U-City Forest Manor: Nutrition Supplement Failures - MO
The inspection happened on October 8, 2025, at 1:30 in the afternoon. An inspector reviewed the dietary slip sitting on a resident's lunch tray and found something missing. The resident was supposed to receive a Majic cup and a house supplement with meals. The Majic cup was listed. The house supplement was not documented anywhere on the slip.
Eight minutes later, Licensed Practical Nurse A sat down with the inspector. She said she had no idea the resident hadn't been getting the supplements. She pulled up the resident's point-of-sale record while they talked. It confirmed what the dietary slip had missed: the resident was supposed to receive both a Majic cup and a house supplement with the meal.
That was not the full picture.
The facility's dietitian had already recommended increasing the house supplement from twice a day to three times a day, meaning the resident should have been receiving it with every meal. Nurse A said she didn't know about that recommendation either. Nobody had told her.
The resident required oversight with all meals because of diet texture requirements. The dietary slip also listed power potatoes and ice cream alongside the Majic cup. This was not a resident who could simply grab something from a vending machine if the kitchen came up short.
The process for getting a dietitian's recommendation into a nurse's hands, as the Assistant Director of Nursing described it at 2:30 that afternoon, involved the dietitian verbally telling staff about changes and also emailing the recommendation to the ADON directly. From there, the nurse was supposed to notify the physician, update the orders, and fill out a new dietary change slip to send to the kitchen.
Somewhere in that chain, the recommendation to increase the supplement to three times a day stopped moving.
The ADON did not say when she had received the dietitian's email. She did not say whether she had forwarded it to nursing staff or whether it had sat in her inbox. What she described was a system that depended on verbal communication between the dietitian and floor staff, an email to one administrator, and a nurse who was expected to translate all of that into updated orders and a new dietary slip, in the right sequence, before the next meal arrived.
Nurse A, by her own account, had not received any of it.
The Administrator, interviewed five minutes after the ADON, said she expected staff to complete dietary recommendations. She expected the resident to receive supplements as ordered.
What the inspector found on that lunch tray at 1:30 in the afternoon suggested those expectations had not been met, at least not that day, and based on the absence of any documentation, not for some time before it either.
The inspection was filed as a complaint. CMS rated the level of harm as minimal harm or potential for actual harm, affecting few residents.
The resident whose tray was reviewed that afternoon had a documented need for nutritional support significant enough that a dietitian had already intervened once to increase it. The gap between what was ordered and what arrived on the tray was not a clerical footnote. It was the difference between a care plan designed to address a specific nutritional need and a meal that arrived without the supplement meant to meet it.
Nurse A said the resident should have received the supplements. The ADON said the system was in place to make that happen. The Administrator said she expected it to happen.
On October 8, at lunchtime, it had not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for U-city Forest Manor from 2025-11-17 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 1, 2026 · Our methodology
U-CITY FOREST MANOR in SAINT LOUIS, MO was cited for violations during a health inspection on November 17, 2025.
The inspection happened on October 8, 2025, at 1:30 in the afternoon.
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.