LA SALLE (WEEK) --- In just one week last fall, the La Salle Veterans Home went from four cases of COVID-19 to over 100.
Now, a report from the Department of Human Services' Office of the Inspector General says the facility never had a clear plan, which led to deadly consequences.
An investigation found the home had virtually no outbreak plan in place - placing blame squarely on the Department of Veterans Affairs.
Employees weren't educated on the dangers of the virus or trained in how to monitor or control symptoms.
The report also says IDVA leadership made things worse by "consolidating too many responsibilities on one person… failing to delegate and assign responsibilities… and failing to learn from other outbreaks" - including one at another Illinois Veterans Home.
Leaders of the home are also to blame.
The report says management of the home was "slow to recognize that there was a problem and slow to ask for assistance."
By November 13th, ten veterans had died, and the report confirms "significant resources were waiting and available to assist the home if individuals on the management or leadership Teams would have asked." - but they never did.
Since the outbreak, the director of the IDVA has been fired, along with the facility's director.
The report ends by recommending corrective actions to prevent such a severe outbreak in the future - now, it is up to the IDVA to implement them.
One thing that was mentioned at the end of the report was the staff.
It notes while leadership largely failed, the staff's "genuine care" for the veterans was evident - even during the worst of the pandemic.
A copy of the full report can be viewed here.