Carrie Elligson Gietner Health Care Center

In the surveyor’s words

From the most serious findings on record at Carrie Elligson Gietner Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 20, 2026

  Based on interview and record review, the facility failed to initiate a Code Purple (protocol for resident who eloped from an off-site location) in accordance with facility policy for one resident (Resident #1) who signed him/herself out for an appointment on 07/14/26 and did not return to the facility. The resident signed him/herself out of the facility on 07/14/26 at 12:58 P.M. with an expected return time of 4:30 P.M., but the resident did not return. Staff were aware the resident did not return as expected and did not communicate this to the subsequent shifts on 07/14/26 and 07/15/26, who failed to initiate the Code Purple. […]

• Immediate jeopardy, isolatedF689Aug 1, 2025

  Based on interview and record review, the facility failed to provide protective oversight for one resident, (Resident #1), when the facility failed to follow their weather advisory procedures regarding going outdoors in extreme heat. The failure put this resident, who was prescribed two medications that could affect the body's ability to regulate temperature, at an increased safety risk due to the extreme heat. The resident was outside of the facility, without supervision, from 9:00 A.M. until approximately 4:00 P.M., during a heat advisory. The resident reported to facility administration that after purchasing cigarettes, he/she became overheated and lost consciousness in someone's backyard for an unknown length of time. The resident was admitted to the hospital on [DATE] at 4:28 P.M. […]

• Actual harm, isolatedF692May 21, 2026

  Based on observation, interview and record review, the facility failed to identify and address nutritional needs and swallowing difficulties for one resident who was at risk for impaired nutrition and hydration. The resident experienced a significant weight loss of 20.52 % in three months (Resident # 2). The sample size was 20. The census was 97.Review of the facility's Nutritional Management policy, last revised on 5/18/24, showed:-Purpose: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition;-Definitions: Acceptable parameter of nutritional status is inadequate, relative to his/her overall condition and prognosis, such as weight, food and fluid intake, and… […]

• Actual harm, isolatedF740May 21, 2026

  Based on interview and record review, the facility failed to identify, assess, monitor, and address behavioral health needs related to substance use disorder for residents with known history of substance abuse, including a thorough review of the referral information identifying recent substance use and positive toxicology results. The facility also failed to implement appropriate behavioral health interventions, monitoring, and services during a period in which social services staff were unavailable, resulting in missed opportunities to identify relapse risk, escalating warning signs, and ongoing substance use within the facility (Residents #104, #105, and #101). The resident sample was 20. The census was 97. The administrator was notified on [DATE], of the past non-compliance. […]

• Actual harm, isolatedF684Oct 21, 2024

  Based on interview and record review, the facility failed to ensure a resident (Resident #10) kept all appointments with the orthopedic surgeon after an unwitnessed fall resulting in a fracture of his/her right arm on 9/13/24. Delay of treatment has caused pain and a decrease in his/her ability to perform activities of daily living (ADLs). The sample was three. The census was 77. Review of the facility's Resident Appointment policy, updated on 8/24, showed: -Purpose: To ensure all appointments and follow-up appointments (as needed) are scheduled. Residents will be taken to all scheduled appointments (barring emergency circumstances that require rescheduling). […]