Ketchikan Med Ctr: Abuse Response Failures - AK
Staff members had been planning the July 18 lake picnic outing, discussing how to safely include Resident #5 and Resident #9, both diagnosed with dementia. Both residents had participated in community outings routinely and safely in the past. But when the administrator joined the discussion on July 18, she declared these residents would "never leave the unit."
Staff #71 tried to explain that excluding the residents would be inappropriate given their history of safe participation. The administrator refused to budge.
The residents missed the picnic.
The blanket ban contradicted the facility's own policies and medical guidance. Ketchikan Med Ctr New Horizons Transitional Care's activities policy, revised just four months earlier in March, specifically lists "early to advanced dementia including Alzheimer's" among the types of residents served. The policy promises "outings to community events" as part of meaningful activities that promote "dignity, respect and the well-being of each resident."
The facility's dignity policy, updated in February, states that staff must "assist resident to attend activities of their choosing."
When federal inspectors interviewed the Chief Nursing Officer on September 4, she acknowledged hearing staff concerns about the dementia outing ban. She admitted she "did not know enough about the federal regulations at the time."
The Medical Director painted a different picture. During his September 9 interview, he confirmed that Resident #5 and Resident #9 had histories of wandering behavior. But he emphasized their track record: "they had attended many outings in the past without concern, and they would not need a 1:1 on outings."
He saw no medical basis for the prohibition. "Caution was always needed, but there was no rule that these residents couldn't attend outings."
The contradiction was stark. An administrator with no apparent medical training had overruled the facility's own Medical Director, who saw no safety concern that would justify excluding residents from community activities they had safely enjoyed before.
Federal investigators documented the violation under regulations requiring facilities to provide activities that meet residents' interests and maintain their highest level of well-being. The inspection found that some residents were affected by the administrator's edict, though the harm was classified as minimal.
The timing made the violation more troubling. Staff had been actively planning to accommodate the residents' participation in the lake picnic, showing they understood how to manage any risks. The administrator's intervention wasn't based on a specific safety incident or medical recommendation. It was a blanket policy imposed mid-conversation.
For residents with dementia, community outings can provide crucial stimulation and connection to life outside institutional walls. The Medical Director's assessment that both residents could participate safely without one-on-one supervision suggested they retained significant functional capacity.
The administrator's declaration that these residents would "never leave the unit" went beyond the specific picnic. It appeared to establish a permanent ban on community activities for any resident with a dementia diagnosis, regardless of their individual capabilities or safety history.
Staff #71's attempt to advocate for the residents reflected proper understanding of individualized care principles. Federal regulations require facilities to assess each resident's needs and capabilities individually, not impose broad restrictions based solely on diagnosis.
The facility's own policies supported inclusion. The activities policy specifically commits to serving residents with dementia through community outings. The dignity policy requires staff to help residents attend activities of their choosing.
But policies meant nothing when the administrator simply said no.
The lake picnic happened without Resident #5 and Resident #9. Two people who had safely enjoyed community outings before were left behind, not because of medical concerns or safety incidents, but because of an administrator's blanket judgment about their diagnosis.
The Medical Director's assessment remained unchanged: there was no rule preventing these residents from attending outings. Caution was needed, as always. But caution didn't require exclusion.
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 members had been planning the July 18 lake picnic outing, discussing how to safely include Resident #5 and Resident #9, both diagnosed with dementia.
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.