U-City Forest Manor

In the surveyor’s words

From the most serious findings on record at U-City Forest Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 10, 2024

  Based on interview and record review, the facility failed to provide adequate supervision, by not ensuring staff were within arm's reach of a resident with a diagnosis of dysphasia (trouble swallowing) and a history of choking (Resident #1). On [DATE], the resident choked during lunch while eating alone at a table in the dining room. Staff intervened and were unsuccessful with clearing the resident's airway and performed lifesaving measures until emergency medical staff (EMS) arrived. EMS staff were eventually able to dislodge a large piece of broccoli, a food that was not served on the resident's lunch tray. Resident #1 expired. The sample size was 5. The census was 81. The Administrator was notified on [DATE] at 4:00 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. […]

• Actual harm, isolatedF686Nov 22, 2021

  Based on observation, interview and record review, the facility failed to have systems in place to identify pressure ulcers and notify appropriate nursing staff of the pressure ulcers in a timely manner, failed to address, assess and monitor pressure ulcers, failed to document and initiate physician ordered treatments for pressure ulcers in a timely manner, and failed to complete treatments as ordered, for two of three residents assessed as high risk for pressure ulcers (Residents #10 and #11). The facility census was 81. Review of the facility Pressure Ulcer/Skin Breakdown - Clinical Protocol policy, dated 2001 and revised on 4/2008, showed: Assessment and Recognition: 1. […]

• No harm, potential for more than minimal, widespreadF812Mar 27, 2026

  Based on observation and interview, the facility failed to ensure facility staff used proper hand hygiene during meal service affecting seven Residents (Residents #54, #2, #47, #25, #29, #26, and #30) and failed to ensure hair restraints were worn properly while handling food in the kitchen. The sample size was 20. The census was 81. Review of the facility's handwashing policy, dated 1/2012, showed:-Policy: Handwashing facilities will be readily accessible and equipped with paper towels and soap. Staff will wash hands frequently as needed throughout the day following proper handwashing procedure;-Procedure: When to wash hands; after touching ears, nose, mouth, hair, etc. Any contact with infected or otherwise unsanitary areas of the body. […]

• No harm, potential for more than minimal, widespreadF727Aug 30, 2024

  Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents. The census was 75. Review of the facility's daily assignment sheets, showed there was no RN in the facility on 8/16, 8/17, 8/18, 8/20, 8/23, 8/27, 8/28 and 8/30/24, for a total of 8 out of 15 days. During an interview on 8/30/24 at 12:46 P.M., the Assistant Director of Nursing (ADON) said the facility only had one RN on staff who worked full time. The ADON is aware the facility is required to have an RN in the facility for eight consecutive hours per day, seven days a week. […]

• No harm, potential for more than minimal, widespreadF578Oct 21, 2022

  Based on interview and record review, the facility failed to perform an annual review of code status, full code (if the heart stops beating or breathing ceases, all life-saving methods are performed) or no code (do not resuscitate [DNR], no life prolonging methods are performed), for 9 of 24 sampled residents (Residents #47, #53, #56, #6, #75, #18, #1, #52 and #63). The facility also failed to ensure code status elections were available and accessible to staff in the electronic medical record. The census was 77. Review of the Communication of Code Status policy, dated ,d+[DATE], showed: -Policy: It is the policy of the facility to adhere to residents' rights to formulate advance directives. […]