Inspection after inspection found problems. How nonprofit Boise nursing home went wrong

May 1—State and federal health officials say they spent months trying to bring Good Samaritan Society-Boise Village into compliance with safety regulations before taking a drastic step that will cause the nursing home to close next month.

Officials with the federal Centers for Medicare & Medicaid Services and the Idaho Department of Health and Welfare said they repeatedly warned local and regional Good Samaritan administrators about concerns that the nursing home had failed to demonstrate it could correct deficiencies identified during a series of inspections.

On April 5, the centers terminated a contract for Good Samaritan, off State Street at 3115 Sycamore Drive in the Collister neighborhood, to obtain Medicare and Medicaid service reimbursements, effective May 20.

"In the month before termination, CMS communicated with the national corporate leadership and warned of the impending termination if the facility did not take adequate steps to return to substantial compliance," spokesperson Lorraine Ryan wrote in an email to the Statesman.

The deficiencies came during the "height of the unprecedented pandemic," said Randy Fitzgerald, executive director of Evangelical Lutheran Good Samaritan Society, a Sioux Falls, South Dakota, nonprofit that operates the nursing home.

"We developed a comprehensive action and sustainability plan and believed we were in substantial compliance with all of the outstanding issues outlined from the state survey agency and CMS," Fitzgerald wrote in an email to the Statesman. "Unfortunately, on April 20, we were informed that we were not in substantial compliance. Without the ability to care for Medicaid and Medicare patients, we are unable to continue our mission in our Boise location."

The centers ensure that nursing homes meet an essential level of safety and quality of care to protect Medicare and Medicaid beneficiaries from abuse, neglect, exploitation, inadequate care or supervision, she said.

For six months, Good Samaritan was in noncompliance, amassing serious violations in medication administration, abuse, quality of care and infection control, Ryan said. Five inspections, or what the centers call surveys, were carried out between October and March. A report from a sixth inspection, on April 16, is pending.

"At the conclusion of each survey, the findings were discussed with the facility, they were given an opportunity to provide a correction action plan, and the state conducted three followup revisit surveys to determine whether the facility had demonstrated a return to compliance," Ryan wrote.

In February, the centers notified Good Samaritan that they would deny payment for services to new Medicare and Medicaid patients admitted March 13 or later. They also fined the nursing home $10,000 and imposed a daily penalty of $760 until the home was in substantial compliance with program regulations.

Even after notifying Good Samaritan April 5 of the impending termination, the agency said the nursing home could avert that action "by correcting its deficiencies."

That didn't happen, nor did Good Samaritan appeal the decision. On April 20, the nursing home told its staff and patients that it would close a month later, on May 20. The Statesman reported the impending closure on April 21.

The state Department of Health and Welfare's Division of Licensing and Certification, on behalf of the federal agency, conducted all of the inspections.

Each of the Good Samaritan inspection reports between Oct. 2 and March 29 documented substandard care provided to some residents.

The Oct. 2 inspection, for instance, found that one patient was mistakenly given medications meant for the man's roommate. Because of the mix-up, he experienced increased confusion, shaking in his hands, and decreased ability to perform self-care activities.

In the same report, another patient was given two drugs in error. Afterward, a doctor ordered nurses to check the man's condition every 15 minutes for an hour and then every hour for the next six hours. There was no documentation that he was monitored during those six hours, even though one of the medications had a high risk for adverse and serious side effects, including serious infection and death, the report said.

A followup inspection on Oct. 20 found that a patient given a heart medication was not monitored appropriately.

A Nov. 10 inspection found that patients and workers weren't promptly tested and retested following a COVID-19 outbreak. After a staff member was diagnosed on Oct. 29 with the coronavirus, 22 patients in one of the nursing home's wings were tested, along with staff.

But the home's 61 other patients were not tested. And while the residents who were tested were retested 11 days later, that should have happened within three to seven days, the report said.

Previously, Fitzgerald told the Statesman that Good Samaritan remained committed to the health and well-being of its residents and staff as it works to place residents in other nursing homes.

It is being assisted in those efforts by Health and Welfare's Division of Licensing and Certification, the Division of Medicaid and the long-term care ombudsman at the state Commission on Aging.

Good Samaritan is one of only two nursing homes in the United States to have its Medicare and Medicaid reimbursement contract canceled so far this year. Belle Terrace in Tecumseh, Nebraska, is the other.

"Terminations are rare," Ryan said.

Institutions and businesses besides nursing homes can also face terminations. In February, the centers canceled their Medicare reimbursement contract with Healing Arts Day Surgery, an ambulatory surgical center in Nampa.

The nursing home is not affiliated with the Good Samaritan Home, which provides housing for low-income people at risk of homelessness, veterans, seniors, and adults with physical and mental health disabilities. The Good Samaritan Home is located at 3501 W. State St., about a mile east of the nursing home.

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