Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Western Horizons Care Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease and Alzheimer’s disease, who was non-verbal, non-ambulatory, and unable to self-transfer, had a care plan requiring substantial assistance by two staff and use of a sit-to-stand lift for transfers after 5 p.m. Facility policy also required use of mechanical lifts as a safer alternative and mandated two staff for mechanical lift transfers. Despite these requirements, a CNA did not follow the care plan during a transfer, and the resident was later found with a head lump, facial and hand lacerations, and blood on the floor. An investigation concluded the injuries likely occurred during or shortly after this improper transfer, in which the required lift and two-person assistance were not used.
A resident with anxiety and PTSD was sexually abused by another resident in the dining room when he put his hand down her shirt and rubbed her chest without consent. She reported being scared to leave her room and said the incident upset her, while video surveillance confirmed the contact.
Improper mechanical lift use during a bed-to-chair transfer led to a resident fall. Staff kept the lift base in the narrow position while moving a resident with hemiplegia into a Broda chair, despite the lift manual and facility procedure requiring the legs to be fully widened for lifting. The resident’s foot became caught in the chair, the lift tipped sideways, and the resident fell, sustaining a bleeding toe laceration and later documented pain, swelling, and a left hip fracture.
Medication storage and supplies were not properly secured in 2 of 4 areas, including the West Wing med cart and the [NAME] Wing med room. The cart was observed unlocked and unattended with residents nearby, and expired needles used for lab draws were found in the med room. Two administrative staff members stated they expected carts to be locked when unattended and med rooms to be checked for expired supplies.
Unattended EMAR Left Visible on Medication Cart: The facility failed to keep resident records private when the EMAR on the West Wing med cart was observed open and visible to visitors and residents without a nurse present. Facility policy identified failure to sign off or lock the computer when leaving a workstation as a confidentiality violation, and two administrative staff said staff were expected to close and lock the EMAR when unattended.
A resident who was documented as taking meds whole was observed receiving crushed meds mixed in pudding without a provider order. The MAR did not show an order to crush the meds, and an LPN stated the meds had been crushed for weeks since the resident returned from the hospital after a stroke.
Inappropriate Food Texture for Residents on Minced Diets: Two residents with physician orders for minced texture diets were served foods that did not match the ordered texture. One resident with CVA and dysphagia was observed receiving peas, diced carrots, and an omelet with chopped peppers and ham pieces larger than 1/8 inch, and a dietary manager agreed the peppers were not appropriate. Another resident with dementia and dysphagia was also served peas and diced carrots, and a dietary consultant stated those foods were not appropriate for a minced and moist diet.
Hand hygiene standards were not followed during resident cares for two residents. Two CNAs provided perineal care, removed soiled gloves, and continued tasks without performing hand hygiene, including after contact with body fluids and before moving from a soiled body site to a clean body site. In one instance, they also touched items in the room before removing gloves and washing hands.
Failure to Provide Transfer and Bed-Hold Notices: A resident was admitted to the hospital for hyponatremia and hypoxia, but the facility did not provide the resident or representative with a written transfer notice or bed-hold notice and did not notify the State LTC Ombudsman. Facility staff confirmed the required notices were not completed.
A resident with dementia and impaired cognition eloped from the facility due to non-functioning door alarms, resulting in injuries and mild hypothermia. The resident exited through an emergency door without triggering the alarm, as it was not engaged. The facility's investigation revealed that two of six emergency exit door alarms were not engaged, and there was a lack of documentation for weekly alarm function tests.
A resident with a history of sexually inappropriate behavior engaged in unwanted sexual contact with another resident who had severe cognitive impairment. The incident was witnessed by a staff member who intervened but was unsure if it was reported. The facility's policy on abuse was not followed, and the incident was not documented in the affected resident's medical record.
A resident with a history of inappropriate behavior was observed touching another resident inappropriately. The incident was documented but not reported to the SSA as required by facility policy. An administrative nurse was unaware of the incident, confirming it was not reported, placing all residents at risk.
The facility failed to maintain sanitary conditions in food preparation and storage areas, with issues in sanitizer solution concentration and food labeling. Observations showed multiple undated and unlabeled food items in the kitchen and kitchenettes, contrary to facility policy. Dietary staff confirmed the expectation for proper labeling and discarding of outdated food items.
