Western Horizons Care Center: Bath Safety Violation - ND
The incident prompted a complaint inspection that found the facility had failed to keep a resident free from preventable harm during a routine bath. Inspectors tagged the violation under F689, the federal standard covering accident hazards and supervision, and classified the harm level as minimal or potential, affecting few residents.
The CNA's failure was straightforward: an electronic device, the inspection report specifically references a hair dryer in the corrective measures, was present near the bathtub or shower while a resident was bathing. Water and electrical devices in proximity is among the most basic safety hazards in any care setting, and the violation here was not a matter of complex clinical judgment. It was a failure to follow a fundamental safety practice during a bath.
What the facility did not have, until after the incident, was a written policy that explicitly said so.
Western Horizons revised its Bath/Shower Tub policy after the fact to add language stating that electronic devices are not to be near a bathtub or shower while a resident is bathing, in or near standing water. That language had not been in the policy before. A CNA was working without a written rule that spelled out what common sense and basic electrical safety already required.
Inspectors determined the deficient practice occurred on June 7, 2024. The facility said it completed corrective actions by June 11, four days later.
Those corrections included an investigation into the incident, re-education of bath aides on tub and shower safety beginning June 10, the policy revision, continued CNA education on the updated policy, and the addition of an audit tool to monitor hair dryer use going forward.
The four-day turnaround from identified violation to stated correction is notable, though inspectors classified the finding as past non-compliance, meaning the facility had already acted before the survey was completed. That classification does not erase what happened. It means a resident was in a bathtub or shower while a staff member had an electronic device nearby, and the facility's written procedures had not prevented it.
The audit tool added after the fact, specifically designed to track hair dryer use as a quality assurance measure, signals that the facility itself recognized this was not a one-time lapse easily dismissed. You do not build a monitoring system around a problem you believe has been fully solved. You build one around a problem you expect to watch.
Western Horizons Care Center serves residents in Hettinger, a small city in the southwestern corner of North Dakota. Nursing homes in rural communities often operate with lean staffing, and CNAs frequently work through bathing routines with limited oversight. The inspection report does not describe the resident's condition, whether they were ambulatory, cognitively impaired, or physically dependent during the bath. It does not say whether the hair dryer was plugged in or simply present. What it says is that a CNA failed to follow safety practice, and that a resident was affected.
That resident, whoever they are, was in water when it happened.
The facility's response, training, policy revision, and monitoring, follows a pattern common to nursing home corrective plans: identify the gap, document the fix, demonstrate ongoing attention. Whether that pattern produces lasting change or simply satisfies the paperwork requirement of a federal inspection is a question the audit tool is now supposed to answer.
For now, bath aides at Western Horizons have been retrained. The policy has been updated. A checklist exists where one did not before.
And somewhere in that facility, a resident took a bath on June 7th with an electronic device nearby, and nobody in the building had a written rule that said that was wrong.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Western Horizons Care Center from 2024-06-19 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: August 9, 2026 · Our methodology
Western Horizons Care Center in HETTINGER, ND was cited for violations during a health inspection on June 19, 2024.
The incident prompted a complaint inspection that found the facility had failed to keep a resident free from preventable harm during a routine bath.
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.