Tieszen Memorial Home

In the surveyor’s words

From the most serious findings on record at Tieszen Memorial Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF804May 28, 2026

  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. […]

• No harm, potential for more than minimal, patternF812May 28, 2026

  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. […]

• No harm, potential for more than minimal, patternF880May 28, 2026

  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. […]

• No harm, potential for more than minimal, patternF585Dec 19, 2024

  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. […]

• No harm, potential for more than minimal, patternF880Dec 19, 2024

  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. […]