Ketchikan Med Ctr: 10 Deficiencies, Training Gaps - AK
Staff members were planning the July 18 outing to [NAME] Lake and discussing how to safely bring Resident #5 and Resident #9, both diagnosed with dementia, when the administrator joined the conversation on July 18. Her response was immediate and absolute.
"Absolutely not," she told the staff. "These residents will never leave the unit."
Staff #71 tried to explain that both residents had routinely participated in community outings and had done so safely. The administrator refused to budge. The residents stayed behind.
The prohibition violated the facility's own policies and contradicted medical assessments. Federal inspectors who investigated the incident in September found that Ketchikan Med Center New Horizons Transitional Care had denied residents their right to participate in activities of their choosing.
Both residents had extensive histories of safe community participation. The facility's Medical Director confirmed during a September 9 interview that while Resident #5 and Resident #9 had histories of wandering, "they had attended many outings in the past without concern." Neither resident required one-on-one supervision during outings.
"Caution was always needed," the Medical Director told inspectors, "but there was no rule that these residents couldn't attend outings."
The facility's own policies supported community participation for dementia residents. The Activities Therapy policy, revised just four months earlier in March, explicitly stated the program served residents with "early to advanced dementia including Alzheimer's." The policy committed to providing "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 went further, requiring staff to "assist resident to attend activities of their choosing" as a way to maintain residents' self-esteem and self-worth.
When inspectors interviewed the Chief Nursing Officer on September 4, she acknowledged hearing staff concerns about the dementia outing ban but said she "did not know enough about the federal regulations at the time."
The administrator's blanket prohibition affected residents who had previously enjoyed community activities safely. Federal regulations require nursing homes to provide activities that meet individual residents' interests and needs, not impose categorical restrictions based on diagnosis alone.
Staff #71's account revealed the arbitrary nature of the decision. The conversation had been routine planning for an established outing when the administrator intervened with what amounted to a permanent ban on community participation for dementia residents.
The lake picnic represented the kind of normal community engagement that federal regulations are designed to protect. Residents with dementia retain rights to participate in activities outside the facility walls, particularly when they have demonstrated the ability to do so safely.
The facility's policies recognized this principle. The Activities Therapy scope of service promised to provide activities that "engage each resident" while maintaining their dignity. The Resident Dignity Policy specifically committed to helping residents attend "activities of their choosing."
The administrator's intervention created a contradiction between written policy and actual practice. While facility documents promised community outings for dementia residents, the administrator's decree ensured they would remain confined to the unit.
The Medical Director's assessment undermined the administrator's rationale. Despite acknowledging wandering histories, the medical professional saw no justification for a complete ban on community activities. Previous safe participation demonstrated that appropriate precautions could manage any risks.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. The citation fell under regulations governing resident rights to participate in activities.
The September inspection followed a complaint about the facility's treatment of dementia residents. Staff #71's willingness to challenge the administrator's decision and later speak with investigators highlighted internal recognition that the ban violated residents' rights.
Resident #5 and Resident #9 missed the July lake picnic and faced an indefinite prohibition on future community outings under the administrator's decree. Their confinement continued despite medical clearance, policy support, and a history of safe participation in the community activities they were now denied.
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 21, 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.
Her response was immediate and absolute.
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.