HETTINGER, N.D. - Residents of Western Horizons Care Center, a nursing home in Hettinger, are in "immediate jeopardy," according to a report issued in early June by the North Dakota Department of Health and made public Friday.

The 147-page report cited 37 violations of Health Department code that included neglect, unsanitary living conditions, lack of proper staffing and many other issues.

In June, the facility was forced to make an immediate plan of correction to ensure the safety of its residents. Western Horizons has until Dec. 7 to address the rest of the problems outlined in the report, or it will be at risk of losing Medicare and Medicaid funding.


The Health Department's report paints a fairly alarming picture of the conditions at Western Horizons. Violations are rated on a scale from one to four. Level one violations describe issues having a minor impact. Level four violations put residents in "immediate jeopardy."

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A majority of the violations were in the level two to three range, meaning that while the violations may have put the comfort or well-being of the residents at risk, the health and safety of the patients was still secure.

Western Horizons was charged with one level four violation. Officials found that the facility did not meet a requirement to have a full-time registered nurse working for at least eight consecutive hours each day, a violation severe enough to put residents in immediate jeopardy, according to the report.

A plan was made to have contracted RNs meet this requirement, the report stated, but as of July 1 the requirement had not been met.

Other violations include:

• Failing to investigate and report allegations of abuse.

• Failing to provide regular showers for residents.

• Failing to provide consistent laundry services.

• Failing to properly contain threatening situations.

• Failing to reasonably respond to the needs and preferences of residents.

• Failing to maintain a sanitary facility.

The report shows that many residents complained they were not provided baths very often. One resident said she "last showered a couple of weeks ago." Another resident said, "I have no idea when I will get another (shower)." That same resident was later observed by a Health Department official crying to staff about her lack of shower access and laundry services.

The report stated that a failure to wash resident's clothes also seems to be a persistent problem. A staff member reported that one resident "went three days without his pants being changed because he didn't have any clean clothing to change into." A Health Department official observed that the resident's pants were "visibly soiled" when he entered the facility.

'Immediate jeopardy'

Bruce Pritschet, director of the division of health facilities for the Health Department, said the department began its investigation after receiving "several complaints over a short period of time toward the end of May, first part of June."

North Dakota keeps the nature of the complaints and the identity of the complainants confidential, but Pritschet did say he thought it "was a combination of staff, patients and families" who complained to the agency.

Agency officials conducted the survey of Western Horizons from May 30 through June 7. The "immediate jeopardy" designation is the most severe category that can given to nursing homes by the Health Department.

Health Department officials remained on the premises of Western Horizons until a plan of correction was given to and accepted by the state, the report states.

Matthew Shahan, CEO of West River Health Services who oversees Western Horizons Care Center, is confident the facility's residents are not currently at risk and questions whether it should have been placed in the "immediate jeopardy" category.

"We have abated the immediate jeopardy (status), and we do not believe that any of the residents were at risk, even with the 'immediate jeopardy' designation," Shahan said.

"Just because it's in the report, doesn't mean we don't have the opportunity to push back on that report," he said in questioning the report's validity.

Western Horizons can challenge the complaints, but challenges are not included in the complaint report.

Causes and broader issues

Many of the facility's problems point toward understaffing and high turnover among staff. The report noted that one resident openly complained that the facility was "short-handed."

Western Horizons officials would not say whether their issues stemmed from staffing levels or other causes.

It appears Western Horizons' problems are not limited to the Health Department report.

The website medicare.gov provides a federally administered rating system for nursing homes across the nation based on several indicators, including staffing, quality measures and health inspections.

The site gives an overall rating to each nursing home, with Western Horizons Care Center receiving two out of five stars last year. Eighteen other nursing homes in North Dakota were rated two stars, placing Western Horizons on the low end of North Dakota's 81 rated nursing home facilities.

Moreover, the Health Department released a 61-page annual report last October outlining the facility's violations, which Pritschet characterized as a "fairly lengthy deficiency list."

For comparison, Dickinson's St. Luke's Home, also rated two stars by medicare.gov, had 11 pages of deficiencies. St. Benedictine's Health Center, also in Dickinson, was rated five stars and was recently given a 10-page list of deficiencies to address.

The Health Department gave the only one-star rated nursing home in the state, Beulah's Knife River Care Center, a 62-page list of deficiencies.

Preliminary research was unable to find a report longer than the 147 pages of deficiencies filed in the recent Health Department complaint report about Western Horizons.

CEO Shahan wanted to assure North Dakotans that, "We are reviewing findings of the survey, moving forward, correcting those findings, and continuing the care we provide to our community."

If the findings are not corrected by Dec. 7, the state "will terminate their provider agreement" and all of Western Horizon's government funds will be lost, Prischet said.