Ketchikan Med Ctr: Abuse Reporting Failures - AK
Staff at Ketchikan Medical Center New Horizons Transitional Care were discussing the July 18 Ward Lake outing when the administrator interrupted their conversation on July 4. They had planned to bring Resident #5 and Resident #9, both diagnosed with dementia, who had participated in previous community activities without incident.
"Absolutely not," the administrator told staff, according to testimony from Staff #71 during a September 4 interview with federal inspectors. "These residents will never leave the unit."
Staff #71 attempted to explain that both residents had routinely participated in outings safely. The effort failed. The administrator refused to reconsider, and the residents missed the picnic.
The prohibition contradicted the facility's own policies and medical recommendations. The facility's Activities Therapy policy, revised March 6, specifically included residents with "early to advanced dementia including Alzheimer's" in programming designed to provide "outings to community events." The policy emphasized providing activities that "promote dignity, respect and the well-being of each resident."
Dr. [Medical Director] confirmed during a September 9 interview that both residents had histories of wandering behavior but had "attended many outings in the past without concern." The medical director stated neither resident 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 acknowledged hearing staff concerns about the dementia outing ban during her September 4 interview but admitted she "did not know enough about the federal regulations at the time" to address the situation.
Federal regulations require nursing homes to provide activities that meet residents' interests and enhance their quality of life. The facility's own Resident Dignity Policy, revised February 18, mandated that staff "assist resident to attend activities of their choosing" as part of maintaining residents' self-esteem and self-worth.
The administrator's blanket prohibition affected residents who had demonstrated they could safely participate in supervised community activities. Both Resident #5 and Resident #9 had established patterns of successful outing participation before the ban.
Staff #71 described the administrator's intervention as arbitrary and inconsistent with established care practices. The conversation occurred as activities staff and floor staff collaborated on transportation and supervision logistics for the Ward Lake event, a routine planning process for community outings.
The facility operates activities programming seven days a week, designed to meet diverse resident needs including those with dementia diagnoses. The Activities Therapy policy explicitly commits to providing "meaningful and age appropriate activities that engage each resident."
Ward Lake, a popular Ketchikan recreation area, had been a regular destination for facility outings. Staff familiarity with the location and resident capabilities had previously enabled safe community participation for residents across various cognitive abilities.
The medical director's assessment directly contradicted the administrator's position. Despite acknowledging wandering behaviors in both residents, the medical professional saw no clinical justification for excluding them from supervised group activities outside the facility.
The prohibition remained in effect through the September inspection period. Staff #71 reported no subsequent discussions with the administrator about modifying the policy or developing individualized risk assessments for community participation.
The two residents with dementia continued receiving activities programming within the facility but lost access to community outings that had previously provided social engagement and environmental stimulation beyond the institutional setting.
Federal inspectors cited the facility for failing to ensure residents could participate in activities of their choosing, finding the administrator's blanket ban on dementia patients' community participation violated dignity and quality of life requirements.
The Ward Lake picnic proceeded without Resident #5 and Resident #9, marking the end of their community outing participation despite medical clearance and established safety records.
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.
They had planned to bring Resident #5 and Resident #9, both diagnosed with dementia, who had participated in previous community activities without incident.
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.