Western Horizons Care Center

Inspectors wroteBased on record review, review of the facility reported incident (FRI), and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #1) injured during a transfer. Failure to utilize the appropriate equipment and staff assistance resulted in an injury to Resident #1 and placed all residents at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented. Findings Include:The surveyor determined a deficient practice existed on 11/23/25. The facility implemented and completed corrective actions by 03/24/26. Review of the facility policy titled Safe Resident Handling/Transfers With Use of Mechanical lifts occurred on 04/28/26. This policy, dated 05/23/25, stated, . [...]

Inspectors wroteBased on record review, facility policy review, and review of the facility reported incident (FRI) investigation, the facility failed to ensure residents remained free from abuse for 1 of 1 closed record (Resident #40) who experienced sexual abuse from another resident. Failure to protect residents from sexual abuse resulted in fear, anxiety, and mental anguish. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.

Inspectors wroteBased on record review, review of facility procedure, review of manufacturer's use instructions, and staff interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #8) who fell from a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and staff interview, the facility failed to promote privacy and confidentiality of the electronic medication administration record (EMAR) on 1 of 2 units (West Wing) observed. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, and staff interviews, the facility failed to obtain a physician's order for 1 of 1 supplemental resident (Resident #17) observed receiving crushed medications. Failure to notify the provider regarding the resident's ability to swallow whole medications and obtain an order for crushed medications may result in an inconsistency in care and choking. Review of a nurse's report sheet occurred on 09/04/25. This form, dated 08/15/25, showed Resident #17 takes her medications Whole. Observation of medication administration occurred on 09/02/25 at 12:42 p.m. and showed a nurse (#11) crush Resident #17's medication, placed them in pudding, and administered them to the resident. The medication administration record (MAR) lacked documentation indicating staff were to crush the resident's medications. During an interview on 09/02/25 at 12:43 p.m. [...]

Inspectors wroteBased on observation, record review, review of a dietary document, and staff interview, the facility failed to provide food in a form to meet individual needs for 2 of 2 sampled residents (Resident #15 and #20) with a physician's order for a minced and moist diet. Failure to provide minced and moist food as ordered may result in reduced meal intake, choking, and aspiration pneumonia.

Inspectors wroteBased on observation and policy review, the facility failed to follow standards of infection control and prevention for 1 of 6 sampled residents (Resident #19) and 1 of 1 supplemental resident (Resident #17) observed during cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of the facility reported incident (FRI) report, review of facility investigation documents and camera footage, and staff interview, the facility failed to ensure resident safety for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to ensure door alarms are engaged and in working order allowed Resident #1 to elope from the facility and sustain injuries.

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from resident to resident abuse for 1 of 1 sampled residents (Resident #3) who experienced unwanted sexual contact with another resident. Failure to identify sexual abuse placed residents at risk for mental and emotional distress.

Inspectors wroteBased on record review, review of facility policy, and staff interview the facility failed to report an incident of resident-to-resident abuse to the State Survey Agency (SSA) for 1 of 1 sampled residents (Resident #3) who experienced abuse. Failure to report resident-to-resident abuse allegations and the results of the facility's investigation to the SSA placed all residents at risk for possible abuse.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to prepare and/or store food in a sanitary manner in 1 of 1 kitchen and 2 of 2 kitchenettes. Failure to ensure proper concentration of the sanitizer solution and failure to apply an identifying label and/or open date to food items has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 2 of 2 multi-compartment sinks observed in the main kitchen. Failure to provide the required air gap for a multi- compartment sink has the potential to allow contamination of the sink in the event of a sewer back-up.

Inspectors wroteBased on observation, review of facility policy, and resident and staff interviews, the facility failed to maintain an effective pest control barrier for 1 of 1 kitchen and 1 of 2 dining rooms (West). Failure to maintain the integrity of the doors has the potential to allow the entrance of mice and other pests.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to assess for self-administration of medications for 1 of 1 supplemental resident (Resident #19) observed with medications at bedside. Failure to evaluate the resident's ability to safely self-administer medications may result in medication errors and/or harm to the resident.

