Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tieszen Memorial Home during CMS and state inspections, most recent first.
Unsafe Food Temperatures and Poor Food Quality: Residents reported cold, bland, dry, and hard-to-chew food, and staff in the Memory Care dining room were observed preparing to serve hot and cold items without knowing or meeting required temperatures. CNAs and an LPN measured ribs, corn, potato salad, and milk at unsafe temperatures, refrigerator logs were missing, and the food temperature log showed repeated hot-food temperatures below policy requirements.
Spoiled food was found in the main kitchen walk-in refrigerator when dietary staff observed moldy strawberries and moldy red bell peppers that had not been removed. A separate refrigerator on the Memory Care unit was also observed with a dried brown substance covering the bottom, and staff interviews showed confusion about who was responsible for cleaning and monitoring it. Facility policies required food storage areas to be clean and sanitary and for refrigerators to be routinely cleaned and monitored.
A CNA failed to follow EBP infection control practices while providing hygiene care and a transfer for a resident with an indwelling urinary catheter, using a soiled glove to take Aquaphor from a jar and handling the catheter bag above bladder level without clean gloves. Two housekeepers also failed to change gloves when moving from dirty tasks, such as cleaning toilets, to clean tasks while cleaning resident rooms. Interviews and policy review confirmed that gloves, gown use, hand hygiene, and catheter positioning were expected.
Failure to assess a resident for self-administration of meds. A resident with intact cognition and hypothyroidism was left unsupervised with a scheduled levothyroxine dose by an LPN, even though there was no physician order or care plan indication allowing self-administration and no self-administration safety assessment completed. Staff also found a bottle brought in by the family labeled as Refresh Eye Drops that actually contained baby oil.
A resident was discharged to another facility, but the Ombudsman was not documented as notified of the transfer. The SS coordinator said she was unaware the discharge needed to be reported to the Ombudsman and had no printed proof of prior submissions, while the facility policy required SS or a designee to notify the Ombudsman in a timely manner when a resident discharges, transfers, or dies.
Failure to complete side rail assessment for a resident with bilateral half siderails. A resident with moderately impaired cognition and assistance needs was observed using the siderails to move in bed, but the EMR had no physician order or safety assessment documented. The MDS coordinator said the resident was not assessed because she was thought not to use siderails and the bed in the new room had them without her awareness; the admin stated siderails required a physician order and quarterly reassessment.
The facility failed to ensure the daily posted nurse staffing form included the resident census. Observation showed the census field was blank on the form posted near the reception desk, and interviews with the DON and secretary R confirmed the form was completed by the secretary and posted by the night nurse, with the DON expecting the night nurse to add the census. The facility policy required the census to be included at the beginning of the shift.
The facility failed to implement its grievance policy, leaving residents' concerns unresolved. A resident was unsure how to file a grievance about his bed removal request, while another faced long meal wait times, worsening her pain. Residents were unaware of grievance procedures, and concerns were often verbalized without follow-up. The grievance coordinator lacked a tracking system, and the administrator viewed grievances as serious issues, expecting other concerns to be handled verbally.
The facility failed to ensure proper infection control practices, including the cleaning of shared safety slings, implementation of Enhanced Barrier Precautions for a resident with an open wound, and monitoring of expired hygiene products. Shared slings were not disinfected between uses, a resident with a stage II pressure ulcer was not placed on EBP, and expired hand sanitizers and personal care items were found throughout the facility.
A resident with declining cognitive function continued to use a power wheelchair unsafely, leading to multiple incidents. Despite staff concerns and policy requirements for reassessment, the resident was not reevaluated by therapy, and no physician's order was obtained for the wheelchair use.
A resident requiring continuous oxygen therapy had their oxygen equipment inadequately maintained, with dusty concentrator filters and nasal cannulas not changed weekly as required. The resident's TAR lacked documentation for equipment changes, and the DON confirmed the oversight, acknowledging the resident's equipment maintenance might have been missed.
