A list of the most recent deficiencies for U-City Forest Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-30 | 2023-08-01 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-10-21 | 2022-12-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-21 | 2022-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-21 | 2022-12-12 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-21 | 2022-12-12 | N |
| Meet other general requirements. | Fire Safety | 2022-10-21 | 2022-12-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-21 | 2022-12-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-10-21 | 2022-12-02 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-10-21 | 2022-12-02 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-10-21 | 2022-12-02 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-10-21 | 2022-12-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-21 | 2022-12-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-10-21 | 2022-12-02 | N |
| Post nurse staffing information every day. | Health | 2022-10-21 | 2022-12-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-21 | 2022-12-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-10-21 | 2022-12-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-21 | 2022-12-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-21 | 2022-12-02 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-10-21 | 2022-12-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-21 | 2022-12-02 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-10-21 | 2022-12-02 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-10-21 | 2022-12-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-21 | 2022-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-12-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-21 | 2022-12-02 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-21 | 2022-12-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-21 | 2022-12-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-21 | 2022-12-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-21 | 2022-12-02 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-21 | 2022-12-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-01 | 2022-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-01 | 2022-09-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-24 | 2022-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-01 | 2022-07-12 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-05-24 | 2022-07-01 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-05-24 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-24 | 2022-07-01 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-24 | 2022-07-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-01 | 2022-07-01 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-04-01 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-01 | 2022-07-01 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-01 | 2022-07-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-01 | 2022-05-13 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-01 | 2022-05-13 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-01 | 2022-05-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-22 | 2021-12-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-24 | 2021-10-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-24 | 2021-10-22 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-08-24 | 2021-10-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-24 | 2021-09-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-08-24 | 2021-09-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-23 | 2021-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-06-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-23 | 2019-09-25 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-08-23 | 2019-09-25 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-08-23 | 2019-09-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-23 | 2019-09-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-23 | 2019-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-23 | 2019-09-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-23 | 2019-09-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-23 | 2019-09-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-23 | 2019-09-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-23 | 2019-09-25 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-08-23 | 2019-09-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-23 | 2019-09-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-23 | 2019-09-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-23 | 2019-09-25 | N |
| Post nurse staffing information every day. | Health | 2019-08-23 | 2019-09-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-08-23 | 2019-09-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-08-23 | 2019-09-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-23 | 2019-09-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-23 | 2019-09-25 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-08-23 | 2019-09-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-23 | 2019-09-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-09-20 | 2018-10-22 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2018-09-20 | 2018-10-22 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-09-20 | 2018-10-22 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-20 | 2018-10-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-09-20 | 2018-10-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-09-20 | 2018-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-20 | 2018-10-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-20 | 2018-10-22 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-09-20 | 2018-10-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-09-20 | 2018-10-22 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-09-20 | 2018-10-22 | N |
| Post nurse staffing information every day. | Health | 2018-09-20 | 2018-10-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-20 | 2018-10-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-09-20 | 2018-10-22 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-09-20 | 2018-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-20 | 2018-10-22 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-09-20 | 2018-10-22 | N |
| Use approved construction type or materials. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-20 | 2018-10-22 | N |