Inspectors wroteBased on record review and review of Medicare Part A letters/notices, the facility failed to ensure the resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 1 of 3 residents (Resident #40) reviewed for termination of Medicare Part A services. Failure to ensure the completion of the SNFABN limited the resident/representative's ability to exercise their rights regarding Medicare Part A services.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 13 sampled residents (Resident #11 and #32). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate Pre-admission Screening and Resident Review (PASARR) for 1 of 2 sampled residents (Resident #31) reviewed with PASARR services. Failure to accurately complete the PASARR screening created the potential for not identifying/providing needed mental health services.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans for 3 of 13 sampled residents (Resident #3, #9 and #36). Failure to review and revise the care plan limited staff's ability to communicate needs, ensure the continuity of care, and may negatively impact the care provided to residents.

Inspectors wroteBased on observation, review of facility policy, resident and staff interviews, the facility failed to ensure an environment free of accident hazards for 1 of 1 supplemental resident (Resident #19) observed with a torn and raised strip of flooring. Failure to ensure flooring is in good repair may result in falls and/or injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to identify a history of trauma, and/or trauma triggers for 2 of 2 sampled residents (Resident #4 and #31) reviewed for Post-Traumatic Stress Disorder (PTSD) and/or Trauma. Failure to identify a resident's history of trauma and/or trauma triggers may cause re-traumatization.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interview, the facility failed to assist in obtaining dental care to meet the needs of 1 of 2 sampled residents (Resident #9) with ill fitting dentures. Failure to assist the resident in making an appointment, may result in chewing difficulties and/or eating difficulties, and unplanned weight loss.

Inspectors wroteBased on record review, review of facility policy, review of resident council meeting minutes, and staff interview, the facility failed to ensure resident allergens/preferences were communicated to dietary staff for 2 of 13 sampled residents (Resident #6 and #31). Failure to ensure resident allergens/preferences were communicated to staff may result in residents experiencing an intolerance to a specific food, a moderate-to-severe allergic reaction, and/or inadequate nutrition.

Inspectors wroteBased on review of the facility reported incident (FRI) report, the facility's investigation report, review of facility policy, and resident and staff interview, the facility failed to ensure an environment free of accident hazards for 1 of 1 resident (Resident #1) while bathing. Failure to ensure staff utilized electronic devices safely and not while a resident is in or near water placed the resident at risk for serious injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately after learning of the incident.

Inspectors wroteBased on observation, record review, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 3 of 4 sampled residents (Resident #19, #23, and #29) observed during a transfer. Failure to provide adequate assistance and/or use the assistive devices appropriately during transfers placed the residents at risk for accidents, falls, and/or injuries. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 08/15/23 at 7:55 a.m. The IJ resulted from staff failure to provide sufficient supervision and use the assistive device (mechanical lift) in a manner to avoid a fall and/or potential injury. [...]

Inspectors wroteBased on review of staff's certification, review of facility policy, and staff interview, the facility failed to designate an individual who has completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. Failure to employ an Infection Control Preventionist (ICP) may affect all residents, staff, and visitors, placing them at risk for acquiring infectious diseases.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to review and revised comprehensive care plan to reflect the current status for 6 of 12 sampled residents (Resident #4, #13, #14, #29, #34, and #39) and one supplemental resident (Resident #35). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 6 of 12 sampled residents (Resident #4, #10, #13, #23, and #39) and 1 supplemental resident (#35) observed during personal cares or transfers. Failure to practice infection control standards related to hand hygiene, glove use, and multiple resident use equipment (mechanical lifts) has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, resident representative interview, and staff interview, the facility failed to notify the resident's representative for 1 of 1 resident (Resident #29) treated for an infection. Failure to promptly notify the resident representative of the infection limited their ability to make informed decisions regarding medical care.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 3 of 3 residents (Resident #14, #15 and #29) reviewed for hospital transfers. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights or inform the Ombudsman of the transfer.

Inspectors wroteBased on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 12 sampled residents (Resident #34). Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status, and identity and implement appropriate care approaches.

Inspectors wroteBased on record review, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 supplemental resident (Resident #35) with orders for a protime (blood clotting test). Failure to follow physician's orders for monitoring a protime may result in bleeding or excessive bruising for the resident.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure 1 of 1 staff member completed the appropriate training to assist residents with meals. Failure to assure staff have completed a State-approved feeding assistant training program has the potential to cause harm to the residents.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 3 of 3 residents (Resident #14, #15 and #29) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice does not allow the resident and/or their representative to make an informed decision regarding their rights.