Federal inspectors documented multiple infection control breakdowns at Miami Shores Nursing and Rehab Center during a March inspection, finding that basic safety protocols collapsed even as 14 residents remained isolated for COVID or COVID exposure.
On March 23 at 7:51 AM, inspectors watched staff enter a contact and droplet precaution room while distributing breakfast trays without any personal protective equipment. The facility's own policy requires staff to wear masks, gowns and gloves before entering rooms of residents on droplet precautions.
Staff knew the rules. When interviewed, Certified Nursing Assistant Staff E said she would "put on mask, gown and gloves before entering the room" for COVID-positive residents. Staff F described wearing "a gown, glove, hat and mask before entering the room." Staff G outlined the proper sequence: "clean my hands, knock, apply gown, gloves, mask and shield for droplet precautions."
But inspectors found doors to droplet precaution rooms propped open despite signs instructing that doors "be closed at all times." When asked about the open doors, Staff O replied, "Sometimes the residents ask to leave the door open. I do not know why the doors were left open, but I will close them."
The Director of Nursing acknowledged the contradiction. She told inspectors that doors should remain closed but "some residents don't like having the door closed and request to leave it open." The facility tries to "honor residents' rights," she said, even when it conflicts with infection control protocols.
Resident #2's catheter tube touched the floor on March 24, creating a direct pathway for bacteria to enter the urinary system. The resident was receiving oxygen at 2 liters per minute through a nasal cannula when inspectors photographed the contaminated tubing.
Staff N, a Licensed Practical Nurse working a double shift, claimed the catheter wasn't touching the floor during her morning rounds. "It appears the reason it was touching the floor was because someone lowered the bed too low," she said. She rounds every two hours "to make sure the proper interventions are in place."
Staff P, the Certified Nursing Assistant caring for Resident #2, insisted the tubing wasn't on the ground during her morning check and denied lowering the bed. "The bed should not be too low because the tubing or bag might touch the ground for infection control purposes," she said.
The nursing educator told inspectors the entire catheter system was replaced at 8:10 AM after the violation was discovered.
Basic housekeeping failures compounded the infection risks. Inspectors found trash and food scattered across the floor of the residents' pantry room on the East side nursing station at 7:01 AM on March 23. The pantry stores residents' food and provides microwave access for capable residents.
Staff L, a Licensed Practical Nurse, couldn't explain the mess. "I don't know, I cleaned it when I came on shift. Housekeeping cleans the room in the morning," she said.
The Environmental Services Director said she cleans the pantry Monday through Friday, with weekend staff covering Saturday and Sunday at 5:00 AM. But the weekend housekeeper called in late that day, leaving the porter responsible for pantry cleaning.
Staff Q, the weekend housekeeper, arrived at 8:00 AM instead of her scheduled 5:30 AM start time. Staff R, the porter, explained he hadn't cleaned the pantry yet because he was "still taking out the trash from around the building" when inspectors arrived at 7:01 AM.
The soiled utility room door wouldn't lock, leaving biohazardous materials accessible to unauthorized personnel. Staff L entered by punching a code into the keypad, but when she walked away, inspectors overheard her tell another staff member "the door doesn't lock."
When confronted with both Staff L and the porter present, both confirmed the lock was broken. The Maintenance Director fixed the lock by 7:58 AM and logged the repair.
Inspectors also discovered a mask and supplement carton abandoned in the East side shower room.
The wound care nurse violated hand hygiene protocols during treatment of Resident #57, who had a diabetic ulcer measuring 6.2 x 4.7 x 0.2 centimeters on the right lateral lower leg. On March 25, inspectors watched the nurse perform wound care using double gloves throughout the procedure, sanitizing the outer gloves instead of changing them between steps.
The facility's hand hygiene policy states "the use of gloves does not replace hand washing" and requires staff to follow proper handwashing procedures "to help prevent the spread of infections." The Director of Nursing told inspectors that "staff should not double glove when giving care to residents" and should "throw away gloves and wash hands."
But the wound care nurse defended her technique, telling inspectors she had "doubled gloved during wound care observations in the past with the Agency for Healthcare Administration and they have been okay with it."
Resident #57 has diabetes, which slows wound healing, and requires specialized care including an air mattress for pressure relief, pillow offloading for heels, and repositioning every two hours. The resident receives Percocet and Tylenol for pain management and has orders for weekly skin checks.
The wound care nurse, employed at the facility since 2022, said the resident "is non-compliant and refuses treatment or medications," complicating the healing process. A podiatrist visits Thursdays for wounds below the knee, while a wound doctor handles injuries from the hip up on Tuesdays.
The facility's infection control program aims to "prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals." The Director of Nursing said staff receive monthly education and surveillance with "on the spot teaching."
She had been in her position for two months at the time of the inspection. The nursing educator "does frequent rounds on the floors and observes staff performing hygiene care," she said.
The facility conducted COVID outbreak training on March 14, covering hand hygiene, proper use of personal protective equipment, and early signs and symptoms of infection. Staff receive "almost everyday" education from the infection control nurse, according to multiple employees.
But the gap between policy and practice remained evident throughout the inspection. Staff could recite proper procedures when interviewed but failed to follow them when they thought no one was watching.
The 96 residents at Miami Shores Nursing and Rehab Center depend on staff to maintain basic infection control barriers that prevent the spread of dangerous pathogens. When those barriers fail, residents face increased risks of healthcare-associated infections that can lead to serious illness or death.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Miami Shores Nursing and Rehab Center from 2025-03-26 including all violations, facility responses, and corrective action plans.
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