Violations found at Pacifica

PINEHURST — Pacifica Senior Living is currently under new, temporary management following the completion of a facility survey by Idaho Department of Health and Welfare’s Division of Licensing and Certification. The survey, completed on Jan. 10, was conducted in response to a complaint IDHW received from either a resident or family member of a resident regarding alleged sexual abuse occurring at the facility.

Following the tip, the DLC sent a team that specializes in assisted living facilities to Pacifica to look into the accusations that had been leveled against them.

Niki Forbing-Orr, a public information manager with IDHW, explained that the DLC licenses and inspects health care facilities and agencies including hospitals, nursing homes, rural health clinics, ambulatory surgery centers, renal dialysis centers, residential/assisted living facilities, developmental disability agencies and residential rehabilitation agencies.

According to Forbing-Orr, depending on the complaint that they receive, nothing and no one is really off the table regarding who gets interviewed during the survey.

“The main focus is to figure out what is going on as quickly as possible, so that we can make sure that the residents are safe,” Forbing-Orr said. “Our staff works really hard to make sure that residents are safe and taken care of. The stakes are really high for these potentially very vulnerable people.”

These surveys are incredibly thorough and include interviews with residents, their family members, employees and even former employees.

During Pacifica’s most recent survey, the DLC team not only found evidence of the sexual abuse allegations and a mishandling of the situation, but they also discovered several other Idaho Administrative Code violations.

According to the survey, the team identified 31 “non-core issues” and six “core issues.”

The non-core issues listed include numerous staff-related violations — such as failing to maintain a clean facility, failing to ensure resident records were accurately maintained, failing to ensure a licensed professional nurse was at the facility to assess changes in resident conditions, failing to assist residents with taking their medications in accordance with their physician’s orders, failing to secure and/or dispose of medications, and many more.

Item 18 of the 31, titled “Unused Medication,” states “the facility had an accumulation of unused, discontinued or expired medications for more than 30 days. A cabinet drawer in the RCD’s office contained several medications that expired in September. Also, destruction logs documented medications were disposed of several months after the residents no longer resided at the facility.”

As for the six core issues, which make up the bulk of the survey, go into closer detail of specific incidents in which the core issues allegedly took place.

Item 2 of 6, titled “Requirements To Protect Residents From Abuse,” presents the team’s findings on the original complaint of sexual abuse.

Their investigation found that “the facility did not protect 4 of 7 sampled female residents from unwanted and inappropriate sexual advances which had the potential to affect 100% of the female residents residing at the facility. Also, the facility failed to protect 2 of 8 residents from possible physical abuse.”

This violation stemmed from the alleged behavior of two particular residents — referred to residents 9 and 13.

Between Jan. 6 and 14, resident 9 was seen by multiple sources to be engaging in unwanted advances toward another female resident that included inappropriate touching and physical actions. The female resident was even seen with physical injuries, such as a large bruise on her shoulder and arm. Despite reports of the behavior being given to the facility’s administrator, Cheryl Kosanke, an investigation of sexual abuse was never conducted and a plan to protect the female resident was never put into place.

A similar situation occurred with resident 13 in which he allegedly engaged in unwanted sexual advances involving several different residents and staff members. In the most extreme case, one female resident in particular was seen by staff with numerous bruises in various areas of her body toward the end of 2019 and into 2020. Based on statements from an outside agency and the female resident herself, resident 13 was strongly suspected of causing the injuries.

Despite these incidents being reported to the facility’s administrator, no investigation was conducted and no action was taken to protect the female resident or any of the other alleged victims from resident 13.

Item 3 of 6, titled “Inadequate Care — Supervision,” presents observations and interviews that the facility failed to provide appropriate supervision to 100% of the residents when unlicensed staff were allowed to make medical decisions.

This section mostly focuses on the presence — or lack thereof — of the facility’s Registered Nurse and the mishandling of prescription medication.

While Pacifica’s invoices from September 2019 to January 2020 showed that they were paying an RN for eight hours of work per month (which equated to two hours of nursing per week), multiple statements from residents, family members, outside agencies and staff indicate that the RN was rarely present.

“I have worked there for 1 1/2 to 2 years…I’ve never seen the nurse,” one employee stated.

Possibly due in part to the absence of the RN, uncertified staff members were told or allowed — depending on the circumstance — to administer and handle resident medications. On many occasions, the facility administrator, business office manager and the resident care director were the ones directing uncertified staff to administer or interchange medications.

As for the medications themselves, the DLC team found substantial evidence of old/unneeded prescriptions being hoarded by the administrator and/or the RCD to be given to residents at their discretion or worse.

“Medications were not disposed of when residents died or left the facility,” one witness stated to the team. “But were stockpiled in the administrator’s or RCD’s office.”

During their survey, the DLC team located both a blue plastic tote in the administrator’s office with various medications in it and a bottom desk drawer in the RDC’s office that was filled with discontinued or expired medications.

The remaining alleged core issues include the facility failing to coordinate outside services for a resident suffering from a pressure wound, violating resident rights by purposely giving a resident someone else’s medication and unknowingly slipping medication to another, and neglecting/failing to provide adequate supervision to many of the residents in the previously stated incidents.

The results of the inspection (which have been widely shared and read), have prompted the DLC to put the facility under a provisional license, instate temporary management and implement a different operator.

The new operator’s job is to do whatever is necessary to make sure that residents of the facility are safe and that they are working to bring the facility back into compliance with the DLC’s regulations.

Facility administrator Cheryl Kosanke is also no longer employed at Pacifica Senior Living. It is unknown if she was terminated or she resigned her position.

One thing Forbing-Orr stressed was that while the DLC leaves no stone unturned in their surveying, the absolute last thing they want is to see a facility get shut down, which is why they work as hard as they do to get the facility back into compliance as quickly as possible.

“We absolutely want to see them back in compliance,” Forbing-Orr said. “Putting a facility out of compliance means that these residents will have to move, which can be traumatic for them.”

The new management at Pacifica Senior Living was unable to comment at this time.