The facility failed to provide the required air gap for two multi-compartment sinks in the main kitchen, as per the 2018 North Dakota Plumbing Code. The drainpipes of a two-compartment sink and a three-compartment sink were joined and ended below the floor drain rim, risking contamination. Dietary staff used these sinks for food prep and thawing, while maintenance staff noted a plumber's recent work on the drainpipe.
The facility failed to maintain an effective pest control barrier, resulting in the presence of flies, gnats, ants, and a centipede in the kitchen and dining room. Observations included flies on clean glasses and gnats in the food prep area. Interviews with a resident and staff confirmed ongoing pest issues, including a mouse found in a sticky trap. The back door was improperly fitted, and an open window without a screen was noted.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. The resident was found with unlabeled medications in an open bedside drawer, and their medical record lacked an assessment or physician's order for self-administration. An administrative nurse confirmed the oversight.
A facility failed to ensure a resident and/or their representative completed the SNFABN for the termination of Medicare Part A services. The SNFABN did not indicate whether the resident or their representative chose to continue services, discontinue services, or request a demand bill. Additionally, the resident's medical record lacked documentation of their decision regarding the continuation of services with personal payment responsibility or discontinuation upon the end of Medicare Part A coverage.
The facility inaccurately coded the MDS for two residents, indicating incorrect medication administration during the look-back period. An administrative nurse confirmed the errors, which could impact care planning and delivery.
The facility failed to accurately complete a PASARR screening for a resident, omitting diagnoses of PTSD and bipolar disorder. The resident's medical record included these diagnoses, but they were not reflected in the Level 1 PASARR screening completed prior to admission. An administrative staff member acknowledged that provider diagnoses should be correctly reviewed and entered.
The facility failed to update care plans for three residents, impacting communication and continuity of care. A resident with breast cancer experienced significant weight loss without corresponding care plan updates. Another resident, observed without dentures, was identified as malnourished, yet lacked nutritional interventions in their care plan. A third resident's care plan did not address diabetes, diuretic use, anemia, and weight loss. Staff confirmed the care plans were not reviewed or revised timely.
A facility failed to maintain safe flooring, as a torn and raised strip of laminate was observed in front of a resident's recliner. The resident, with a history of falls, reported the flooring had been in disrepair for some time and often self-transfers despite needing assistance. An administrative staff member confirmed the need for repair.
The facility failed to identify trauma history and triggers for two residents with PTSD. One resident's record included a PTSD diagnosis and medication for related symptoms but lacked a trauma assessment and care plan. Another resident's care plan did not identify triggers or interventions despite a PTSD diagnosis. An administrative staff member confirmed the expectation for staff to assess potential triggers, which was not fulfilled.
A resident with ill-fitting dentures did not receive necessary assistance from the facility to obtain dental care, as required by policy. The resident was observed without dentures, had documented chewing difficulties, and experienced significant weight loss. Despite expressing a desire for new dentures, there was no documentation of appointment refusals, and the last dental exam was over a year ago. Interviews with staff confirmed the resident's prolonged lack of dentures.
The facility failed to communicate and document the allergens and food preferences of two residents, as required by its policies. One resident's preference to avoid certain vegetables was not recorded, and another resident's mushroom allergy was not noted on their diet card, despite being known by dietary staff.
A resident was placed at risk when a CNA used a hair dryer while the resident was in a tub full of water, violating the facility's safety policy. The incident was reported by the resident's family, leading to an investigation that confirmed the CNA's failure to follow safety practices.
