Ketchikan Med Ctr: Abuse Prevention Failures - AK
The July confrontation at Ketchikan Med Ctr New Horizons Transitional Care left staff scrambling to explain why Resident #5 and Resident #9 couldn't attend the community outing they had safely enjoyed many times before.
Staff #71 tried to reason with the administrator during the planning discussion for the July 18 [NAME] Lake picnic. The staff member explained that both residents had routinely participated in outings without incident. The administrator refused to budge.
Federal inspectors documented the exchange during a September complaint investigation. Staff #71 told inspectors the residents were excluded from the outing entirely.
The medical director contradicted the administrator's blanket ban when interviewed September 9. While acknowledging that Resident #5 and Resident #9 had histories of wandering, the medical director said both had attended many outings in the past without concern. Neither would require one-on-one supervision during community activities.
"Caution was always needed, but there was no rule that these residents couldn't attend outings," the medical director told inspectors.
The chief nursing officer admitted to inspectors September 4 that she had heard staff concerns about the dementia outing restriction. She said she didn't know enough about federal regulations at the time to intervene.
Federal regulations require nursing homes to provide activities that meet each resident's interests and maintain their highest level of well-being. The facility's own policies supported community participation for residents with dementia.
The facility's activities policy, revised March 6, specifically lists "early to advanced dementia including Alzheimer's" among the types of residents served. The policy promises "meaningful and age appropriate activities that engage each resident while promoting dignity, respect and the well-being of each resident."
Community outings are explicitly included in the facility's activity offerings. The policy commits to providing "one on one and group activities, special events, in house and outings to community events."
The facility's resident dignity policy, updated February 18, requires staff to "assist resident to attend activities of their choosing." The policy aims to help residents "maintain and enhance his/her self-esteem and self-worth."
Both policies directly contradicted the administrator's categorical exclusion of residents with dementia from community activities.
The restriction affected residents who had previously participated safely in similar outings. Staff #71 emphasized to inspectors that both residents had established track records of successful community participation.
The administrator's intervention came during routine activity planning. Staff had been discussing logistics for the lake picnic when she emerged from her office and imposed the restriction without consultation with medical or nursing leadership.
The medical director's assessment suggested individualized evaluation rather than blanket exclusions. While noting the residents' wandering histories, the medical director determined that appropriate precautions could allow safe participation.
Federal inspectors cited the facility for failing to ensure residents could participate in activities of their choosing. The violation affected multiple residents and carried potential for actual harm.
The September inspection followed a complaint about the facility's treatment of residents with cognitive impairments. Inspectors found the administrator's categorical ban violated federal requirements for resident-centered care and dignity.
Staff #71's attempts to advocate for the residents' participation rights were unsuccessful. The administrator's position remained firm despite explanations about the residents' successful outing history and the facility's own policies supporting community engagement.
The restriction left two residents who had previously enjoyed community activities confined to the facility during a summer outing their peers attended. Neither resident's care plan or medical condition supported the exclusion, according to the medical director's assessment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ketchikan Med Ctr New Horizons Transitional Care from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE in KETCHIKAN, AK was cited for abuse-related violations during a health inspection on September 9, 2025.
Staff #71 tried to reason with the administrator during the planning discussion for the July 18 [NAME] Lake picnic.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.