Unsafe Food Temperatures and Poor Food Quality
Penalty
Summary
Food and drink were not kept and served at safe temperatures in the Memory Care Unit dining room, and residents in the main dining room reported that food was often cold, bland, dry, hard to chew, or hard to swallow. Resident 23, whose BIMS score was 15, stated her food was sometimes cold. Resident 8, whose BIMS score was 15, stated some food tasted bland and was sometimes cold, and that condiments such as ketchup, mustard, or mayo were not available at her table. During the Resident Council meeting, residents 8, 20, 53, 54, and 57, all with BIMS scores indicating intact cognition, reported ongoing concerns that food was cold, dry, hard to chew, hard to swallow, too spicy, or not what they had selected on their menus. In the Memory Care Unit dining room, CNA N was observed bringing in a food warmer and preparing to serve ribs, corn, and potato salad without knowing the required serving temperatures. The ribs were measured at 118 degrees F and 132 degrees F, and the potato salad was 57 degrees F. LPN O later checked the same foods and found the ribs at 110 degrees F and 122 degrees F, the corn at 120 degrees F, and the potato salad at 56 degrees F; she stated hot foods should be greater than 165 degrees F and cold foods should be less than 41 degrees F. CNA N stated she had not been educated on the required food temperatures. Later, CNA P removed potato salad from the refrigerator and was going to serve it without checking the temperature; when checked, it was 51 degrees F. Additional observations showed the Memory Care Unit refrigerator temperature was 50 degrees F, milk from the refrigerator measured 42 degrees F, and the refrigerator temperature logs could not be found even though the refrigerator was supposed to be checked daily. Review of the Memory Care food temperature log from 3/29/26 to 5/26/26 showed 52 instances of hot foods documented below 135 degrees F and 10 instances where temperatures were not documented. The provider's Food Temperature policy required hot foods to be at least 135 degrees F and cold foods to be 41 degrees F or below, and the logs stated unsafe temperatures were to be reported immediately.
Spoiled Food Left in Refrigerator and Unclean Unit Refrigerator
Penalty
Summary
Food items were found spoiled in the main kitchen walk-in refrigerator during observation and interview with dietary staff. Two one-pound containers of strawberries contained moldy strawberries, and a five-pound box of red bell peppers with six peppers in it had mold growing on all of the peppers. Dietary staff confirmed the items were moldy and agreed they should have been removed. The dietary manager stated the facility was having issues with condensation ventilation in the walk-in refrigerator and that staff were trying to rotate produce to reduce exposure to the condensation, but the moldy strawberries and red bell peppers remained in the refrigerator until they were discarded during the survey. The refrigerator on the Memory Care Unit was also observed to be unclean, with a dried brown substance covering the bottom of the refrigerator. Staff interviews showed that overnight CNAs were expected to clean the refrigerator on Saturdays, but the dietary manager was not sure who was responsible for monitoring completion of the task. The RN/IC stated the overnight CNAs were responsible for cleaning it and thought dietary staff monitored it, while the DON stated she expected the overnight CNAs to clean it and that the dietary manager was responsible for monitoring cleanliness. The DON also stated she could not find the task on the CNA checklist and would put it there. The facility policy required food storage areas to be clean and sanitary, and the refrigerator cleaning and monitoring policy stated each department using a refrigerator was responsible for ensuring routine cleaning and monitoring was completed.
Infection Control Failures During EBP Care and Room Cleaning
Penalty
Summary
The provider failed to ensure infection prevention and control practices were followed during resident care and housekeeping activities. During observation of a CNA assisting a resident who required Enhanced Barrier Precautions (EBP), the CNA wore gloves and a gown initially, but then used a soiled glove to scoop Aquaphor from a jar and apply it to the resident’s buttocks. After removing only one glove and adjusting the resident’s brief and clothing, the CNA handled the transfer sling and urinary catheter bag, attached the full body lift, and transferred the resident to his wheelchair without washing hands or putting on clean gloves. The catheter bag was observed hanging above the level of the resident’s bladder with approximately 350 mL of urine in the bag. The resident had a diagnosis of neuromuscular dysfunction of the bladder, an indwelling urinary catheter order, and a care plan requiring EBP and keeping the catheter bag below bladder level. Housekeeping observations also showed glove-use failures during room cleaning. One housekeeper cleaned toilet surfaces and then, with the same gloves, obtained a new cloth and wiped the tops of the dresser, end tables, and bedside tables in one resident room. In another room, the same housekeeper cleaned the sink and toilet, changed garbage bags, then used the same gloves to handle items on the bedside table, wipe furniture, mop the bathroom and bedroom floor, and move the bedside table. A second housekeeper cleaned a toilet and bathroom sink, then used the same gloves to mop the resident’s room, move the bedside table, and later wiped the