Improper Transfer Without Required Lift and Staff Assistance
Penalty
Summary
The deficiency involves the facility’s failure to properly utilize required assistive devices and staff assistance during a resident transfer, contrary to its Safe Resident Handling/Transfers With Use of Mechanical Lifts policy. The policy required that mechanical lifts be used as a safer alternative when appropriate and that two staff members be utilized when transferring residents with a mechanical lift. The care plan for Resident #1, who had diagnoses including Parkinson’s disease and Alzheimer’s disease and could not self-transfer, specified that the resident required substantial assistance by two staff to move between surfaces from morning until evening, and that after 5 p.m. transfers were to be completed using a sit-to-stand lift with assistance from two staff. On the date of the incident, Resident #1’s progress notes documented that the resident, who was non-verbal and non-ambulatory, was found with a significant lump on the right forehead, a small laceration above the right eye, and a laceration on the right hand, with a small amount of blood on the floor. The resident was unable to undergo a complete neurological assessment due to their condition and was sent to the ER for further evaluation. The facility’s incident investigation concluded that the injuries likely occurred during or shortly after an improper transfer and that a CNA failed to follow the resident’s care plan requiring use of a sit-to-stand lift with two staff, resulting in the unsafe transfer and subsequent injuries.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure one resident remained free from sexual abuse by another resident. A cognitively intact resident with diagnoses including anxiety and post-traumatic stress disorder reported that another resident put his hand down her shirt while she was sitting in the dining room, asked if she liked it, and rubbed her chest. She stated that she was scared to go out of her room and did not want it to happen again, describing that the incident upset her and caused fear and anxiety. The facility’s review of dining room video surveillance showed the other resident approaching her, rubbing his hand on her chest, and walking away a few moments later. The report identified this as non-consensual sexual contact and stated that the resident experienced fear, anxiety, and mental anguish as a result of the incident.
Improper Mechanical Lift Use During Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and proper use of a mechanical lift for one resident with hemiplegia who required a mechanical lift with two staff assistance for transfers. The resident was being transferred from bed to a Broda tilt-in-space chair when staff kept the lift base/legs in the closed, narrow position while moving the resident toward the chair, even though the facility procedure and the lift manufacturer’s instructions stated the legs must be fully extended into the wide position when lifting and should be widened once clear from the bed. Staff reported the resident was tall, his legs did not bend, and he needed to be placed in the Broda chair sideways because his legs would hit the lift bar if he was placed forward. During the transfer, the resident’s foot became entangled in the Broda chair and the mechanical lift tipped sideways, causing the resident to fall to the floor. Staff then placed the resident on the floor and noted a laceration to the left great toe with bleeding. The resident was sent to the hospital, and later nursing notes documented increasing pain, swelling of the left knee migrating to the left hip, and a subsequent report of a left hip fracture.
Medication Cart Left Unlocked and Expired Lab Needles Found
Penalty
Summary
The facility failed to store medications and biologicals appropriately in 2 of 4 medication storage and supply areas, including the West Wing medication cart and the [NAME] Wing medication room. Review of the facility policy titled Expiration of Medications and Supplies showed that weekly checks were to be completed for supply expiration dates and that expired supplies were to be disposed of after removal from medication rooms, but the facility did not provide a policy regarding locking the medication cart. Observation of the [NAME] Wing medication cart showed it was unlocked and unattended from 11:51 to 11:56 a.m. and again from 12:30 to 12:34 p.m. with residents nearby. Observation of the [NAME] Wing medication storage room showed three boxes of needles used for lab draws expired in [DATE] and three individually wrapped needles used for lab draws expired in [DATE]. During interview, two administrative staff members stated they expected staff to close and lock medication carts when unattended and to audit medication rooms for expired supplies.
Unattended EMAR Left Visible on Medication Cart
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when the electronic medication administration record (EMAR) on the West Wing medication cart was left open and visible to visitors and residents without a nurse present. Facility policy titled Violation Sanctions HIPPA Policies, dated June 2020 and reviewed on 09/04/25, stated that confidentiality is the right of an individual to have personal, identifiable information kept private and identified failure to properly sign off from or lock the computer when leaving a workstation as a violation. During observation on 09/02/25, surveyors saw the EMAR open on the medication cart at 11:51 a.m. and again from 12:30 p.m. to 12:34 p.m. while unattended. In interview on 09/03/25 at 4:20 p.m., two administrative staff members stated they expected staff to close and lock the EMAR when unattended.
