Tieszen Memorial Home

Based on interview, record review, observation, document review, and policy review, the provider failed to ensure that food was kept and served at a safe temperature for one of one Memory Care Unit dining room, and that food was palatable, appetizing, and warm in one of one main dining room. Findings include:1. Interview on 5/26/26 at 11:27 a.m. with resident 23 in room revealed that her food was sometimes cold. 2. Review of resident 23's electronic medical record (EMR) revealed her 5/1/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. 3. Interview on 5/26/26 at 11:30 a.m. and 2:27 p.m. with resident 8 in her room revealed that some of the food tasted bland and was sometimes cold. There were no spices or sauces, such as ketchup, mustard, or mayo, at her table to use. She stated she had discussed this at the Resident Council meeting before. 4. Review of resident 8's EMR revealed her 3/30/26 BIMS assessment score was 15, which indicated her cognition was intact. 5. Observation and interview on 5/26/26 from 11:46 a.m. through…

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 policy review the provider failed to ensure food items did not spoil in one of one walk-in refrigerators in the main kitchen, and one of one refrigerator on the Memory Care Unit was clean. Findings include: 1. Observation and interview on 5/26/26 at 12:04 p.m. in the walk-in refrigerator in the main kitchen with dietary F revealed, two one-pound containers of strawberries left in a flat. Both containers had moldy strawberries in them. There was a five-pound box of red bell peppers with six peppers in it. All the peppers had mold growing on them. Dietary F started working at the facility in December 2025 and, was being trained to take over some of the dietary manager's duties after she retired. He had completed his ServSafe training. He confirmed there were moldy strawberries and red bell peppers in the walk-in refrigerator. He agreed they should have been removed. He took them out of the walk-in refrigerator and discarded them. 2. Interview on 5/27/26 at 11:02 a.m. with dietary manager G regarding the moldy strawberries and red bell peppers…

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, record review, and policy review, the provider failed to ensure standard infection control prevention practices were followed by one of two observed certified nursing assistants (H) who used soiled gloves to obtain Aquaphor (a skin ointment) from a jar, and did not wear gloves for high-contact care provided to one of one sampled resident (5) who required Enhanced Barrier Precautions (EBP, glove and gown use when providing contact care), and by two of two observed housekeepers (J and K) who did not change their gloves before going from a dirty to a clean task while cleaning three of three observed residents rooms (39, 57, 58, and 66). Findings include:1. Observation on 5/27/26 at 3:37 p.m. of CNAs H and I in resident 5's room revealed he was lying in bed on his back, and he had a urinary catheter (flexible tubing inserted into the bladder to drain urine) bag hanging on the side of his bed frame. There was a sign on his bathroom door from the Centers for Disease Control (CDC) that…

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, record review, and policy review, the provider failed to ensure that one of one sampled resident (66), who was left unsupervised to take her medication by a licensed practical nurse (LPN) (U), was assessed for the ability to safely self-administer medications. Findings include:1. Observation on 5/27/26 at 8:31 a.m. in resident 66's room revealed she was not in her room, and there was a medication cup with a grey pill inside of it and a bottle of Refresh Eye Drops sitting on her bedside table. 2. Interview on 5/27/26 at 8:41 a.m. with nursing assistant (NA) S revealed she verified that resident 66 had a pill in a medication cup on her bedside table and a bottle of eye drops. She paged the nurse. 3. Interview on 5/27/26 at 8:50 a.m. with registered nurse (RN) T revealed she verified that there was a pill in a medication cup on resident 66's bedside table, and that the resident's family brought her the bottle of Refresh Eye Drops, but it contained baby oil. She verified that…

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 record review, interview, and policy review the provider failed to ensure the Office of State Long-Term Ombudsman (an advocate of residents' overall quality of care and rights) was notified when a resident discharged from the facility, for one of two sampled residents (6).Findings include:1. Review of resident 6's electronic medical record (EMR) revealed she was discharged on 4/21/26 to another facility. Her primary care physician (PCP) was notified of the intent to discharge on [DATE] and the facility received a physician's order on 4/21/26 for resident 6 to be discharged to the assisted living with her current orders. There was no documentation that the Office of State Long-Term Care Ombudsman was notified of resident 6's transfer to another facility.2. Interview on 5/27/26 at 4:19 p.m. with social services (SS) D revealed resident 6 transferred to the assisted living facility attached to the nursing home. She was not aware she needed to report the discharge to the ombudsman. She had reported it to…

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, record review, and policy review, the provider failed to complete a side rail assessment for one of seven sampled residents (1). Findings include: 1. Observation and interview on 5/26/26 at 2:32 p.m. with resident 1 in her room revealed she was sitting in her recliner. She had bilateral half siderails on her bed. She stated she did use the side rails to move around in bed.2. Interview on 5/27/26 at 3:02 p.m. with Minimum Data Set (MDS) Coordinator Q revealed that resident 1 moved to a new room on February 4th. Resident 1's bed in her previous room did not have side rails. MDS Coordinator Q did the quarterly side rail safety assessments for the residents who had side rails. Resident 1 did not use side rails, so MDS Coordinator Q did not complete a side rail safety assessment for her. She was not aware the bed in resident 1's new room had side rails. She confirmed there was no physician's order obtained, and a safety assessment was not completed for resident 1.3. Interview on…

