NBC 6 Investigators

Inspection Reveals Nursing Home Failures Put Residents at Risk of Contracting COVID-19

Records obtained by NBC 6 Investigators show how small actions can place an entire senior care facility in “immediate jeopardy” during the coronavirus pandemic.

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Residents and staff members at Golden Glades Nursing and Rehabilitation Center in Miami were in “immediate jeopardy” according to a survey completed by federal investigators in early April.

The state reports dozens of residents and staff members from the same facility have contracted the virus since.

NBC 6 Investigators obtained a survey conducted by the Centers for Medicare and Medicaid Services (CMS) at the nursing home located at 220 Sierra Drive in Miami. The survey, which lasted three days beginning on April 1, found the facility was not following “infection control safety practices and guidance,” recommended by CMS and the Centers for Disease Control and Prevention (CDC) to respond to the coronavirus pandemic.

During their visit, investigators noted the facility “failed to implement isolation precautions to control or prevent the potential spread” of the virus.

Among the deficiencies, they found a resident came in contact with a COVID-19 positive resident while sharing the same room. But the facility failed to isolate him and alert the nursing home and hospital staff about the potential exposure, even when he was transferred to a hospital for a low grade fever. 

In fact, the resident's hospital transfer form said he had not been in contact with anyone who had tested positive for the virus, according to the CMS survey report.The staff member who completed the form told investigators she was not aware that the resident was exposed and that his roommate had tested positive days prior. She didn’t recall any signage posted on their room's door or any protective gear available outside of it to use as a precaution.

On April 2, the facility's infection control nurse told investigators she had not included any residents on her surveillance tracking form related to COVID-19, including those who required isolation precautions.

The survey revealed how the smallest details in this pandemic can put many in the building at risk.

Inspectors found a receptionist was screening individuals before entering the facility on April 1 by using a “pulse-oximeter,” a small machine that measures a person's pulse and blood oxygen levels, but she didn't follow the proper instructions.

The receptionist told investigators she used the same pulse-oximeter on staff, visitors and residents that day, but she did not clean their fingers “before or after use, to minimize the risk for transmission of COVID-19.” Investigators noted the machine’s manufacturer instructs users to clean the individuals’ fingers and the oximeter using alcohol before and after each test is done. 

The consequences were dire. According to CMS investigators, the failures to comply with infection control requirements put the more than 170 people in the building in “immediate jeopardy” and “had caused, or was likely to cause, serious injury, harm, impairment or death to residents.”  

Margalie Williams, a certified nurse assistant and union leader who works at Golden Glades, was not surprised about the findings.

“They don’t tell nobody who has corona,” Williams said in an exclusive interview with NBC 6 Investigators. “They have to change because we work with the patient. We have to know what the patient has.”

Williams says she hasn’t been in the facility for over a month after testing positive for the coronavirus.

 “My body was aching. Every bone in my body was hurting me,” Williams said when asked about the symptoms she experienced. “I thought my life was over. I was sick like a dog. I couldn’t even stand up.”

She’s feeling better now but she worries about her health, as well as giving the virus to others if she is forced to return to work.

Margalie Williams

“Me? It’s easy for me to catch even a cold because I am a survivor. And I had a stroke three times. So that makes any little thing, it’s easy for me to get it,” said Williams, who is also a cancer survivor.

“My body can’t fight with 'corona.' I know I have problems," she said. 

So far in this pandemic, 454 long-term care facilities in Florida have reported at least one positive COVID-19 case. More than 1,500 residents and 1,500 staff members have tested positive.  

According to the Florida Department of Health, Golden Glades has reported three deaths related to the virus and 12 residents and 13 staff who have had the virus. They transferred out 13 other residents after testing positive.

“When I look at these numbers, they could prevent that before. If they take 'corona' serious, they could prevent that,” Williams said when asked about the number of residents and staff impacted.

NBC 6

The inspection came as part of a Centers for Medicare and Medicaid Services survey announcement, allowing states to schedule more than 7,000 targeted “infection control” and “immediate jeopardy” investigations on nursing homes. 

The report shows CMS removed the 'immediate jeopardy' designation on April 3, after Golden Glades staff took corrective action. The facility remained out of compliance due to less severe violations related to residents’ records.

CMS said that state investigators returned to Golden Glades four days later for a follow up inspection and found the facility was in compliance with regulations. There were no deficiencies cited.  

NBC 6 contacted Golden Glades' administration for this story but we were directed to its parent company, Ventura Services Florida. Neither of them responded to our repeated requests for an on camera interview or comment about the survey report and Williams’ claims.

NBC 6 Investigators received an anonymous tip about positive cases at Golden Glades in early April. At the time, Jamie Lashley, Vice President of Strategic Planning from Ventura Services, declined to provide information about COVID-19 cases inside citing privacy concerns but said, in a statement, that the facility had reviewed its infection prevention and control policies. 

Williams says she hopes the nursing home is more transparent with workers moving forward.

“When we don’t know what the patient has, it’s not good for us, it’s not good for our family, because we put ourselves in danger and we bring that to our family,” the veteran nurse assistant and mother of five said. “We have to protect ourselves and protect our families.”

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