Missing Order for Crushed Medications
Penalty
Summary
The facility failed to obtain a physician’s order for Resident #17, who was documented on a nurse’s report sheet as taking medications whole, yet was observed receiving crushed medications mixed in pudding. During medication administration observation, a nurse crushed the resident’s medications and gave them to the resident without documentation in the MAR indicating that medications were to be crushed. The nurse stated that the resident had been receiving crushed medications for a couple of weeks since returning from the hospital after a stroke. Two administrative staff members later confirmed that the resident’s medical record did not contain an order to crush the medications.
Inappropriate Food Texture for Residents on Minced Diets
Penalty
Summary
The facility failed to provide food in a form designed to meet individual needs for 2 of 2 sampled residents with physician orders for a minced texture diet. A dietary document titled Hormel Health Labs Checklists for IDDSI Levels 7, 6, 5, and 4 described Level 5 minced and moist requirements as very small soft and moist pieces, less than 1/8 inch for adults, that fit between fork tines. The deficiency was identified through observation, record review, review of the dietary document, and staff interview. Resident #20 had diagnoses of cerebral infarction and dysphagia, and a physician order dated 02/28/25 for a regular diet with minced texture and honey consistency. During lunch on 09/02/25, the facility served cooked peas and diced carrots with the meal. On 09/04/25 at 8:17 a.m., Resident #20 was observed eating an egg omelet with small pieces of chopped peppers and ham larger than 1/8 inch; at 8:30 a.m., a dietary manager attempted to mash the peppers and noted the skins did not mash, and agreed the peppers were not appropriate for the minced and moist diet. Resident #15 had diagnoses of dementia and dysphagia, oropharyngeal phase, and a physician order dated 07/28/25 for a regular diet with minced texture and regular consistency. During lunch on 09/02/25, the facility served cooked peas and diced carrots with the meal, and a dietary consultant stated the peas and carrots would not be appropriate for a minced and moist diet.
Hand Hygiene Not Performed During Resident Cares
Penalty
Summary
Failure to follow infection control and prevention standards related to hand hygiene was identified for 1 of 6 sampled residents (Resident #19) and 1 of 1 supplemental resident (Resident #17) observed during cares. The facility policy titled Hand Hygiene, revised December 2024, stated that hand hygiene is the act of cleaning one's hands to remove potentially harmful substances and organisms and listed indications for performing hand hygiene, including before moving from work with a soiled body site to a clean body site and after contact with body fluids. During an observation on 09/02/25 at 10:18 a.m., two CNAs (#8 and #9) applied gloves and provided perineal cares for Resident #17, then removed their soiled gloves and continued providing perineal cares without performing hand hygiene before moving on to other tasks. During another observation on 09/02/25 at 11:33 a.m., the same two CNAs transferred Resident #19 from a wheelchair to a bed, provided perineal cares with gloved hands, removed the soiled gloves, applied clean gloves, replaced clothing, transferred the resident back to the wheelchair, and touched various items in the room before removing gloves and performing hand hygiene.
Failure to Provide Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide Resident #10 or the resident’s representative with a written notice of transfer and a written bed-hold notice, and also failed to notify the State Long Term Care Ombudsman of the transfer. The facility policy titled Bed Hold Policy, reviewed on 09/04/25 and dated 05/15/25, stated that the facility would provide written information to the resident or resident’s representative regarding the bed-hold policy prior to a transfer, notify the resident or resident’s representative in writing of the reasons for the move in a language and manner they understand, and send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. Resident #10’s record showed a nurse’s note on 04/28/25 at 3:09 p.m. stating that the clinic called at 3:00 p.m. and reported the resident was admitted for hyponatremia and hypoxia. The medical record lacked a written notice of transfer, a written bed-hold notice, and notification of the transfer to the State Long Term Care Ombudsman. Two administrative staff members confirmed during interview that the facility failed to complete the written transfer notice form, the written bed-hold notice, and Ombudsman notification.
