Western Horizons: Sexual Abuse Between Residents - ND
The April 27 assault left Resident #40 so frightened she told therapists the next day she was "kind of scared to go out of my room."
"He touched me, and it really upset me," she told staff on April 28. "He reached his hand down my shirt, between my breast, and began rubbing up and down. I don't ever want it to happen again."
Video surveillance confirmed the attack. At 6:55 p.m. on April 27, Resident #15 approached Resident #40 in the dining room, rubbed his hand on her chest, and walked away moments later.
The occupational therapist discovered the assault when Resident #40 reported that Resident #15 "had put her hand down her shirt while she was sitting in the dining room, asked her if she liked it." Resident #40 shook her head no.
Federal inspectors cited Western Horizons for failing to protect residents from sexual abuse, finding the facility violated regulations requiring nursing homes to keep residents free from abuse by anyone, including other residents.
Resident #40 had been diagnosed with anxiety and post-traumatic stress disorder. Her medical records showed she was cognitively intact, meaning she fully understood what happened to her.
The assault occurred because staff left the two residents alone together in the dining room. When therapists asked Resident #40 the next day whether she wanted to stay in her room or go to the main area, she explained her fear of "being left alone in the dining room the night before with Resident #15."
The facility's own policy, revised in May 2025, explicitly states that residents "must not be subject to abuse by anyone, including other residents." It defines sexual abuse as "non-consensual sexual contact of any type."
Western Horizons completed its investigation within five days of the assault. The facility notified both residents' families and their physicians about the incident.
Administrators moved Resident #15 to another hallway occupied only by male residents. They implemented hourly checks on his location and required staff to ensure he was never left alone in the same room with a female resident.
The facility updated care plans for both residents and conducted staff education about abuse and responding to sexually inappropriate behavior. All staff present during the April 28 shift and subsequent shifts received training about the incident and monitoring Resident #15's location.
A staff meeting on May 1 provided additional education about abuse prevention.
Federal inspectors determined the violation caused "actual harm" and affected "few" residents. The citation was classified as past non-compliance because Western Horizons implemented corrective actions immediately after discovering the assault.
The facility completed its corrective measures on April 28, the day after the assault occurred and the same day staff discovered it through Resident #40's report to her occupational therapist.
Resident #40's experience illustrates how quickly sexual assault can occur in nursing home settings when residents are left unmonitored. Her fear of leaving her room demonstrated the lasting psychological impact of the attack.
The video evidence proved crucial in documenting exactly what happened. Without surveillance footage, the incident might have been difficult to substantiate, potentially leaving Resident #40 without protection from future assaults.
Western Horizons' response showed both the facility's failure to prevent the initial assault and its ability to act swiftly once staff learned of the attack. The decision to segregate Resident #15 with male residents only addressed the immediate risk to female residents.
The hourly location checks and prohibition on leaving him alone with women represented additional safeguards. However, these measures highlighted how the initial assault could have been prevented with proper supervision in the dining room.
Staff education about sexually inappropriate behavior became necessary after the incident, suggesting previous training may have been inadequate. The facility's need to update both residents' care plans indicated the assault required ongoing attention to prevent recurrence.
Resident #40's cognitive integrity meant she could clearly communicate what happened and understand the violation she experienced. Her ability to report the assault to her occupational therapist proved essential in bringing the incident to light.
The timing of events showed how sexual assault can occur rapidly in institutional settings. The attack happened at 6:55 p.m. on April 27, but wasn't discovered until Resident #40 spoke with therapy staff the following day.
Federal regulations require nursing homes to protect residents from all forms of abuse, including sexual contact by other residents. Western Horizons' violation demonstrated how supervision gaps can create opportunities for assault.
The facility's immediate response after learning of the incident contrasted with its initial failure to prevent the assault through adequate supervision. Moving Resident #15 to a male-only hallway eliminated his access to potential female victims.
Resident #40's statement that she never wanted the assault to happen again reflected the trauma experienced by nursing home residents who become victims of sexual abuse. Her fear of leaving her room showed how such incidents can restrict victims' freedom within their own living environment.
The case highlighted the importance of video surveillance in documenting nursing home incidents. Without the dining room footage, investigators might have had difficulty confirming the details of Resident #40's account.
Western Horizons' policy clearly prohibited the type of abuse that occurred, yet the facility failed to implement adequate supervision to prevent it. The gap between written policy and actual protection left Resident #40 vulnerable to assault.
The federal citation for actual harm reflected the psychological impact on Resident #40, whose existing anxiety and PTSD diagnoses made her particularly vulnerable to additional trauma from sexual assault.
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 abuse-related violations during a health inspection on September 4, 2025.
"He reached his hand down my shirt, between my breast, and began rubbing up and down.
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.