Western Horizons Care Center
Western Horizons Care Center in HETTINGER, ND — inspection on September 4, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Federal health inspectors cited WESTERN HORIZONS CARE CENTER in HETTINGER, ND for a deficiency under regulatory tag F-F0583 during a standard health inspection conducted on 2025-09-04.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Keep residents' personal and medical records private and confidential.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of WESTERN HORIZONS CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 09/03/25.
This policy, revised May 2025, stated, Each resident has the right to be free from abuse .
Residents must not be subject to abuse by anyone, including . other residents .
Sexual Abuse is non-consensual sexual contact of any type .The initial FRI, dated 04/28/25, stated, On 4/28/25 OT [occupational therapy] approached DON [director of nursing] and administrator stating [Resident #40] had reported to her that [Resident #15] had put her [sic (his)] hand down her shirt while she was sitting in the dining room, asked her if she liked it, in which [Resident #40] shook her head no.
The 5-day FRI investigation, dated 05/01/25, indicated at the end of a therapy session on 04/28/25 staff asked Resident #40 if she would like to stay in her room or go out to main area. Resident #40 replied, I am kind of scared to go out of my room.
When asked why, she explained being left alone in the dining room the night before with Resident #15. Resident #40 stated, 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.
The facility's review of the dining room video surveillance showed on 04/27/25 at 6:55 p.m. Resident #15 approached Resident #40, rubbed his hand on her chest, and walked away a few moments later.Review of Resident #40's medical record occurred on 09/03/25.
Diagnoses included anxiety and post-traumatic stress disorder. An admission Minimum Data Set (MDS), dated [DATE], identified Resident #40 as cognitively intact.
Based on the following information, non-compliance at F-F600 is considered past non-compliance.
The facility implemented correction actions for all resident who may be affected by the deficient practice as follows:* Completed an immediate investigation following the incident. * Notified both residents' families of the incident. * Notified the physician of the incident. * Moved Resident #15 to another hallway of the building, occupied by male residents only.* Implemented one-hour checks on Resident #15's location.* Required staff to ensure Resident #15's is not left alone in same room with a female resident. * Educated all staff present during 04/28//25 shift and each shift thereafter, regarding the incident and monitoring Resident #15's location. * Updated care plans for Resident #15 and Resident #40. * Conducted a staff meeting on 05/01/2025 to further educate regarding abuse, and Responding to Resident's Sexually Inappropriate Behavior.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Western Horizons Care Center
1104 Hwy 12 Hettinger, ND 58639
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and the State Long Term Care Ombudsman a written notice of transfer and bed-hold notice for 1 supplemental resident (Resident #10) reviewed for hospitalizations.
Failure to provide a notice of transfer and a bed-hold notice does not allow the resident and/or their representative to make informed decisions regarding their rights, or inform the Ombudsman of the transfer.
Findings include:
Review of the facility policy titled Bed Hold Policy occurred on 09/04/25.
This policy, dated 05/15/25, stated, . will provide written information to the resident or resident's representative regarding the bed hold policy prior to a transfer . the resident or resident's representative will be provided written information regarding the bed hold policy. will be notified in writing the reasons for the move in a language and manner they understand.
The facility will send a copy of the notice to a representative of the Office of the State Long term Care Ombudsman.Review of Resident #10's medical record occurred on 09/03/25. A nurse's note, dated 04/28/25 at 3:09 p.m., stated, .
Clinic called at 1500 [3:00 p.m.] and stated that [Resident #10] was admitted for hyponatremia and hypoxia.
The medical record lacked a written notice of transfer, a written notice of bed-hold, and notification of the transfer to the State Long Term Care Ombudsman.
During an interview on 09/03/25 at 9:15 a.m., two administrative staff members (#1 and #7) confirmed the facility failed to complete a written notice of transfer form, a written bed-hold, and notify the Ombudsman.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Western Horizons Care Center
1104 Hwy 12 Hettinger, ND 58639
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited WESTERN HORIZONS CARE CENTER in HETTINGER, ND for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-09-04.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of WESTERN HORIZONS CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
The facility failed to ensure staff widened the base/legs of the mechanical lift while transferring Resident #8.
The facility implemented corrective actions for all residents who may be affected by the deficient practice as follows:*Completed an investigation into Resident #8's fall.*Assessed and transferred Resident #8 for treatment.*Educated CNAs and nurses on proper mechanical lift use.*Sent an educational message to all CNAs and nurses via the HomeBase scheduling app regarding proper mechanical lift use on 09/04/25.*Educated all CNAs and nurses working 09/04/25 on proper mechanical lift use.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Western Horizons Care Center
1104 Hwy 12 Hettinger, ND 58639
SUMMARY STATEMENT OF DEFICIENCIES
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, and staff interview, the facility failed to store meds and biologicals appropriately in 2 of 4 medication storage and supply areas (West Wing medication cart and [NAME] Wing medication room).
Failure to secure medications in the medication cart and to dispose of expired needles has the potential for unauthorized access of medications and has the potential for inaccurate laboratory results.
Findings include:
Review of the facility policy titled Expiration of Medications and Supplies occurred on [DATE].
This policy, dated [DATE], stated, . 2.
Weekly on every Wednesday, the CMA [certified medication aide]/nurse working on the East and [NAME] Nurses' station will check . the medication room . for . supply expiration dates .
Any expired . supplies will be disposed of after removal from . medication rooms .
The facility failed to provide a policy regarding locking the medication cart.-Observation on [DATE] of the [NAME] wing medication cart showed the cart unlocked and unattended from 11:51 to 11:56 a.m. and from 12:30 to 12:34 p.m. with residents nearby. -Observation of the [NAME] wing medication storage room occurred on [DATE] at 1:44 p.m. and showed the following:* Three boxes of needles used for lab draws expired in [DATE].* Three individually wrapped needles used for lab draws expired in [DATE].During an interview on [DATE] at 4:20 p.m., two administrative staff members (#1 and #2) stated they expected staff to close and lock the medication carts when unattended and audit the medication rooms for expired supplies.
Facility ID:
Federal health inspectors cited WESTERN HORIZONS CARE CENTER in HETTINGER, ND for a deficiency under regulatory tag F-F0805 during a standard health inspection conducted on 2025-09-04.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of WESTERN HORIZONS CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
Federal health inspectors cited WESTERN HORIZONS CARE CENTER in HETTINGER, ND for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-04.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of WESTERN HORIZONS CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.