Ketchikan Med Ctr: 10 Deficiencies, Rights Denied - AK
Staff members at Ketchikan Med Ctr New Horizons Transitional Care were planning the July 18 outing to [NAME] Lake when the administrator joined their discussion on September 4. Staff #71 told inspectors that when floor and activities workers mentioned bringing Resident #5 and Resident #9, both diagnosed with dementia, the administrator immediately shut down the idea.
"Absolutely not," the administrator said, according to Staff #71's account to federal inspectors.
Staff #71 tried explaining that both residents had routinely participated in outings safely in the past. The administrator wouldn't budge. The two residents stayed behind.
The Medical Director contradicted the administrator's blanket ban during a September 9 interview. Both residents had histories of wandering, he acknowledged, but they 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 administrator's prohibition violated the facility's own written policies. The Activities Therapy policy, revised just months earlier in March, explicitly 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 Resident Dignity Policy goes further, requiring staff to "assist resident to attend activities of their choosing."
The Chief Nursing Officer admitted she had heard staff concerns about the dementia outing ban but said she "did not know enough about the federal regulations at the time" when interviewed on September 4.
Federal regulations require nursing homes to provide activities that meet residents' interests and physical, mental and psychosocial well-being. Facilities cannot categorically exclude residents from activities based solely on their diagnosis.
The September inspection found the facility violated residents' rights to dignity and self-determination. Inspectors determined the harm was minimal but affected multiple residents.
Both Resident #5 and Resident #9 had established patterns of safe community participation before the administrator's edict. Their exclusion from the lake picnic represented a sudden policy shift that contradicted medical judgment and written facility commitments.
The administrator's declaration that dementia residents would "never leave the unit" suggested a permanent restriction rather than individualized care decisions. Staff #71's unsuccessful attempt to advocate for the residents highlighted the conflict between frontline workers who knew the residents' capabilities and administrative decisions made without clinical input.
The facility operates as a transitional care unit, serving residents with various conditions including dementia, wound care needs, and end-of-life care. Its activities program runs seven days a week, designed to meet diverse resident needs through both group activities and community outings.
The timing of the administrator's intervention was particularly notable. Rather than participating in care planning or consulting medical staff, she overruled the outing during an informal hallway conversation. Her immediate rejection left no room for discussion about safety measures or individualized accommodations that might have allowed participation.
The lake picnic proceeded without the two dementia residents, despite their previous safe participation in similar community activities. The Medical Director's later confirmation that no clinical reason existed for their exclusion underscored the arbitrary nature of the administrator's decision.
Staff #71's willingness to challenge the administrator's ruling, though unsuccessful, demonstrated awareness that the blanket ban contradicted both resident rights and facility policy. The administrator's refusal to consider individual circumstances or clinical input resulted in two residents losing access to community engagement they had previously enjoyed safely.
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.
"Absolutely not," the administrator said, according to Staff #71's account to federal inspectors.
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.