Western Horizons: Failed Transfer Notices - ND
The facility's own administrators admitted during a federal inspection that they never completed required transfer notices for Resident #10, who was hospitalized in April with hyponatremia and hypoxia. They also failed to provide mandatory bed-hold information or notify the State Long Term Care Ombudsman.
The oversight left the resident and their family without critical information about their rights during the hospitalization.
Resident #10's emergency began on April 28 when a clinic called the nursing home at 3:00 p.m. to report the patient had been admitted for hyponatremia, a potentially life-threatening condition where blood sodium levels drop too low. The resident also suffered from hypoxia, meaning their body wasn't getting enough oxygen.
A nurse documented the call in the medical record at 3:09 p.m. that same day. But that's where the facility's compliance with federal notification requirements ended.
Federal inspectors found no written notice of transfer anywhere in the resident's file. No written bed-hold policy notice. No notification sent to the State Long Term Care Ombudsman, who serves as an advocate for nursing home residents.
The facility's own policy, updated just weeks before the incident on May 15, clearly outlined these requirements. The document stated the nursing home "will provide written information to the resident or resident's representative regarding the bed hold policy prior to a transfer."
The policy also required that residents "will be notified in writing the reasons for the move in a language and manner they understand." Additionally, "the facility will send a copy of the notice to a representative of the Office of the State Long term Care Ombudsman."
None of this happened.
During interviews on September 3, two administrative staff members confirmed what inspectors had already discovered through their record review. Staff #1 and Staff #7 both acknowledged the facility had failed to complete any of the required documentation.
The violations matter because they strip residents and families of essential information during medical crises. Transfer notices explain why a resident is being moved and what their rights are during the process. Bed-hold notices detail whether the nursing home will save the resident's room and for how long, preventing families from making uninformed decisions about care.
The ombudsman notification serves as a crucial safeguard. These state-appointed advocates monitor nursing home transfers to ensure residents aren't being dumped inappropriately or denied proper care. When facilities fail to notify the ombudsman, this oversight disappears.
Hyponatremia, the condition that sent Resident #10 to the hospital, can cause confusion, seizures, and even death if sodium levels drop severely. Hypoxia compounds these dangers, as insufficient oxygen can damage organs and brain tissue.
The timing of Western Horizons' policy update makes the violation particularly striking. The facility had refreshed its bed-hold procedures just two weeks before Resident #10's emergency transfer. Yet when the crisis occurred, staff ignored their own recently reviewed protocols.
Federal regulations require these notices specifically to protect vulnerable residents during one of their most precarious moments. When someone needs emergency hospitalization from a nursing home, families often feel overwhelmed and uncertain about next steps.
Written documentation ensures they understand their options and rights, rather than having to navigate complex decisions without guidance during a medical emergency.
The inspection occurred in response to a complaint, suggesting someone outside the facility noticed the missing notifications and reported the problem to state authorities. Federal inspectors classified the violation as causing minimal harm with potential for actual harm, affecting few residents.
But for Resident #10 and their family, the impact was immediate and personal. They were left to manage a serious hospitalization without the information federal law guarantees them, while the ombudsman who should have been monitoring the situation remained unaware it had even occurred.
The facility now must submit a plan of correction to address these notification failures, but that won't restore the information and advocacy that Resident #10's family needed during their April crisis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Western Horizons Care Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Western Horizons Care Center in HETTINGER, ND was cited for violations during a health inspection on September 4, 2025.
They also failed to provide mandatory bed-hold information or notify the State Long Term Care Ombudsman.
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.