Many Nursing Homes Battling COVID-19 Previously Had Infection Control Problems

Before the pandemic, a Hialeah Gardens nursing home was cited three times for infection control issues in about a year. 

NBC Universal, Inc.

A cellphone video shows Laura Gil celebrating her 94th birthday surrounded by her family. Two years later, she died after testing positive for the coronavirus.

“She did not have to die alone. Two months without seeing us, I don’t think that was fair to her,” said her granddaughter, Yamilet Pena, while fighting back tears. “She was dying for this to be over.”

Pena says her grandmother went to Signature Healthcare of Waterford in Hialeah Gardens for physical therapy in early March. Then, she fell ill. 

“All we knew is that she was sent to the hospital because she couldn’t breathe, that they have to intubate and that they didn’t have any means to do that there,” Pena said.

Laura Gil celebrating her 94th birthday with her family, including her granddaughter Yamilet Pena. Courtesy: Gil's family.

The Miami-Dade Medical Examiner attributed Gil’s death to COVID-19 and pneumonia. 

Gil is one of at least 15 residents from the nursing home who have died after contracting the virus. According to the Florida Department of Health, at least 100 people from there have tested positive for COVID-19, including 50 workers and 50 residents. Some have been transferred out. 

Never did we expect her to get infected with the virus or to die.

Yamilet Pena

Two days after Gil’s death, on April 23, investigators from the Centers for Medicare and Medicaid Services (CMS) found the nursing home “failed to implement infection control” amid COVID-19.

In emails to NBC 6, Signature Healthcare has repeatedly disputed the CMS’ findings calling the survey “flawed.” The facility provided a letter that was sent to the Agency for Healthcare Administration (AHCA), which oversees long-term care facilities in the state, requesting the deficiencies to be dropped and the results of a survey that was completed days later, which found no deficiencies.

The AHCA declined to comment about the previous inspection and referred us to CMS. 

In a statement, a CMS spokesperson told NBC 6 Investigators the agency stands by the inspection’s findings, adding the state conducted a follow-up survey on April 30 and found the facility corrected the deficiencies and “came back into compliance with regulatory requirements at that time.”

Laura Gil, a resident from a local nursing home, died after testing positive for COVID-19. Courtesy: Gil's family.

Before the pandemic, the nursing home was cited three times for infection control issues in about a year. 

In October, a CMS inspection found the facility failed to “thoroughly” investigate and report the case of a resident with salmonella to the Department of Health within the required timeframe. A doctor told investigators that no other residents were impacted. All deficiencies related to infection control were corrected a month later and were listed as “minimal harm or potential for actual harm.” The report also states the facility has been repeatedly cited for infection control deficiencies during annual inspections.

In another report, investigators noted the nursing home failed to maintain “transmission based precautions,” after a worker removed a shower chair from the room of a resident who was placed in isolation. According to the inspection, the worker put the chair in another resident’s bathroom without properly disinfecting it.  The chair was eventually removed from the room.

Signature Healthcare Center of Waterford in Hialeah Gardens.

When asked about the previous citations, the facility said: “All deficiencies, from all surveys have been 100% corrected” and that it remains “in 100% compliance with all federal and state regulations.”

An NBC 6’s analysis of the CMS’ citations revealed that about 90% of the nursing homes cited for infection control problems in South Florida, prior to the crisis (2017-2020), have reported cases or deaths related to the coronavirus.

“That’s unfortunate, but not surprising,” said AARP Florida Director Jeff Johnson when asked about our findings. “A lot of the things that inspectors are finding are little things that perhaps most of us for most of our lives don’t think about. But if your job is to keep people who are particularly frail from contracting illnesses, they become very important.”

Kristen Knapp from the Florida Health Care Association, a large trade group that represents nursing homes in the state, says the virus is also spreading in facilities with no prior citations.

“This virus is hard to control regardless of all the steps you take," Knapp said in a statement. “This is why we are restricting visitors, continue working with the state and private vendors on obtaining proper PPE and are asking for expanded testing.”

While Johnson agrees that all senior care facilities are at risk, he says infection control issues should be a warning sign.

“Obviously you want to be able to care for everybody who is at a long term care facility but you want to focus your resources in the places where you think there is more concern,” he said.

The Centers for Medicare and Medicaid Services told us they have prioritized inspections at facilities with past issues and they have conducted dozens in our area so far this year.

Contact Us