Resident Elopement Due to Non-Functioning Door Alarms
Penalty
Summary
The facility failed to ensure the safety of a resident who eloped from the building, resulting in injuries. The resident, diagnosed with dementia and adjustment disorder, was identified as having severely impaired cognition and was at high risk for elopement and falls. Despite wearing a wander guard, the resident managed to exit the facility through an emergency door without triggering the alarm, as the alarm was not engaged. The resident was found outside in cold weather, inadequately dressed, and sustained multiple abrasions and mild hypothermia. The incident occurred when the resident exited his room and left the building through an emergency exit door. The door alarm failed to sound, allowing the resident to leave unnoticed. The facility's camera footage confirmed the resident's movements and the failure of the alarm system. The resident was later found by a community member and transported to the emergency room for evaluation and treatment of his injuries. Further investigation revealed that two of the six emergency exit door alarms were not engaged, and the facility lacked documentation of weekly alarm function tests. Additionally, a staff member admitted to noticing issues with the alarms but failed to replace the batteries in a timely manner. This oversight contributed to the resident's ability to elope from the facility undetected.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from unwanted sexual contact by another resident, leading to a deficiency in ensuring residents remain free from abuse. The incident involved a resident with a history of sexually inappropriate behavior towards female staff and residents. Despite being identified as having moderate cognitive impairment and being independent for ambulation, this resident was noted to have placed his hand on the upper leg and crotch of another resident, who had severe cognitive impairment. This inappropriate contact was witnessed by a staff member who intervened by removing the resident's hand and separating the two residents. The facility's policy on abuse, neglect, and exploitation, which emphasizes the right of residents to be free from abuse, was not adhered to in this instance. The administrative nurse was unaware of the incident, and the staff member who witnessed the event was unsure if it was reported. The medical record of the resident who experienced the unwanted contact lacked documentation of the incident, indicating a failure in communication and documentation processes within the facility.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the State Survey Agency (SSA) as required by their policy. The incident involved a resident with dementia, adjustment disorder, mood disturbance, and anxiety, who was identified as having moderate cognitive impairment and a history of being sexually inappropriate. This resident was observed placing his hand on the upper leg and crotch of another resident, who had severe cognitive impairment and diagnoses of depression and anxiety. The incident was documented in a progress note but was not reported to the facility administrator or the SSA. The facility's policy on abuse, neglect, and exploitation mandates that all alleged violations involving abuse must be reported to the administrator and the SSA within 24 hours. However, the administrative nurse interviewed was unaware of the incident, confirming that it had not been reported as required. This oversight placed all residents at risk for possible abuse, as the facility did not follow its own procedures for reporting and addressing such incidents.
Sanitation and Food Labeling Deficiencies in Kitchen Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation and storage areas, as observed in one kitchen and two kitchenettes. During an interview, a dietary staff member revealed that the sanitizer solution used for cleaning food preparation areas was not functioning properly, as the automatic dispenser had parts replaced recently, and the sanitizer bucket contained only hot water. This failure to ensure the proper concentration of the sanitizer solution could compromise food safety. Additionally, the facility did not adhere to its policy on food receiving and storage, which requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Observations revealed multiple instances of food items, such as cranberry juice, sandwiches, pies, noodles, cod, churros, bread dough, garlic bread, donuts, chicken cordon bleu, chicken strips, fish sticks, corn dogs, and pork patties, that were either undated, unlabeled, or stored in unsealed bags. Dietary staff members confirmed the expectation for staff to label and date food items when opened and to discard outdated food items, which was not being followed.
Deficiency in Kitchen Sink Air Gap Compliance
Penalty
Summary
The facility failed to provide the required air gap for two multi-compartment sinks in the main kitchen, as observed during the survey. According to the 2018 North Dakota Plumbing Code, an air gap is necessary to prevent contamination in the event of a sewer back-up. The survey revealed that the drainpipes of a two-compartment sink and a three-compartment sink were joined and ended approximately two inches below the rim of a cut-out in the tiled flooring containing the floor drain, which did not meet the code's requirement for an air gap. Interviews with dietary staff members revealed that the three-compartment sink was used for thawing items in water and draining vegetables, while the two-compartment sink was used for food preparation. A maintenance staff member reported that a plumber had recently worked on the drainpipe and indicated that the current setup was necessary. However, this configuration did not comply with the plumbing code, leading to the deficiency noted in the report.
