PINEHURST, Idaho — A nursing home for seniors and those with disabilities has been out of compliance after an Idaho Department of Health and Welfare inspection found numerous violations. 

Idaho Department of Health and Welfare spokesperson Niki Forbing-Orr told KREM's Taylor Viydo staff received complaints about Pacifica Senior Living in Pinehurst, Idaho, before completing an inspection to determine the complaint’s merit.

The inspection, called a survey, includes interviews with residents, family member and employees, among others.

As a result of the investigation, the facility is under a provisional license with temporary management as of Jan. 29, 2020, records show. A different operator has also been appointed to the facility.

A provisional license is one where the facility is out of compliance with rules pending the correction of deficiencies.  

Records indicate that a variety of allegations leveled at the senior care facility were deemed "substantiated" in January, including abuse, exploitation, lack of adequate staffing, medication and treatment issues.

Viydo has reached out to Pacifica for comment but has not received a response. 

Documents obtained by Viydo from the IDHW say the inspection found evidence of failing to protect residents from sexual abuse and improper medical care, among other violations.

The documents list 31 “non-core issues” and six “core issues” at Pacifica.

Records show that non-core issues were also found as the result of investigations of the facility in April 2019. 

The non-core issues listed for 2020 include failure to maintain a clean facility, assist residents in taking their medication, and complete an investigation and written report when allegations of abuse were made known, among others.

The six core issues listed in the inspection go into detail about the facility’s failure to protect residents from abuse and improper medical care.

Facility did not protect residents from 'unwanted sexual advances'

Documents say the facility did not protect four out of seven sampled female residents from “unwanted and inappropriate sexual advances,” and two out of eight residents from possible physical abuse.

The investigation’s findings stem from behavior of two of the facility’s residents who are not named.

Between Jan. 6 and Jan. 14, 2020, two staff members noted that one resident “groped” female caregivers, documents say. 

Between Jan. 6 to Jan. 14, residents, staff members and outside agencies said the resident was seen with his hand up a female resident’s blouse and that he “would corner” her, documents say. 

Documents say the incident where the resident put his hand up the woman’s blouse was reported to the facility’s administrator, Cheryl Kosanke, who responded by instructing staff to “keep a better eye on” the resident.

A staff member said on Jan. 14 that the alleged female victim had bruises on her body, including her shoulder and arm, according to documents. The staff member added that resident screamed for help when touched by other staff.

Documents say that Kosanke “failed to conduct an investigation of sexual abuse” after it was reported by various staff member, and that the administrator did not put a plan in place to protect the female resident.

More incidents between the same resident and another, including touching a female resident’s inner thigh, went undocumented, according to the inspection. 

A charting note made in July 2019 documented that another resident displayed “a lot of sexual aggressiveness” toward staff and some residents. Documents say the same resident tried to kiss an administrator and one incident was captured on video.

Between Jan. 6 and Jan. 14, 2020, residents, staff members and outside agencies said the resident touched a caregiver’s buttocks and kissed a resident multiple times.

Kosanke was unable to provide any investigations conducted within the last year, documents say.

On Jan. 9, Kosanke stated the resident was “only sexually inappropriate with staff.” She added that resident had patted a caregiver on the bottom and kissed staff on the cheek, documents say. 

“The facility failed to protect [residents] from unwanted sexual advances, did not document these incidents or report them to the survey agency or AP. Also, the facility administrator failed to conduct an investigation,” inspection documents read. 

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Unlicensed staff made medical decisions, investigation finds 

Based on observations, interviews and record reviews, the inspection also found that the facility failed to provide “appropriate supervision” to all residents when the facility “allowed unlicensed staff to make medical decisions.” The facility also failed to coordinate wound care for several residents.

Violations also stem from the facility’s failure to provide a licensed professional nurse who must visit the facility at least once every 90 days or when there is a change in a resident’s condition, inspection documents say. 

One staff member, who was not a nurse, said the nurse had delegated her to complete documentation on the nurse’s behalf.

Staff members, family members and residents interviewed said they had never met the nurse or had never seen the nurse, despite working there for a year-and-a-half or more in some cases.

One person interviewed said, “In 12 months I have only seen a nurse two times.”

Documents say that Ambien was given to residents without a physician’s order and medications were hidden in an office file cabinet.

“There was "so much corruption going on. Multiple times they gave someone meds that were not theirs,” said one person who was interviewed.

In January, two staff members said they saw a resident fall and then ask to go the hospital, but the administrator “would not send her out,” documents say. The resident’s doctor later determined that she had cracked ribs.

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