On May 15, 2020, Mosaic of Lakeshore, located in Chicago, IL, released long term care outbreak data reporting of laboratory confirmed COVID-19 outbreak cases. These statics confirm that 105 infections and 19 deaths have occurred at the facility during the COVID-19 outbreak.
In Quarter 1 of 2020 (January-March), a survey conducted on November 7, 2019, found Mosaic of Lakeshore to have committed a Type B violation. The violation included sections 300.1210b), 300.1210d)6), 300.1220b)3), and 300.3240a) of the code. The violations resulted in a fine of $2,200.
Based upon interviews and a record review, Mosaic of Lakeshore failed to provide the proper safeguards for a resident who was known for fall risks, as noted in the residents’ care plan. This lapse resulted in the resident falling and suffering a head injury, which required five sutures.
In Quarter 2 of 2018 (April-June), a survey conducted on April 20, 2018, found Mosaic of Lakeshore to have committed a Type B violation. The violation included sections 300.1010h), 300.1210b), 300.1210d)3), 300.1210d)5) and 300.3240a) of the code. The violations resulted in a fine of $2,200.
Based upon interviews and a record review, Mosaic of Lakeshore failed to properly identity and assess an injury to a resident. This resulted in a resident developing a stage 4 pressure ulcer that became infected and required hospitalization. The facility also failed to follow their feeding policies for residents with gastrostomy tubes.
In Quarter 4 of 2018 (October-December), a survey conducted on October 5, 2018, found Mosaic of Lakeshore to have committed a Type A and Type B violation. The Type A violation included sections 300.610a), 300.1210b), 300.1210c), 300.1210d)6), 300.1220b)3), 300.3240a) and 300.2900d)2) of the code and resulted in a $25,000 fine. The Type B violate included sections 300.610a), 300.1210b), 300.1210d)1), 300.1210d)2), 300.1210d)3) and 300.3240a) and resulted in a $2,200 fine.
Based upon interviews and a record review, the Type A violations that Mosaic of Lakeshore committed occurred when staff failed to monitor and supervise two residents to prevent the elopement of the resident. Further, the facility failed to follow a resident’s care plan, which alerted staff members that frequent monitoring was required to prevent falls from occurring. This resulted in hospitalization of a resident with a fracture. Furthermore, Mosaic of Lakeshore failed to implement fall interventions to prevent a resident from frequently falling.
Based upon interviews and a record review, the Type B violations that Mosaic of Lakeshore was found to committed occurred when the facility failed to follow its pain assessment policy for a resident. Further, the facility failed to follow their policy on administering medication. This occurred when a resident was not provided with pain medication as scheduled.
On November 7, 2019, the Illinois Department of Public Health conducted its yearly recertification review of Mosaic of Lakeshore In this report the facility was cited for multiple failures. The violations included; failure to follow multiple personal hygiene care plans for residents, failure to prevent cross contamination during wound care treatment, failure to provide assistance to a resident known for fall risks, and failure to maintain infection control measures for residents.
To combat the spread of COVID-19 in nursing homes, staff members must ensure that infection control measures are being followed. This not only protects all residents, but all staff members as well. The infection control violation that Mosaic of Lakeshore was cited for stemmed from the handling/placement of a resident’s urinary bag. Further, the conditions of the bathroom toilets and wash basins were not up to standards. The bathroom equipment was not properly stored, which can lead to contamination. The violation continued, with a staff member noted for improperly cleaning a resident and the residents’ room by using soiled gloves.
Mosaic of Lakeshore issued a plan of correction in response to the infection control violation. The facility noted that all residents can be affected when infection control policies are not followed, so they will subsequently monitor all staff to ensure future violations do not occur. Mosaic of Lakeshore also stated they would service all staff members on the proper practice of infection control.
Founding partner Steven M. Levin described these outbreaks in many Illinois Nursing Homes: “for many years prior to this outbreak, Mosaic of Lakeshore operated with insufficient staff and with a lack of adherence to recognized infection control protocols. It is not surprising that they were ill equipped to handle this outbreak.”
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As COVID-19 continues to spread, it has also magnified systemic breakdowns within Illinois’ long-term care facilities, nursing homes, or assisted living centers. After this latest release of reported data by IDPH, more than half of the COVID-19-related fatalities in Illinois have now occurred at these facilities.