Ketchikan Med Ctr New Horizons Transitional Care

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain patient care equipment in a safe operating manner. Specifically, the facility failed to ensure a shower chair, which was used by 8 residents (#'s 4, 5, 6, 8, 10, 15, 23, and 24), out of 23 residents reviewed, was free of cracks and/or tears. A shower chair with a compromised surface exposed residents to the padding within, which had the potential to be contaminated with bodily fluids and diseases. A compromised surface created the inability to completely sanitize the surface between resident use, which placed all 8 residents at risk for the development and transmission of communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored to maintain medication identity and control. This failed practice placed all residents, based on a census of 23, at risk for medication error, misidentification, and drug diversion.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on record review and interview, the facility failed to report the results of an investigation of an allegation of abuse to the State Agency within 5 working days as required under CFR 483.12(c)(4). The lack reporting investigation results concerning an allegation of abuse in an appropriate and timely manner inhibited the State Agency from accurately assessing and investigating this allegation, which placed all residents (based on a census of 26) at risk for future exposure to potential abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure float nursing staff (NS) and travel NS, had the job specific competencies and skill sets necessary to care for long-term care (LTC) residents' needs. Specifically, the facility failed to ensure: 1) float/travel NS had current LTC training for ADL (activities of daily living) Coding and Definitions;2) float/travel NS had current LTC training for Behavioral Health (BH);3) float/travel NS had current LTC training for QAPI (quality assurance performance improvement);4) float/travel NS had current LTC training for Dementia for LTC; and5) float/travel NS had current LTC training for Trauma Informed Care. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure their facility assessment was reviewed and updated annually. This failed practice had the potential to place all residents (based on a census of 26) at risk of not having the necessary care and resources from an accurate assessment.

Inspectors wroteBased on record review and interview, the facility failed to ensure four float Certified Nurse Assistants (CNAs) out of four float CNAs chosen for review, received the required 12 hours of annual in-service training, specifically including education on dementia care and abuse/neglect prevention. This failed practice placed all residents (based on a census of 26) at risk for substandard care due to staff not being provided with the education necessary to ensure continuing competence in the care of long-term care (LTC) residents .

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 resident (#12), out of 1 allegation of abuse investigation reviewed. Specifically, the facility failed to: 1) Accurately interview Resident #12 to determine the nature and timing of the allegation of abuse; 2) Have evidence of the Administrator's interview conducted during the investigation; 3) Contact the Resident's Provider regarding the allegation of abuse; and 3) Investigate reports of intimidation and verbal abuse received from 2 residents (#'s 20 and 25), out of 5 residents interviewed during the investigation. These failed practices: 1) caused a misinterpretation of what the allegation of abuse was and when it occurred; 2) resulted in the investigation being incomplete; [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to provide an ongoing, resident-centered activity program, aligned with individual care plans, for 17 Residents (#'s 4, 5, 7, 9, 12, 13, 18, 20, 21, 23, 25, 27, 28, 31, 33, 34, and 36), out of 26 residents who enjoyed activities outside of their rooms. Specifically, the facility failed to: 1) Consistently provide activities as documented on the facility's monthly activity calendar for the months of July, August, and September 2025; 2) Provide scheduled outings with the use of the facility's transportation van; and 3) Allow residents with the diagnosis of dementia from participating in scheduled outings. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat one resident (#16), out of 26 residents reviewed, with dignity and respect. Specifically, the facility's Administrator took the resident's personal checkbook, against the resident's wishes, and kept this item in her personal desk without communicating an appropriate rationale for the restriction. This failed practice violated the resident's right to be treated with dignity and respect and placed undue stress on the resident which had the potential to affect the resident's overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to update and revise the care plan for two residents (#s 1 and 19), out of 13 sampled residents. Specifically, the facility failed to update and revise the care plans to reflect: 1) anticoagulant medication use for Resident #1; and 2) chronic right shoulder pain for Resident #19. Failure to assess and revise care plan problems, goals, and interventions placed the residents at risk for not receiving appropriate and/or necessary care and services.

Inspectors wroteBased on record review and interview, the facility failed to provide a program of meaningful activities for 1 resident (#44), out of 13 sampled residents based on an individualized assessment and care plan. This failed practice denied the resident opportunities that contributed to quality of life and placed the resident at risk for depression, loneliness, and boredom.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 resident (#9), out of 13 sampled residents, received ordered restorative exercises. This failed practice placed the resident at risk of not maintaining or decreasing his/her highest level of range of motion and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the total number and the actual hours worked by Certified Nurse Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) per shift. This failed practice provided inaccurate information to the residents and their representatives.