Ketchikan Med CTR New Horizons Transitional Care

In the surveyor’s words

From the most serious findings on record at Ketchikan Med CTR New Horizons Transitional Care, in the surveyor’s own words.

• Actual harm, isolatedF550Dec 5, 2022

  Based on record review and interview, the facility failed to ensure residents were able to exercise their rights as residents of the facility. Specifically, the facility: 1) Failed to honor the resident's right to discontinue, or refuse continued, peri cares (the cleansing of a resident's genital/anal area) for 1 resident (#12), out of 11 sampled residents; and 2) Made it a stipulation for all residents, based on a census of 17, to be COVID-19 vaccinated as a requirement of admission to the facility. This failed practice violated the resident's right to: 1) stop a treatment or intervention, which resulted in psychosocial harm; and 2) choose to be immunized. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2026

  .Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed. Specifically, the facility failed to ensure: 1. The concentration of sanitizer, in their red sanitation buckets, met manufacturer's recommended concentration levels for effective sanitation on kitchen surfaces; 2. Food items, stocked for resident meals, had not expired; and 3. Opened packages of food items were properly labeled. These failed practices placed 22 residents who received food from the kitchen, out of 23 residents, at risk for foodborne illness and communicable disease. Findings: 1) Sanitizer concentration An observation on 4/8/26 at 11:10 AM, of the main kitchen, revealed four red sanitizer buckets at various locations in the kitchen. […]

• No harm, potential for more than minimal, widespreadF565Sep 9, 2025

  .Based on interview and record review, the facility failed to allow resident-invited visitors and/or guests to attend a resident council meeting. This failed practice denied the resident's right to invite visitors to the resident council meeting, which denied all residents (based on a census of 26) the right and opportunity to advocate for themselves and placed them at risk for decreased feelings of self-worth and had the potential to affect their mood and overall wellbeing. Findings:During an interview on 9/2/25 at 1:45 PM, Resident #12 stated that he/she invited his/her family member, who was his/her resident representative, to the resident council meeting that occurred on 7/23/25. […]

• No harm, potential for more than minimal, widespreadF600Sep 9, 2025

  .Based on interview and record review, the facility failed to ensure residents were free from abuse. Specifically, the Administrator's conduct towards residents was construed, by residents and staff, as verbally abusive. This failed practice placed all residents (based on a census of 26) at risk for continued exposure to verbal abuse and mental anguish which had the potential to affect their overall health and well-being.Findings:Resident #12 During an interview on 9/2/25 at 1:45 PM, Resident #12 stated she felt verbally abused by negative comments the Administrator had said to him/her, and this made him/her very sad, and he/she was now hopeless, like I'll never get out of here. […]

• No harm, potential for more than minimal, widespreadF607Sep 9, 2025

  .Based on record review and interview, the facility failed to implement written policies and procedures to investigate an allegation of abuse for 1 Resident (#12), out of 1 allegation of abuse investigation reviewed. Specifically, the facility's HR Department and Risk Management Department failed to: 1) adequately monitor the investigation process to ensure all steps of the investigation procedure were completed appropriately; 2) ensure all investigations processes were adequately documented; and 3) ensure additional investigations from the results of the investigation process were appropriately carried out 2 residents (#'s 20 and 25), out of 5 residents interviewed during the investigation. […]