Carrie Elligson Gietner: Delayed Urology Referral - MO
That is the core of what federal inspectors found during a September 2025 complaint investigation at Carrie Elligson Gietner Health Care Center, a nursing facility at 5000 South Broadway in south St. Louis.
The urologist had made a specific recommendation: the resident needed to be seen right away. The call came in. The recommendation was documented. And then nothing happened, at least not for a while.
Nurse C, a staff member who works alongside the urologist, explained to inspectors on September 22 what should have been obvious to anyone at the facility. When the urologist calls and says see this person immediately, the facility schedules the appointment as soon as possible. "Without an appointment," Nurse C said, "the resident will not be seen."
The resident was eventually seen on September 12, 2025. The inspection report does not say when the urologist made the original call, so the full length of the delay is not documented in what inspectors released. What is clear is that between the urologist's recommendation and the actual appointment, no one at the facility made the call to schedule it.
The facility's own Director of Nursing described exactly what was supposed to happen. The Charge Nurse was responsible for making the appointment and charting the date and time in the resident's medical record. After that, the Charge Nurse was supposed to notify Social Services to arrange transportation. The DON said, during an interview on September 8, that he or she expected the facility's policy to be followed. The facility's Administrator was in the room at the time and agreed.
That interview happened on September 8. The inspection was completed on September 22. The report does not indicate whether anyone was disciplined or whether the Charge Nurse on duty at the time of the missed referral was ever identified.
The deficiency was cited under F0658, which covers professional standards of care. Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. Those classifications sit near the lower end of the federal severity scale, but they do not mean the failure was minor in the life of the person waiting.
Urology referrals marked urgent by the treating specialist are not routine scheduling matters. They typically involve conditions where delay can worsen outcomes, whether that means an infection, a blockage, or something else the report does not specify. The inspection report does not describe the resident's underlying condition or what the urologist was concerned about. It records only that the specialist said immediately, and the facility did not act on that word.
What the report captures, in the flat language of regulatory findings, is a gap between what a doctor ordered and what a nursing home did. The urologist made a call. The facility received it. The appointment was not made. A resident waited.
The Director of Nursing and the Administrator both confirmed, when inspectors asked, that the process was clear and that staff were expected to follow it. Neither offered an explanation, at least not one that appears in the released portion of the report, for why it did not happen this time.
The resident was seen on September 12. The inspection report does not say what was found at that appointment, or whether the delay changed anything about what came next.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carrie Elligson Gietner Health Care Center from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 14, 2026 · Our methodology
CARRIE ELLIGSON GIETNER HEALTH CARE CENTER in SAINT LOUIS, MO was cited for violations during a health inspection on September 22, 2025.
The urologist had made a specific recommendation: the resident needed to be seen right away.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.