bathroom sink and outside of the toilet without changing gloves between dirty and clean tasks. Interviews confirmed the expected practices. The CNA acknowledged she was to wear gloves for residents on EBP, that she used a soiled glove to obtain Aquaphor from the jar, and that the catheter bag should remain below bladder level because raising it could cause backflow of urine and increase infection risk. The housekeeper acknowledged gloves should be changed between tasks and that she did not change them after cleaning the toilet. The RN/Infection Control nurse, DON, and maintenance director all stated that gloves were expected for EBP care, that soiled gloves should be removed before applying Aquaphor, and that housekeepers were expected to change gloves when moving from dirty to clean tasks. Policy and procedure reviews reflected these same requirements.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to safely self-administer medications before being left unsupervised with a scheduled dose. On 5/27/26, resident 66 was observed not in her room, with a medication cup containing a grey pill and a bottle of Refresh Eye Drops on her bedside table. Nursing staff later verified that the pill was levothyroxine 75 mcg due at 7:00 a.m., and that it had been left on the bedside table by an LPN. The LPN stated she left the medication there and was supposed to watch the resident take it because the resident did not have a physician order to self-administer medications. Record review showed resident 66 was admitted to the facility with a diagnosis of hypothyroidism and had a BIMS score of 15 on 5/12/26, indicating intact cognition. She had a physician order dated 5/5/26 for levothyroxine 75 mcg daily, but there was no order allowing self-administration and no care plan indication that she could self-administer. The DON confirmed the resident did not have a physician order or self-administration safety assessment completed, and also stated she was not aware the resident's family had brought in a bottle labeled as Refresh Eye Drops that actually contained baby oil.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure the Office of State Long-Term Care Ombudsman was notified when resident 6 was discharged from the facility to another facility. Record review showed resident 6 was discharged on 4/21/26 to another facility, with the PCP notified of the intent to discharge and a physician order entered on 4/21/26 for discharge to the assisted living with current orders. However, there was no documentation that the Ombudsman was notified of the resident’s transfer. During interview, the social services coordinator stated resident 6 transferred to the assisted living facility attached to the nursing home and that she was not aware she needed to report the discharge to the Ombudsman. She stated she had reported the change in pay source to Dakota at Home, but did not print the Ombudsman notifications after submission and had no documentation to prove prior submissions. The administrator later stated the Ombudsman notification for resident 6 was made that morning. The facility policy stated the Social Services Coordinator or designee would notify appropriate state agencies, including the Ombudsman, in a timely manner when a resident discharges, transfers, or dies.
Failure to complete side rail assessment
Penalty
Summary
The facility failed to complete a side rail assessment for one of seven sampled residents who had bilateral half siderails on the bed. During observation, the resident was seen sitting in a recliner in her room, and she stated that she used the side rails to move around in bed. The resident had a BIMS score of 8, indicating moderately impaired cognition, and required one staff member for transfers. Review of the electronic medical record showed no documentation of a physician’s order or a side rail safety assessment for the resident. Interview with the MDS Coordinator revealed that quarterly side rail safety assessments were completed for residents who had side rails, but this resident was not assessed because she did not use side rails and the coordinator was unaware that the bed in the new room had side rails. The coordinator confirmed that no physician’s order had been obtained and that a safety assessment was not completed. The administrator stated that side rails required a physician’s order and that quarterly assessments were to be completed and reassessed to ensure they were being used for the intended purpose. The facility policy stated that evaluations were to be performed at least quarterly and that a Bed Rail/Assist Bar Evaluation form was to be completed when half side rails were ordered for mobility or repositioning.
Daily Nurse Staffing Posting Missing Resident Census
Penalty
Summary
The provider failed to ensure the daily posted nurse staffing information included the resident census. Observation from 5/26/26 at 5:00 p.m. through 5/28/26 at 7:48 a.m. of the staffing form posted on the wall near the reception desk showed the census section was blank. Interviews with the DON and secretary R revealed that secretary R completed the daily staffing form and gave it to the night nurse to post, and the night nurse was expected to edit the form for staffing changes. Secretary R stated she was not aware the resident census needed to be included, while the DON stated she expected the night nurse to add the current resident census to the form. Review of the provider's May 2025 Staff Posting policy showed the staffing form should include the resident census at the beginning of the shift for which the information is posted.
