winona Lake, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Miller's Merry Manor
Warsaw, IN
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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