Western Horizons Care Center: Sexual Abuse Violation - ND
That was the morning of April 28, 2025, at Western Horizons Care Center, a nursing home on Highway 12 in Hettinger, a small city in the southwestern corner of North Dakota. Federal inspectors, arriving in September as part of a complaint investigation, found that the facility had failed to protect the woman, identified in records only as Resident #40, from sexual abuse by a fellow resident.
The woman had anxiety and post-traumatic stress disorder. She was cognitively intact. She understood exactly what had happened to her.
The incident itself had occurred the evening before, on April 27, 2025, at 6:55 p.m. Dining room surveillance video captured it: another resident, identified as Resident #15, approached Resident #40, rubbed his hand on her chest, and walked away. She was left alone in the room with him at the time. No staff were present to intervene.
She did not tell anyone that night.
The next morning, at the end of a therapy session, a staff member asked Resident #40 whether she would like to stay in her room or go out to the main area. That was when she said she was scared. When the therapist pressed her, she described what Resident #15 had done. She said it had really upset her. She said she never wanted it to happen again.
The occupational therapist went directly to the director of nursing and the administrator. The facility opened an investigation the same day.
According to the inspection report, investigators spoke with Resident #40 and reviewed the dining room surveillance footage, which confirmed her account. Resident #15 had approached her, made contact with her chest, and walked away. The interaction lasted only a few moments. The video does not appear to have been reviewed until after Resident #40 came forward.
The facility's response, once the abuse was reported, was swift. Within a day of the incident coming to light, staff notified the families of both residents and contacted the physician. Resident #15 was moved to a different hallway, one occupied only by male residents. Staff were directed to ensure he was never left alone in the same room with a female resident. One-hour location checks on Resident #15 were put in place. All staff working the April 28 shift and each shift that followed were educated about the incident and about monitoring Resident #15's whereabouts. A staff meeting was held on May 1 to cover abuse response and how to handle residents who display sexually inappropriate behavior. Care plans for both residents were updated.
The facility's abuse policy, revised in May 2025 in the weeks following the incident, states that each resident has the right to be free from abuse by anyone, including other residents, and defines sexual abuse as non-consensual sexual contact of any type.
Federal inspectors cited the facility for a failure to protect residents from abuse, a violation tagged under federal nursing home regulations. The citation was classified as causing actual harm. Inspectors noted that the failure resulted in fear, anxiety, and mental anguish for Resident #40. Because the facility had moved quickly to implement corrective actions after the incident was discovered, inspectors designated the finding as past non-compliance, meaning the deficient practice had been corrected before the September inspection.
That designation matters in terms of regulatory consequence, but it does not change what Resident #40 experienced. She had anxiety and PTSD before she ever came to Western Horizons Care Center. Those diagnoses were part of her medical record on admission. She was placed in a dining room, left without supervision, and sexually assaulted by another resident. Then she spent a night carrying that alone, in a facility where she now felt afraid to leave her own room.
The inspection report does not say how long she had been a resident at Western Horizons before April 27. It does not describe her living situation in the days and weeks that followed, beyond noting that her care plan was updated. It does not say whether she ever returned to the dining room.
What the report does say is that when a therapist asked her the next morning if she wanted to go out to the main area, her answer was that she was scared. That fear, inspectors found, was a direct result of the facility's failure to protect her.
The question of how Resident #15 came to be alone with Resident #40 in the dining room that evening is not fully addressed in the inspection report. The report does not identify whether this was a known risk, whether Resident #15 had displayed similar behavior before, or whether any prior incidents had been documented. The corrective actions taken after April 28 suggest the facility recognized, at minimum, that Resident #15 required supervision around female residents going forward.
The facility is located in Adams County, one of the least populous counties in North Dakota. Western Horizons Care Center serves a rural community where it may be the only long-term care option for many miles. The inspection report does not address staffing levels on the evening of April 27, or how many residents were in the dining room, or why Resident #40 was left there without a staff member present.
CMS inspectors completed the complaint survey on September 4, 2025. The inspection covered a single closed record, Resident #40's, and a single deficiency was cited.
The occupational therapist learned what had happened because she asked a routine question at the end of a therapy session. If she had not asked, or if Resident #40 had not answered honestly, it is unclear when, or whether, anyone at the facility would have known.
Resident #40 told her: "He touched me, and it really upset me. 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."
She was cognitively intact. She knew what she was describing. And she had been afraid to say it until someone thought to ask.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
Western Horizons Care Center in HETTINGER, ND was cited for abuse-related violations during a health inspection on September 4, 2025.
The woman had anxiety and post-traumatic stress disorder.
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.