U-city Forest Manor
U-CITY FOREST MANOR in SAINT LOUIS, MO — inspection on March 27, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation on 3/25/26 at 8:53 A.M. and 10:07 A.M., showed the resident lay in bed.
The resident was unable to communicate, and all four extremities were contracted.
The resident's call light was positioned at the foot of the resident's bed, out of the resident's reach.
Observation on 3/26/26 at 6:30 A.M., 8:55 A.M. and 10:58 A.M., showed the resident lay in bed.
The resident was unable to communicate, and all four extremities were contracted.
The resident's call light was on the floor under the resident's bed, out of the resident's reach.
During an interview on 3/27/26 at 10:28 A.M., LPN C said the resident's call light should be positioned within the resident's reach even though he/she could not use the call light.
During an interview on 3/27/26 at 8:39 A.M., Certified Nursing Assistant (CNA) B said the call light should be within the resident reach no matter what the residents cognition status was. If the resident could not use the light, then frequent rounding was to be completed. 3.
During an interview on 3/27/26 at 12:46 P.M., the Administrator and Director of Nursing (DON) said they would have expected call lights to be in reach of all residents at all times while they were in their rooms no matter what their cognition status was.
After providing care, staff should ensure residents had their call light before exiting the room.
They would have expected a resident who had frequent falls to have their call light within reach.
265736 03/27/2026
U-City Forest Manor 1301 Partridge Avenue Saint Louis, MO 63130
believed the incident affected the resident.
Laundry Assistant S never saw Restorative Aide/CNA E
Administrator said the facility concluded their investigation, and the decision was to terminate
265736 03/27/2026
U-City Forest Manor 1301 Partridge Avenue Saint Louis, MO 63130
During an interview on 3/27/26 at 12:20 P.M., the DON said he expected nursing staff to
Staff are prompted on the schedule on the EMR.
The shift nurses are expected to enter the treatment orders, or the nurse can provide the DON the order to enter in on their behalf.
The DON expected nurses to enter a progress note related to treatments being declined by residents.
Staff should also notify the Medical Doctor of any new recommendation from the hospital related to wound treatments.
All care plans should be updated by the MDS coordinator within 24-48 hours to reflect new changes for the resident. If the resident declines a treatment, staff should try a second approach or allow some time to lapse before documenting a refusal. 274163127417612742276
265736 03/27/2026
U-City Forest Manor 1301 Partridge Avenue Saint Louis, MO 63130
During an interview on 3/27/26 at 7:28 A.M, Licensed Practical Nurse (LPN) C said the resident has had frequent falls.
The resident should have fall interventions put in place.
His/Her care plan should include interventions that have been put in place.
The Director of Nurses (DON) is responsible for updating the care plan.
During an interview on 3/27/26 at 12:50 A.M., the Administrator and DON said they have tried many different interventions but nothing has worked to prevent the resident's falls.
They have tried frequent rounding, ensuring the call light is in reach of the resident, and having the resident sit where he/she can be observed.
Interventions should be documented on a resident's care plan.
Interventions should be in place for the resident due to his/her frequent falls. 2.
Review of Resident #15's admission MDS, dated [DATE], showed:-Diagnoses included Huntington's disease (neurodegenerative disorder) and weakness;-Moderately impaired cognition.
Review of the resident's electronic medical record, reviewed 3/24/26 at 12:00 P.M., showed no smoking assessment.
Observations on 3/25/26 at 1:25 P.M. and 3/26/26 at 8:12 A.M., showed the resident outside smoking.
During an interview on 3/27/26 at 7:28 A.M., LPN C said staff should have completed as smoking assessment on the resident upon his/her admission.
Completion of a smoking assessment is important to ensure the resident's safety while smoking.
During an interview on 3/27/26 at 12:30 P.M., the Administrator and DON said they expected for staff to have completed a smoking assessment on the resident upon admission. 2741631