Pest Control Deficiency in Kitchen and Dining Room
Penalty
Summary
The facility failed to maintain an effective pest control barrier in the kitchen and one of the dining rooms, leading to the presence of pests such as flies, gnats, ants, and a centipede. Observations revealed flies walking across clean glasses and gnats flying in the food prep area. Dead flies and gnats were found on the window ledge and floor, and a large winged bug was observed near the ice machine. Ants and a centipede were seen crawling on the dining room floor, and flies were noted on a menu plan above the food during the evening meal. Additionally, gnats were observed near plants at the facility entrance, and an open window without a screen was found in the dining room entrance, with visible gaps between the door and frame. Interviews with residents and staff highlighted the ongoing pest issues. A resident reported an ant and fly problem in the dining room, while a dietary staff member confirmed the presence of bugs, flies, gnats, and mice, noting a mouse was found in a sticky trap the previous week. The back door was reported to not fit the foundation properly, allowing dirt to come through. A maintenance staff member mentioned that delivery personnel often leave the kitchen entrance door open and planned to replace the weather strip on the door to the outside, acknowledging the presence of a mouse earlier in the year.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, as observed during a survey. The policy in place required an interdisciplinary team to determine the safety of self-administration for each resident, and this should be documented in the care plan. However, the resident was found with unlabeled medications, including two types of eye drops and a vapor rub, in an open bedside drawer. The resident's medical record did not contain an assessment or a physician's order for self-administration of these medications. An administrative nurse confirmed the lack of assessment and physician's order, acknowledging the facility's failure to evaluate the resident's capability to self-administer medications safely.
Failure to Complete SNFABN for Medicare Part A Termination
Penalty
Summary
The facility failed to ensure that a resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for the termination of Medicare Part A services. This deficiency was identified for one of the three residents reviewed, specifically for a resident who was discharged from Medicare Part A on March 20, 2024. The SNFABN did not indicate whether the resident or their representative chose to continue services, discontinue services, or request a demand bill. Additionally, a review of the resident's medical record on July 24, 2024, revealed a lack of documentation indicating the resident's or representative's decision regarding the continuation of services with the understanding of personal payment responsibility or the discontinuation of services upon the end of Medicare Part A coverage. This oversight limited the resident's or representative's ability to exercise their rights concerning Medicare Part A services.
Inaccurate MDS Coding for Medications
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which is essential for reflecting each resident's current status and needs. For one resident, the annual MDS indicated that the resident received an antidepressant and antibiotic during the seven-day look-back period, but the medical record did not support this. Similarly, for another resident, the quarterly MDS indicated the administration of an antianxiety medication, which was not documented in the medical record. Additionally, the Medicare five-day MDS for the same resident incorrectly indicated the administration of a hypnotic, which was also not supported by the medical record. During an interview, an administrative nurse confirmed that the staff had incorrectly coded Section N of the MDS for both residents. This inaccuracy in the MDS coding could potentially affect the development of a comprehensive care plan and the care provided to the residents, as the assessments did not accurately reflect the residents' medication usage during the specified period.
Inaccurate PASARR Screening for a Resident
Penalty
Summary
The facility failed to ensure an accurate Pre-Admission Screening and Resident Review (PASARR) for a resident reviewed with PASARR services. The deficiency was identified during a record review and staff interview. The resident's medical record included diagnoses of dementia, anxiety, dissociative identity disorder, major depression, PTSD, and bipolar disorder. However, the Level 1 PASARR screening completed by the facility prior to admission did not include the resident's diagnoses of PTSD and bipolar disorder. During an interview, an administrative staff member stated that provider diagnoses should be reviewed and entered correctly on the PASARR screening.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise care plans for three residents, which limited staff's ability to communicate needs and ensure continuity of care. Resident #3, diagnosed with malignant neoplasm of the right breast, experienced significant weight loss, yet their care plan lacked problems, goals, and interventions related to this issue. An administrative staff member confirmed the oversight during an interview. Resident #9, who was observed without dentures, had a care plan that did not include nutritional interventions despite being identified as malnourished. The resident expressed dissatisfaction with ill-fitting dentures, and a CNA confirmed the resident had been without dentures for a long time. Resident #36's care plan was also found lacking, as it did not address issues related to diabetes, diuretic use, anemia, and excessive weight loss. The resident's medical record included diagnoses of chronic kidney disease, hypertension, edema, diabetes, altered mental status, and anemia. An administrative staff member confirmed that the care plans had not been reviewed or revised in a timely manner, contributing to the deficiency in care planning for these residents.
