NORWICH, Conn. (WTNH) — A Connecticut Department of Public Health investigation into an ongoing COVID-19 outbreak at Three Rivers Nursing Home in Norwich found serious infection control violations, such that the residents in the facility are in “immediate jeopardy.”

The outbreak began July 24, 2020, when one staff member tested positive for the coronavirus during routine, weekly testing.

The DPH reports their investigation found serious violations facility-wide “in general infection control practices, staffing, cohorting (grouping together) residents who tested positive, and use of personal protective equipment (PPE).” 

The outbreak, so far, has infected 21 residents of the nursing home – three of whom have died and one of which is hospitalized – and five staff members. DPH says the rest of the residents who have tested positive for COVID-19 are recovering at the facility, “segregated from other residents who have not tested positive.”

RELATED: CT Dep. of Health investigating COVID outbreak at Norwich nursing home

DPH began their investigation of the outbreak Aug. 17. Since then, they have conducted “daily on-site visits, reviews of facility records, and interviews with multiple residents and staff.”

The DPH issued a “statement of deficiency” for the facility following the investigation. The DPH says these statements can be made when “violations in management or practice are found in nursing homes that put patients’ care at risk.”

DPH says for the Three Rivers facility they issued a finding of “immediate jeopardy,” meaning the violations were serious enough to risk immediate harm to the life of residents.

The state is also investigating whether the facility violated state regulations, laws, or executive orders.

In a statement, DPH said they are saddened by the loss of life at the facility due to the outbreak and will continue their investigation to ensure safety for residents.

DPH is deeply saddened by the further loss of life in nursing homes related to COVID-19. We will continue our robust monitoring and enforcement activities in partnership with CMS to ensure that nursing homes are providing a safe environment for their residents.

Our investigation uncovered system-wide failures in this nursing home in infection control practices, that merited the finding of immediate jeopardy. DPH is committed to holding facilities accountable and ensuring that improvements in patient care are made so residents’ lives are not put in danger.

– Acting DPH Commissioner Deidre S. Gifford, MD MPH

Gov. Ned Lamont said of the investigation into Three Rivers Nursing Home at a press conference Monday, “There were severe deficiencies that we’re gonna look at, and hold people accountable. Look, more to the point, all the other nursing homes have done pretty well. This one, it was severe.”

Josh Geballe, C.O.O. for the Office of the Governor added, “We’re hopeful at this point that action has been taken to mitigate the impacts at this point.”

Gov. Lamont said “broadly speaking,” he thinks they’ll be able to open things up a little, allowing loved ones to see their parents or grandparents “safely” but a little more frequently.

Three Rivers has 10 days to present a corrective plan-of-action to the Dept. of Health.

The detailed, full investigative report in the statement of deficiency is available online by searching for it by date (between August 25-30).

Thursday, Three Rivers Health Care released a statement reporting this week they submitted a “comprehensive plan for corrective action to DPH.”

The health and safety of our residents and the staff members who care for them is our greatest priority at Three Rivers Healthcare—after the COVID-19 pandemic began in March, our infection control policies and procedures kept our residents and staff COVID-free for over four months.

Since the occurrence of positive COVID-19 cases reported in our home, we have been working with the state Department Public Health (DPH) and its epidemiologists as we monitor the health of our residents and staff.

This week, we submitted a comprehensive plan for corrective action to DPH, and we continue to work with DPH on a daily basis to implement the plan as the situation evolves.

We offer our deepest sympathies to the families and loved ones of the three residents who succumbed to the virus and remain ever-vigilant in keeping everyone in the Three Rivers family safe.

–   Scott Ziskin, President/CEO, JACC Health Center of Norwich, which operates Three Rivers Health Care