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 policy review the provider failed to ensure the daily posted nurse staffing information included the resident census. Findings include:1. Observation from 5/26/26 at 5:00 p.m. through 5/28/26 at 7:48 a.m. of the daily posted nurse staffing form located on the wall near the reception desk revealed it did not include the resident census as required. There was a spot for the census that was blank. 2. Interview on 5/28/26 at 11:59 a.m. with director of nursing (DON) B revealed that secretary R completed the daily posted nurse staffing form, gave it to the night nurse, and the night nurse posted it on the wall by the reception desk. 3. Interview on 5/28/26 at 12:01 p.m. with secretary R revealed she completed the daily posted nurse staffing form and gave it to the night nurses to post on the wall by the front reception desk. The nurse was to edit the form for staffing changes. Secretary R was not aware that the resident census needed to be included on the nurse staffing form. 4. Interview on 5/28/26 at 12:07 p.m. with DON B revealed that she expected…

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, record review, and policy review, the provider failed to effectively implement and follow their policy related to grievances for three of three sampled residents (18, 19, and 24) with unresolved reported concerns. They failed to ensure: *Residents were informed and information was available on how to file a grievance. *All grievances were documented and included the date received, summary statement of resident's grievance, steps taken to investigate and keep resident informed of progress, summary of pertinent findings or conclusion, any necessary corrective action, and date the grievance was resolved. *Documentation of grievances and their resolution was maintained. *Resident council notification of group-reported grievance progress and resolution. Findings include: 1. Interview on 12/17/24 at 9:32 a.m. with resident 19 in his room revealed he: *Reported he had requested that his bed be taken out of his room because he slept in his recliner and wanted more room to use his electric wheelchair.…

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 A. Based on observation, interview, and policy review the provider failed to ensure proper infection control practices for the cleaning of shared safety slings for two of two sampled residents (4 and 19) who required the use of a sit-to-stand lift (mechanical lift used to assist to a standing position for transfers). Findings include: 1. Observation on [DATE] at 8:21 a.m. of a sit-to-stand lift parked in the hallway revealed: *The lift had a laminated sign on the side of it that read 12. *There was a medium-sized sling draped over the lift. 2. Observation on [DATE] at 8:32 a.m. with resident 4 and nursing assistant (NA) D revealed: *NA D used a sit-to-stand lift labeled 11 to transfer resident 4 from her wheelchair to her recliner and then placed that lift in the hallway outside that room. -The lift had two green safety slings stacked on top of it, one medium-sized and one large. 3. Observation and interview on [DATE] at 9:23 a.m. with NA D revealed: *NA D brought sit-to-stand lift 11 into resident 19's room…

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, record review, interview, and policy review, the provider failed to: *Adequately assess, reassess, and monitor for resident changes in cognition and safety awareness for self and others for one of eight sampled resident (19) who used a power wheelchair for mobility. *Obtain a physician's order for use with cognitive ability acknowledged for that resident. Findings include: 1. Observation on 12/17/24 at 12:18 p.m. of resident 19 while he exited the dining room while in his power wheelchair revealed he bumped into resident 210's chair, who was seated at the table. 2. Observation on 12/19/24 at 10:46 a.m. of resident 19 while in his power wheelchair revealed he hit the couch in the hallway seating area near the chapel with his power wheelchair and moved that couch by several inches. 3. Review of resident 19's paper chart and electronic medical record revealed: *He was admitted on [DATE]. *His diagnosis included *He received an occupational therapy (OT) evaluation for the initial use of 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, record review, and policy review the provider failed to ensure the oxygen concentrator filter was clean and the nasal cannula tubing was changed weekly, for one of three sampled residents (4) who received oxygen from four oxygen concentrators that were separately located throughout the facility. Findings include: 1. Observation and interview on 12/17/24 at 8:57 a.m. with resident 4 in her room revealed: *She was able to say hello but was unable to answer questions about her oxygen. *She wore an oxygen nasal cannula (flexible tubing with prongs that deliver oxygen into the nose) connected to an oxygen concentrator beside her chair. *The nasal cannula connected to that oxygen concentrator was not labeled or dated. *The filter on the back of that oxygen concentrator had visible gray dust. 2. Observation on 12/17/24 at 11:18 am in the sunroom revealed: *An oxygen concentrator located in the back corner labeled TMH#7. *Attached to that concentrator was a plastic bag labeled with resident 4's first name and last initial, and had date issued 10/20, and O2…

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 record review, interview, and policy review the provider failed to ensure two of two resident-to-resident altercations had been reported to the South Dakota Department of Health (SD DOH) in the designated time frame for one of one sampled resident (6). Findings include: 1. Review of resident 6's medical record revealed: *Diagnoses of the following: Sensorineural hearing loss, bilateral, major depressive disorder, epilepsy, and chronic pain. *Her most recent Brief Interview of Mental Status (BIMS) examination score was 14 indicating she was cognitively intact. *The care plan updated on 7/19/23 for physically aggressive behavior: -Do not argue with the resident. -Refer to Social Services for evaluation. -Reinforce unacceptability of verbal abuse. -Remove from public area when behavior was disruptive and unacceptable. -Monitor and document target behaviors. -Assist in selection of appropriate coping mechanisms. Review of resident 6's nursing progress notes on the following dates revealed: *7/9/23 6:08 p.m.…

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.