Resident #6 at Miami Nursing Center shared a room with Resident #5, who tested positive for COVID-19 on December 10. Despite the exposure risk, facility staff allowed Resident #6 to move freely throughout the building without protective equipment or isolation protocols.
On December 12 at 12:35 p.m., inspectors found both residents in their shared room without masks. No barriers separated the two beds. No isolation gowns, gloves, or masks were visible in the room, and no biohazard bags containing used protective equipment were present.
Five minutes later, Resident #6 walked out of the room using a walker and traveled to the lobby area near the front office and nurses' station. The resident wore no isolation mask during the journey through common areas.
Multiple nursing staff members passed Resident #6 in the hallway and lobby. None wore isolation masks themselves, and none encouraged the resident to wear a mask or asked them to return to their room.
Resident #6 had severe cognitive impairment with a BIMS score of three and required supervision or assistance with all decision-making, according to a November 30 quarterly assessment. A care plan from the same date confirmed the resident needed help with all decisions.
The facility's infection control failures went beyond a single incident. Nurse's notes from December 11 documented that Resident #6 had removed isolation signage from their door and the personal protective equipment basket from outside their room. Notes from December 12 showed the resident continued removing signage and biohazard bins.
LPN #1 told inspectors that Resident #5 was in isolation for COVID-19 but Resident #6 "was not in isolation 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. The roommate tested positive on December 10 while out of the facility for an appointment.
After Resident #5's positive test, the facility gave Resident #6 a choice: move to another room while their roommate isolated, or remain in the shared space. Resident #6 chose to stay.
The Director of Nursing acknowledged that Resident #6 repeatedly removed isolation signs, moved isolation carts from around the door, and took biohazard containers out of the room. Staff informed the resident they needed to wear a mask when leaving the room, but the Director of Nursing said "it was the resident's right to decline to wear a mask and their right to leave their room whenever they wished."
The facility's approach ignored federal infection control requirements for nursing homes, particularly for residents with severe cognitive impairment who cannot make informed decisions about isolation protocols.
Six residents and seven staff members had contracted COVID-19 since December 1, according to the Director of Nursing. The outbreak occurred during a period when the facility failed to implement basic infection prevention measures for exposed residents.
Resident #6 eventually tested negative for COVID-19 on December 16, four days after inspectors documented the isolation failures. The negative result came after nearly a week of unrestricted movement throughout the facility while sharing a room with an infected roommate.
The inspection found Miami Nursing Center failed to minimize infection spread risk, citing minimal harm or potential for actual harm. The facility's decision to defer to a cognitively impaired resident's preferences over infection control protocols put other residents and staff at risk during an active COVID-19 outbreak.
Federal regulations require nursing homes to implement infection prevention programs that protect all residents, particularly those unable to understand or follow isolation requirements due to cognitive impairment.
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.