Western Horizons Care Center

In the surveyor’s words

From the most serious findings on record at Western Horizons Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 29, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Jul 20, 2021

  THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY CONDUCTED ON 03/17/21 Based on observations, record review, information from the complainant, review of facility policy, review of the mechanical lift operator's manual, review of facility's fall investigation report, and staff and service technician interviews, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #1). Failure to safely utilize/maintain a mechanical lift with a sling resulted in a fall with injury for Resident #1. Failure to complete a thorough investigation and immediately educate nursing staff on safe mechanical lift procedures placed all residents requiring this type of transfer at risk for accidents and/or injury. […]

• Actual harm, isolatedF689Apr 28, 2026

  Based 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. […]

• Actual harm, isolatedF600Sep 4, 2025

  Based 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. Findings include:The survey team determined a deficient practice existed on 04/27/25. The facility implemented corrective action immediately, completed corrective action on 04/28/25, and continued with staff education and monitoring. […]

• Actual harm, isolatedF689Sep 4, 2025

  Based 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. Findings include:Review of the facility procedure Use of Hoyer (Full Body) Lift occurred on 09/04/25. This undated procedure stated, . Mechanical Lift from Bed to Chair . Positioned the lift under the bed and widened the base of the lift.Review of the Volaro Series 4 Lift Operator's Manual occurred on 09/04/24. This manual, dated March 2019, stated, . Safety Notes . […]