Federal inspectors found Miami Nursing Center failed to control infection risks for the resident, who shared a room with someone who tested positive for COVID-19 on December 10. The facility had already identified six residents and seven staff members who contracted the virus since the beginning of December.
Resident #6 had severe cognitive impairment with a BIMS score of three and required supervision with all decision-making, according to care plan documents. Their quarterly assessment showed they exhibited no problematic behaviors and walked with assistance from a walker.
On December 12 at 12:35 p.m., inspectors observed Resident #6 standing beside their bed while their roommate, Resident #5, lay in the adjacent bed. Neither resident wore a mask. No barriers separated the two beds, and no isolation equipment was visible in the room.
Five minutes later, Resident #6 left their room and walked with their walker to the lobby area near the front office and nurses' station. The resident wore no isolation mask during this journey through common areas of the facility.
Multiple nursing staff members passed Resident #6 in the hallway and lobby. None wore isolation masks themselves, and none encouraged the resident to put on a mask or asked them to return to their room, according to the inspection report.
The room lacked basic isolation protocols. No signage indicating isolation status appeared on or around the door, and no personal protective equipment was stored near the entrance for staff or visitors to use when entering.
LPN #1 told inspectors that Resident #5 was in isolation for COVID-19, but Resident #6 was not isolated and "could come and go from the room as they wished."
The Director of Nursing explained that Resident #5 had not been part of the facility's initial COVID-19 exposure testing on December 1. Instead, Resident #5 tested positive while out of the facility for an appointment on December 10.
That same day, Resident #6 tested negative for COVID-19. The facility offered the resident two options: move to another room while their roommate isolated, or remain in the shared room with the COVID-positive resident.
Resident #6 chose to stay with their infected roommate.
The decision created ongoing problems for infection control. Nurse's progress notes from December 11 documented that Resident #6 removed isolation signage from their door and took the personal protective equipment basket from outside their room.
The behavior continued the next day. Progress notes from December 12 showed Resident #6 kept removing signage from their door and biohazard bins from their room, undermining the facility's attempts to maintain isolation protocols.
The Director of Nursing acknowledged these actions but said the facility's hands were tied. She told inspectors that staff informed Resident #6 they needed to wear a mask when leaving their room, but "it was the resident's right to decline to wear a mask and their right to leave their room whenever they wished."
This approach left other residents and staff potentially exposed to COVID-19 transmission from someone who had direct, unprotected contact with a positive case and was actively dismantling safety measures.
Four days after the inspection, on December 16, Resident #6 tested negative for COVID-19 again. But for nearly a week, the cognitively impaired resident had moved freely through the facility's common areas without protective equipment, potentially carrying the virus to vulnerable populations.
The outbreak at Miami Nursing Center represented exactly the kind of uncontrolled spread that federal infection control requirements are designed to prevent. By December 23, when inspectors completed their report, thirteen people in the facility had contracted COVID-19 in less than a month.
The facility's approach of allowing a cognitively impaired resident to make infection control decisions while actively removing safety equipment highlighted the challenge of balancing resident rights with public health protection during disease outbreaks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Miami Nursing Center, LLC from 2025-12-23 including all violations, facility responses, and corrective action plans.