Ketchikan Med Ctr: Resident Dignity Violations - AK
The confrontation unfolded July 18 as staff at Ketchikan Med Center New Horizons Transitional Care planned a lake picnic. When floor and activities staff discussed bringing Resident #5 and Resident #9, both diagnosed with dementia, the administrator emerged from her office and joined the conversation.
"Absolutely not," she told staff, according to testimony from Staff #71 during a September 4 interview with federal inspectors.
Staff #71 attempted to explain that both residents had routinely participated in outings safely and excluding them would be inappropriate. The administrator refused to budge. The residents stayed behind.
The medical director contradicted the administrator's blanket prohibition. During a September 9 interview, he confirmed that while Resident #5 and Resident #9 had histories of wandering, "they had attended many outings in the past without concern, and they would not need a 1:1 on outings."
"Caution was always needed, but there was no rule that these residents couldn't attend outings," the medical director told inspectors.
The facility's own policies supported including dementia residents in community activities. The Long Term Care Activities Therapy policy, revised March 6, explicitly lists "early to advanced dementia including Alzheimer's" among the types of residents served. The policy commits to providing "outings to community events" as part of meaningful activities that promote "dignity, respect and the well-being of each resident."
A separate dignity policy requires staff to "assist resident to attend activities of their choosing."
The chief nursing officer acknowledged the controversy during a September 4 interview, telling inspectors she "had heard this was a concern from staff" but "did not know enough about the federal regulations at the time."
The incident reflects a broader tension between safety concerns and resident rights in dementia care. Federal regulations require nursing homes to accommodate residents' preferences and maintain their dignity while ensuring appropriate supervision.
Both residents had demonstrated they could handle community outings with standard precautions. The medical director's assessment that neither required one-on-one supervision during outings suggested the administrator's blanket ban exceeded necessary safety measures.
The administrator's intervention came despite staff expertise and medical oversight supporting the residents' participation. Activities staff, who work directly with residents daily and understand their capabilities, had planned to include both residents based on their successful history with similar events.
The July lake picnic represented exactly the type of community engagement the facility promised in its policies. Activities therapy aims to provide "meaningful and age appropriate activities" while maintaining resident dignity through choices about participation.
Staff #71's willingness to advocate for the residents' inclusion demonstrated awareness of their rights and capabilities. The pushback against the administrator's decision suggested staff recognized the exclusion violated both facility policy and resident dignity principles.
The medical director's contradiction of the administrator's position highlighted internal disagreement about appropriate care standards. His assessment that the residents could safely participate with normal precautions directly challenged the "never leave the unit" decree.
The facility operates activities programs seven days a week, "open as needed to meet the needs of events for residents." The broad prohibition against dementia residents attending outings would effectively exclude them from a core component of their care plan.
Federal inspectors cited the facility for failing to maintain resident dignity, finding that the blanket ban on outings for dementia residents violated requirements to support resident choices and self-worth. The administrator's categorical exclusion ignored individual assessments and successful participation history.
The September inspection revealed how administrative decisions can override clinical judgment and resident preferences, leaving two people who had safely enjoyed community activities confined to the facility against medical and staff recommendations.
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.
The confrontation unfolded July 18 as staff at Ketchikan Med Center New Horizons Transitional Care planned a lake picnic.
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.