Norwich — With “very good guidance” in place on handling COVID-19 in nursing homes, the state’s long-term care ombudsman called it “reckless” that staff at the Three Rivers nursing home would go to work sick after known exposure to the coronavirus and interact with staff and residents without a mask and that the home mingled infected residents with those who didn't have the disease.

Mairead Painter, state long-term care ombudsman, said Wednesday her office is awaiting further findings by the state Department of Public Health into the COVID-19 outbreak at the Three Rivers nursing home at 60 Crouch Ave. The state found serious deficiencies at the home, where 21 residents have contracted COVID-19 and three have died.

Painter said her office will take its lead from DPH and will be looking for the possibility of criminal charges and license revocation for staff found in violation of federal and state mandates.

“There is a level of accountability that we need to seek for all of the residents there,” Painter said Wednesday. “Yes, there was a tragic impact, but it did put all the residents in the home at risk, as well as the team members. We’re looking into and getting an understanding of the full picture, and my office will look to see what the response will be from DPH.”

Painter co-chairs the steering committee of the Coalition for Elder Justice in Connecticut, which met Wednesday and on Thursday issued a statement on the Three Rivers nursing home COVID-19 outbreak and the state’s investigation.

The coalition "believes the serious events that took place at Three Rivers Healthcare in Norwich, demonstrate the need for all (health care) professionals to continue their vigilant adherence to all infection control practices as set forth by our public health officials to prevent the spread of (COVID-19)," it said in the statement.

The coalition called on health care providers' management to take responsibility for all the people they serve and ensure that employees have access to proper protective equipment and training. It asked that the outbreak at Three Rivers continues to be investigated and called for "appropriate accountability."

"All older adults receiving services are dependent upon the commitment of every staff member to follow infection control protocols," the coalition said.

Three Rivers officials have not returned repeated requests for comments on the outbreak and the state’s investigation since the outbreak was first announced Aug. 20.

DPH released its findings on Monday, along with the detailed inspection report on the Three Rivers home. DPH spokesman Av Harris said Wednesday that enforcement action is pending based on the findings of the investigation.

DPH found numerous violations at the 114-bed nursing home that put the lives of residents and staff in “immediate jeopardy” on Aug. 18. DPH staff have been at the home daily since the outbreak was detected. Investigators interviewed 20 residents and numerous staff in different positions.

The inspection report stated that the Three Rivers home instituted immediate corrections, and the designation of “immediate jeopardy” was removed later the same day, Aug. 18.

According to the inspection report, the first resident tested positive for COVID-19 on Aug. 2 at the hospital. The home had a plan to designate the A unit as the COVID-19 positive unit, but the director of nursing services told state investigators that as more residents tested positive — 10 on Aug. 15 — the unit became overwhelmed and could not accommodate all the residents who were either under investigation for coronavirus or who had tested positive for it.

There was no plan in place for three distinct units, the report stated, “and residents who were positive, negative and under investigation for COVID-19 were interspersed on the A and B Units.”

Several interviews by state investigators revealed that a registered nurse, called RN#2 in the report, had traveled out of state on a family vacation. RN#2 told investigators she had been exposed to two family members who had tested positive and knew she could test positive. RN#2 tested positive on July 27.

Co-workers and a supervisor told investigators RN#2 frequently removed her mask. A supervisor said RN#2 was told repeatedly to replace her mask and to keep socially distant from one resident she had visited. One LPN who had worked with the RN subsequently tested positive for COVID-19. The LPN told investigators RN#2 told her on July 24 she was not feeling well, with "sinus issues.” Another LPN told investigators that RN#2 was not wearing a mask at times during her shift that day.

Investigators also reported that the LPNs did not inform supervisors that the RN was not feeling well and not wearing a mask.

As of Monday, five Three Rivers nursing home staff have tested positive for COVID-19 during the outbreak.

Painter said there are definite lessons for other nursing homes in the state, and she was pleased with DPH’s quick response to the outbreak. “I was happy that the Department of Public Health got right in and pleased the state got the results quickly,” she said. “My concern now is a level of accountability.”

The lesson, she said, is that nursing homes cannot afford to become complacent on the exhaustive protocols to prevent the spread of COVID-19.

“We are dependent on every staff member following every protocol and that management is ensuring that every precaution is taken,” Painter said. “This shows that an outbreak can occur and can have deadly results.”

c.bessette@theday.com