Failure to Implement Grievance Policy
Penalty
Summary
The facility failed to effectively implement and follow their grievance policy for three sampled residents, leading to unresolved concerns. Residents were not informed about how to file grievances, and there was a lack of documentation regarding grievances, including the date received, summary of the grievance, steps taken to investigate, and resolution. Resident 19 expressed frustration over his unresolved request to have his bed removed to make room for his wheelchair, and he was unsure how to file a grievance. Resident 24 reported long wait times for meals, which exacerbated her back pain and numbness in her legs, and despite raising this issue at a resident council meeting, no improvements were made. Interviews with residents during a group meeting revealed that they were unaware of how to file grievances and that their concerns were often expressed verbally to department staff without follow-up. The activities coordinator confirmed that resident concerns about food and wait times were frequently discussed at council meetings, but these concerns were not documented in the minutes, nor was there assistance provided to residents in filing grievances. The social services coordinator, who was the grievance coordinator, acknowledged the lack of a specific form for grievances and the absence of a documented tracking system for resident concerns, which were often addressed verbally. The administrator considered grievances to be serious issues related to abuse, neglect, or mistreatment, while other concerns were expected to be handled immediately through a verbal process. The facility's grievance policy outlined a procedure for addressing grievances, but there was no clear distinction between concerns and grievances, and the contact information for the State Ombudsman was incorrect. The facility's failure to document and follow up on grievances, as well as the lack of a clear process for residents to file grievances, contributed to the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The provider failed to ensure proper infection control practices for the cleaning of shared safety slings used with a sit-to-stand lift. Observations revealed that the slings were shared among multiple residents without being properly disinfected between uses. Nursing Assistant D confirmed that the slings were only washed when visibly soiled and sanitized once a day, contrary to the facility's policy that required disinfecting wipes to be used between each use. This practice was observed with residents 4 and 19, and it was noted that the slings were shared by three or four other residents on the second floor. The provider also failed to implement Enhanced Barrier Precautions (EBP) for a resident with an open wound. Resident 20, who had a stage II pressure ulcer, was not placed on EBP despite having open skin areas. Interviews with the RN/skin nurse and the RN/infection control nurse revealed a lack of consistent criteria for initiating EBP, with the infection control nurse indicating that a resident with a stage II pressure ulcer should have been on EBP. The facility's policy required EBP for residents with chronic wounds or indwelling medical devices, but this was not communicated or implemented for resident 20. Additionally, the facility did not ensure that alcohol-based hand sanitizers (ABHS) and other hygiene products were not expired. Observations showed multiple expired ABHS dispensers throughout the facility, and interviews revealed a lack of responsibility and oversight in checking expiration dates. The maintenance department was responsible for refilling and checking the expiration dates, but expired products were still in use. Furthermore, shared personal care items in the shower and whirlpool rooms were not labeled, and many were expired, posing a risk of cross-contamination among residents.
Failure to Reassess Resident's Power Wheelchair Use Leads to Safety Concerns
Penalty
Summary
The provider failed to adequately assess, reassess, and monitor a resident's changes in cognition and safety awareness, which led to multiple incidents involving the unsafe operation of a power wheelchair. The resident, who was initially evaluated and deemed safe to operate the power wheelchair in June 2023, demonstrated a decline in cognitive function as indicated by a decrease in the BIMS score from 13 in July 2024 to 9 in October 2024. Despite this decline, the resident continued to use the power wheelchair without a physician's order or a reassessment by occupational therapy. Several incidents were observed where the resident operated the power wheelchair unsafely, including bumping into another resident's chair, hitting a couch, and getting too close to staff and other residents. Progress notes documented the resident's behavior of following a floor cleaning machine too closely, resulting in the wheelchair getting hooked on the machine. Staff expressed concerns about the resident's safety and reported these incidents to the director of nursing, but no reassessment was conducted. The facility's policy required a physician's order for the use of electric transportation devices and mandated reassessment by therapy if unsafe operation was observed. However, the resident's unsafe behavior was not communicated to the therapy department, and no reassessment was performed. This lack of communication and failure to follow policy contributed to the deficiency in ensuring the resident's safety while using the power wheelchair.
Failure to Maintain Oxygen Equipment for Resident
Penalty
Summary
The provider failed to ensure proper maintenance and replacement of oxygen equipment for a resident who required continuous oxygen therapy. Observations revealed that the oxygen concentrator filter was visibly dusty, and the nasal cannula tubing was not labeled or dated, indicating it had not been changed weekly as required. The resident, who was moderately cognitively impaired, used four separate oxygen concentrators located throughout the facility, but there was no documentation in the treatment administration record (TAR) to indicate when the nasal cannulas were last changed. Interviews with the Director of Nursing (DON) confirmed that the resident was the only one using these concentrators and that the nasal cannulas should have been changed weekly and documented by the night shift nurse. However, the resident's TAR did not include orders to change the nasal cannulas or specify the locations of the concentrators. The DON acknowledged that the resident's equipment maintenance might have been overlooked. The facility's oxygen administration policy required weekly changes of oxygen masks, nasal cannulas, and equipment storage bags, which was not adhered to in this case.
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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 Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Terrace | 10.4 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society Canistota | 12 mi | ★★★★★ | 11 | 0 |
| Diamond Care Center | 15.3 mi | ★★★★★ | 0 | 0 |
| Pioneer Memorial Nursing Home | 19.5 mi | ★★★★★ | 1 | 0 |
| Menno-olivet Care Center | 20.6 mi | ★★★★★ | 1 | 0 |
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