Westminster Woods at Huntingdo

In the surveyor’s words

From the most serious findings on record at Westminster Woods at Huntingdo, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 28, 2022

  Based on review of investigation reports and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe and accident hazard-free environment related to not removing medications from a resident's possession for one of two residents reviewed (Resident 1), which allowed Residents 1 and 2 to attempt suicide resulting in actual harm, unresponsiveness, and transfer to the hospital for both residents and eventual death for one resident (Resident R2). […]

• No harm, potential for more than minimal, patternF610May 7, 2026

  Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete a thorough investigation for a choking incident that occurred for one of 17 residents reviewed (Resident 17). Findings include:A facility policy for abuse and neglect dated January 9, 2026 , revealed that events involving evidence or reports of physical, sexual, mental or verbal abuse involuntary seclusion, neglect and misappropriation or resident's property shall be thoroughly investigated including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 hours or within the timeframe that has been identified. […]

• No harm, potential for more than minimal, patternF684May 7, 2026

  Based on review of investigative reports, and residents' clinical records, observations, as well as staff interviews, it was determined that the facility failed to ensure physician's orders were followed for four of 30 residents Reviewed (Residents 1, 22, 33, and 55). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 19, 2026, indicated that the resident was severely cognitively impaired and required supervision or touching assistance for eating, had a unexpected weight loss, and had diagnoses that included malnutrition. […]

• No harm, potential for more than minimal, patternF812Apr 3, 2025

  Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to store frozen foods appropriately, failing to keep kitchen equipment clean and sanitary, and failing to have staff wear appropriate hair restraints during food preparation and tray line service. Findings include: The facility's policy regarding food labeling and dating, dated January 22, 2024, revealed staff were to properly seal the container of bulk freezer items like frozen vegetables to maintain their integrity. Observations in the kitchen's walk in freezer on March 31, 2025, at 9:20 a.m. […]

• No harm, potential for more than minimal, patternF756May 16, 2024

  Based on review clinical records, as well as staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for two of 31 residents reviewed (Residents 3, 14). Findings include: The facility policy regarding Consultant Pharmacist report, dated March 26, 2024, indicated that the comments and recommendations concerning medication therapy were to be communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. Recommendations were to be acted upon and documented by the facility staff and/or prescriber. […]