Timbercrest Church of the Brethren Home

In the surveyor’s words

From the most serious findings on record at Timbercrest Church of the Brethren Home, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 16, 2021

  Based on observation, interview, and record review, the facility failed to assess a skin impairment and implement interventions to prevent the development of a pressure injury and failed to provide treatment and interventions to prevent the worsening of a pressure injury for 1 of 1 residents reviewed for pressure injuries (Resident 30). This deficient practice resulted in Resident 30's wound progressing from a reddened area with shearing to an unstageable pressure wound. Findings include: During a wound care observation, on 7/13/21 at 2:20 p.m., accompanied by the Wound Care Nurse and LPN 33, the following was observed: Resident 30 was in bed. She had an open wound to her coccyx, approximately the diameter of a softball and irregular in shape. […]

• Actual harm, isolatedF689Jul 16, 2021

  Based on observation, interview, and record review, the facility failed to provide supervision to prevent repeated falls and failed to prevent falls during staff-assisted transfers for 2 of 5 residents reviewed for falls (Residents 1 and 29). This deficiency resulted in occipital (skull bone) and hip fractures for Resident 1. Findings include: 1. On 7/12/21 at 1:27 p.m., Resident 1 was in bed. On 7/13/21 at 9:32 a.m., the resident was in bed. On 7/14/21 at 8:31 a.m., the resident was in bed. Review of Resident 1's clinical record was completed on 7/11/21 at 2:47 p.m. Diagnoses included, but were not limited to, left hip fracture, restlessness and agitation, repeated falls, [CONDITION(S)] stage 2, and type 2 diabetes. […]

• No harm, potential for more than minimal, widespreadF802Aug 26, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2025

  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. […]

• No harm, potential for more than minimal, patternF689Jun 27, 2022

  A. Based on observation, interview and record review, the facility failed to prevent falls with major injury and fall with injury for 2 of 7 (Resident 39 and Resident 22) and the facility failed to follow care plan interventions for 2 of 7 residents reviewed for falls (Resident 46 and Resident 47). Findings include: 1. On 6/22/22 at 12:59 p.m., the door to Resident 39's room was closed. On 6/23/22 at 9:20 a.m., he sat in his recliner in his room with his walker in front of him. On 6/23/22 at 1:09 p.m., his door was closed. On 6/24/22 at 11:15 a.m., he ambulated independently to common area outside of dining room with a rollator walker. On 6/24/22 at 2:31 p.m., he sat in his recliner in his room with a visitor in his room. […]