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State ombudsman: Investigation into Norwich nursing home won't end with closure order

Norwich — The state long-term care ombudsman’s office started getting complaints from residents at the Three Rivers Healthcare nursing home just as the state Department of Public Health stationed staff daily at the home during a spike in COVID-19 cases that eventually infected 22 residents and six staff, leading to four residents’ deaths.

But state Long-term Care Ombudsman Mairead Painter said Thursday that her team of regional ombudsmen and support staff could not enter the facility or any other nursing home in the state. The ombudsman’s office representatives are considered to be “visitors,” no different than family and friends and are prohibited from entering nursing homes under federal COVID-19 protective guidelines from the Centers for Medicare & Medicaid Services.

Painter said she has been trying to get the prohibition changed, to have her staff considered “essential health care oversight” to allow them to enter nursing homes and meet with residents, providing additional eyes on the levels of care and potential problems at homes. Prior to COVID-19, ombudsmen would visit residents, ask questions and leave their cards for people to contact them.

“There is unquestionably less oversight right now due to people not being in the building,” Painter said Thursday, one day after the state  ordered the nursing home closed and all residents relocated. “That’s normally where we get a lot of complaints. Family might see something that may be wrong, maybe not even involving their own relative, and pass it along to us.”

Painter said she has been working with many family members of the 53 residents at Three Rivers who will be relocated. Several have contacted her office since Wednesday’s announcement. Several said they already were trying to move to other facilities, because they felt they were not getting proper care at Three Rivers.

Painter said the closure of the nursing home does not mean the investigation is over and the state is “moving on.” Staff attorneys at the ombudsman’s office are tied to the state Attorney General’s Office, which is investigating. The state’s attorney’s office is involved to investigation possible criminal violations, and DPH and the federal Centers for Medicare & Medicaid Services also will investigate.

“These are people with licenses in our state and with the federal government to provide this care, and that’s why it’s important for them to be held accountable,” Painter said.

Department of Public Health inspectors and staff have been at the Three Rivers home since mid-August, when the COVID-19 outbreak became known.

“It was all alarming to me,” Painter said of the extensive and detailed inspection reports and notices of violations written by DPH investigators. “What raises questions to me is, how do we make sure management is held accountable for these things? Many of these are not (COVID-19) related. These are normal nursing home operations, these are misses.”

DPH acting Commissioner Deidre Gifford issued the unusual emergency order Wednesday that the facility be vacated of all residents, with the 17 residents infected with COVID-19 and the seven under observation for possible infection going to the state-approved COVID-19 facility, Riverside Health and Rehabilitation Center in East Hartford. The remaining 29 residents are receiving top priority at nursing homes of their choice in the greater Norwich area.

DPH has released two extensive inspection reports based on investigations of residents’ care records and interviews with staff and residents. The first report, released Aug. 31, chronicled how a registered nurse had vacationed out of state with family and returned to work feeling sick, frequently interacting with staff and residents without a mask while family members were sick at home awaiting COVID-19 tests.

The second, 71-page report and a 35-page violation notice were released Monday detailing investigations of daily care records, administering of medicines and staffing levels. By Sept. 10, state officials determined that a temporary manager was needed to oversee a corrective plan ordered to be done by Sept. 30. The report found lack of documentation on daily patient care records, times when an entire wing was left without staffing and patients not provided proper hydration.

The report also said 29% of staff — 16 of the 55 employees — had not received required weekly COVID-19 tests.

After 30 hours at the facility, state-appointed temporary manager Katharine Sacks reported that the problems were beyond correcting and recommended the home be closed — the first time such an order has been given by the state in the collective memory of state officials with 20 to 30 years of service who attended Wednesday’s news conference.

The relocations will be done slowly and carefully, Sacks said, about 10 per day starting with the COVID-19 residents.

Families concerned

Painter said Thursday residents and family members she has been in contact with are concerned about the level of care they will receive at Three Rivers while waiting to be relocated. Painter said she is confident proper care will be provided, with Sacks’ 30 years of experience dealing with troubled nursing homes and DPH's daily presence at the home.

Painter’s office held an online meeting with family members Wednesday morning prior to the state’s closure announcement and will have another live meeting with families Friday to answer “high level” questions and arrange for individual meetings to answer specific concerns one-on-one.

William Alvarez, husband of Three Rivers resident Noelle Henderson Alvarez, said he is seeking assistance from the state to allow his wife to be discharged to their home, a handicapped-accessible apartment in Wequonnoc Village in Taftville. Alvarez said his wife, 55, suffered a stroke in 2018 and has been at Three Rivers since then.

He said he saw a report of the state’s order to close the nursing home on TV on Wednesday night.

“I believe they should go in there and clean up house, the entire facility and hire new staff,” he said Thursday, “and I would prefer to have the state purchase the property, or have it condemned. It’s not the patients’ fault, it’s the staff or the owners for not hiring the proper people.”

Alvarez and his wife’s sister, Meliss Swanson, who is conservator for Noelle, have been trying to get Noelle discharged but Three Rivers had refused the request. The family believes William Alvarez and home nursing visits could provide the proper care, and Noelle, a retired nurse on disability, could become more independent and happier.

“I would love my wife to be home again,” William Alvarez said. “She’s only a young lady of 55, and I want to see her smile again. No one gives her a hug and loves her there.”


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