Ketchikan Med Ctr: 10 Deficiencies, Assessment Gaps - AK
Staff #71 was discussing the July 18 Ward Lake outing with floor and activities personnel on September 4, explaining how they planned to include Resident #5 and #9, both diagnosed with dementia. When the administrator joined the conversation and heard the residents' names, she immediately shut down the idea.
"Absolutely not," the administrator stated. "These residents will never leave the unit."
Staff #71 tried explaining that both residents had routinely participated in community outings safely. The administrator refused to reconsider. The residents stayed behind.
Federal inspectors found the blanket prohibition violated residents' rights to dignity and choice. The facility's own policies promised "meaningful and age appropriate activities" including "outings to community events" for residents with "early to advanced dementia including Alzheimer's."
The Medical Director confirmed both residents had attended "many outings in the past without concern." While Resident #5 and #9 did have histories of wandering, the Medical Director said they wouldn't need one-on-one supervision during outings and "there was no rule that these residents couldn't attend outings."
Caution was always needed, the Medical Director acknowledged. But not prohibition.
The Chief Nursing Officer admitted hearing staff concerns about the dementia outing ban during a September 4 interview. She said she "did not know enough about the federal regulations at the time" to address the administrator's decision.
The facility's Activities Therapy policy, revised just months earlier in March, explicitly stated its purpose was providing appropriate daily activities while complying with state and federal regulations. The policy identified dementia patients among the resident types served and promised both group activities and community outings.
Staff #71 described the administrator's intervention as definitive. After the office confrontation, the message was clear: residents with dementia diagnoses were barred from leaving the facility for any community activity.
The prohibition directly contradicted the facility's Resident Dignity Policy, revised in February. That policy required staff to "assist resident to attend activities of their choosing" as part of maintaining residents' self-esteem and self-worth.
For Resident #5 and #9, the choice was made for them. Despite years of safe community participation, despite medical clearance, despite facility policies promising inclusive programming, they would remain inside while other residents enjoyed the summer picnic at Ward Lake.
The administrator's blanket ban affected multiple residents diagnosed with dementia, according to inspection findings. Staff had been planning to include both residents in the outing based on their established participation history and assessed capabilities.
The Medical Director's assessment directly challenged the administrator's position. Both residents could safely attend community activities with appropriate but not intensive supervision. Their wandering histories didn't justify complete exclusion from the facility's community programming.
The September inspection revealed a pattern of administrative decisions overriding clinical judgment and resident preferences. Staff familiar with the residents' capabilities and histories found themselves unable to advocate effectively for inclusive programming.
The facility's own documentation supported community participation for dementia residents. Policies promised dignity, choice, and meaningful activities regardless of cognitive status. The Activities Therapy scope of service specifically included dementia patients in community outing eligibility.
Federal investigators found the administrator's prohibition violated residents' rights to participate in activities of their choosing. The blanket ban based solely on dementia diagnosis, rather than individual assessment, contradicted both facility policy and federal requirements.
While the administrator declared these residents would "never leave the unit," the Medical Director and direct care staff knew better. They had witnessed successful community participation. They understood individual capabilities beyond diagnostic labels.
The lake picnic proceeded without Resident #5 and #9. They remained inside, excluded from an activity they had safely enjoyed many times before, victims of an administrative decision that prioritized blanket restrictions over individual dignity and choice.
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 violations during a health inspection on September 9, 2025.
When the administrator joined the conversation and heard the residents' names, she immediately shut down the idea.
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.