Deficiency in Maintaining Safe Flooring
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by a torn and raised strip of laminate flooring in front of a resident's recliner. This condition was observed during a survey, and the resident confirmed that the flooring had been in disrepair for some time. The resident, who has a history of falls, mentioned that he should ask for assistance but often self-transfers from the recliner to the wheelchair. An administrative staff member acknowledged the need for flooring replacement.
Failure to Identify Trauma Triggers for Residents with PTSD
Penalty
Summary
The facility failed to identify a history of trauma and trauma triggers for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Resident #4's medical record included a diagnosis of PTSD and a physician's order for Venlafaxine HCI ER to manage depression and anxiety related to PTSD. A psychiatry provider note indicated symptoms such as poor concentration, irritability, and depression following a traumatic brain injury. However, the medical record lacked a trauma assessment, identification of potential triggers, and a trauma care plan. Similarly, Resident #31's medical record identified a diagnosis of PTSD in the Minimum Data Set, but the care plan did not include triggers or interventions to prevent re-traumatization. A psychiatry provider note confirmed a past medical history of PTSD, yet the record did not contain a trauma assessment or potential triggers. An administrative staff member confirmed that they expected staff to interview the resident or family and review psychiatric notes for potential triggers related to PTSD, which was not done.
Failure to Assist Resident with Dental Care
Penalty
Summary
The facility failed to assist a resident with obtaining necessary dental care for ill-fitting dentures, which was a requirement according to their policy. The policy stated that social services personnel were responsible for helping residents make dental appointments and arrange transportation as needed. Despite this, the resident was observed without dentures throughout the survey period, and the medical record indicated issues with chewing and a significant weight loss over 180 days. The resident expressed a desire for new dentures, and a CNA confirmed that the resident had been without dentures for a long time. The facility's records lacked documentation of the resident's refusal of appointments, as mentioned by an administrative staff member. The resident's last dental exam was noted to have occurred over a year prior, and a recent oral/dental assessment highlighted the need for dental care. Additionally, a mini nutritional assessment identified the resident as malnourished, further emphasizing the impact of the lack of dental care. The deficiency was identified through observations, record reviews, and interviews with the resident and staff.
Failure to Communicate Resident Allergens and Preferences
Penalty
Summary
The facility failed to ensure that resident allergens and food preferences were properly communicated to the dietary staff, affecting two of the thirteen sampled residents. The facility's policy on food allergies and intolerances, revised in 2009, mandates that residents with food allergies and intolerances be identified upon admission to prevent exposure to allergens. Additionally, the policy on resident food preferences, revised in 2007, requires nursing staff to document residents' likes, dislikes, and special dietary instructions in their clinical records. However, these policies were not effectively implemented for Resident #6 and Resident #31. Resident #6 had expressed a preference not to be served asparagus or broccoli during a Resident Council Meeting, but this preference was not documented in their medical record or diet card. Similarly, Resident #31 had a known allergy to mushrooms, which was acknowledged by a dietary staff member, yet this allergy was not recorded on their diet card. The failure to document and communicate these dietary needs could lead to residents experiencing food intolerances or allergic reactions.
Failure to Ensure Bathing Safety
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident during a bathing session. The incident involved a certified nurse aide (CNA) who used a hair dryer while the resident was still in a tub full of water. The resident expressed concern about the safety of using the hair dryer in such conditions, but the CNA proceeded to dry one side of the resident's hair while they were still in the tub and completed the task after the resident exited the tub. This action placed the resident at risk for serious injury due to the potential hazard of using an electronic device near water. The incident was reported by the resident's family member to the Director of Nursing (DON), prompting an investigation. The facility's policy, revised in June 2024, explicitly stated that electronic devices should not be near the bathtub or shower while a resident is bathing or near standing water. The CNA's actions were in direct violation of this policy, highlighting a failure to adhere to established safety practices during resident care.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Hettinger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Five Counties Nursing Home | 25.5 mi | ★★★★★ | 6 | 0 |
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