Cycle 1
Health 2024-12-19 · Fire 2024-12-19
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Marion, SD
Tieszen Memorial Home
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
312 East State St, Marion, SD
(605) 648-3611
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
58
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-06-15
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
0.77
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.24
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.01
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,689
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.77
Composite VBP score used to determine payment impact.
Payment multiplier
1.0097
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
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
6.50
Baseline 49.21% · Performance 37.10% · Measure score 6.50 · Achievement 6.50 · Improvement 4.47
Adjusted total nurse staffing
4.45
Baseline 4.30 hours · Performance 4.34 hours · Measure score 4.45 · Achievement 4.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.51% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 0% · Lower 95% interval 5.81% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.56 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 23 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | 45% |
53.69%
8.7 pts worse
|
Numerator 9 · Denominator 20 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 12 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 8.7% |
2.29%
6.4 pts worse
|
Numerator 2 · Denominator 23 · Adjusted rate 12% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.08% |
8.2%
4.9 pts better
|
Numerator 14 · Denominator 107 |
| Staff flu vaccination coverage | 68.21% |
42%
26.2 pts better
|
Numerator 103 · Denominator 151 |
| Discharge function score | 65% |
56.45%
8.5 pts better
|
Numerator 13 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 0.8 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.9
1.1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
95.4%
3.2 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 96.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.9%
3.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.0% |
5.1%
1.9 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.1% · Q3 8.3% · Q4 7.4% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.6%
3.6 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.5%
1 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.4% · Q3 0.0% · Q4 8.3% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
17.8%
7.4 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.9% · Q3 9.5% · Q4 10.2% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.6% |
25.1%
3.5 pts better
|
16.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 24.3% · Q3 20.0% · Q4 21.4% · 4Q avg 21.6% · 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 | 15.3% |
21.3%
6 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 22.9% · Q3 15.5% · Q4 16.7% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
21.6%
3.3 pts better
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 21.7% · Q3 22.0% · Q4 16.7% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.9% |
2.0%
2.9 pts worse
|
1.0%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.4% · Q3 6.5% · Q4 3.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
3.3%
2.4 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
25.8%
2 pts better
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 16.1% · Q3 25.7% · Q4 33.0% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.6%
1 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.0% · Q3 4.7% · Q4 7.9% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
83.2%
14.4 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 95.5% · Q3 100.0% · 4Q avg 97.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
78.2%
17.3 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-23 · Fire 2023-08-23
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-05-26 · Fire 2022-05-26
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2024-12-19
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Not marked corrected
C · Minimal harm
2023-08-23
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Not marked corrected
C · Minimal harm
2022-05-26
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Not marked corrected
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-19
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-19
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 2025-01-31
D · Potential for more than minimal harm
2024-12-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-31
D · Potential for more than minimal harm
2023-08-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-25
E · Potential for more than minimal harm
2022-05-26
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-06-29
E · Potential for more than minimal harm
2022-05-26
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 2022-06-29
Penalties and ownership
What sits behind the stars
Ownership
Arbeiter, Lawrence
Corporate Director · Individual
Berens, Ravila
Corporate Director · Individual
Berens, Ravila
Corporate Officer · Individual
Johnson, Paul
Corporate Director · Individual
Johnson, Paul
Corporate Officer · Individual
Jones, James
Corporate Director · Individual
Luke, Richard
Corporate Director · Individual
Luke, Richard
Corporate Officer · Individual
Tieszen Memorial Home Inc
Operational/Managerial Control · Organization
Tieszen, Eric
Corporate Director · Individual
Wilson, Laura
W-2 Managing Employee · Individual
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#3
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