MOORHEAD, Minn. — A Moorhead nursing home that's had at least three residents die from COVID-19 violated several protocols in preventing the spread of the illness, including failing to alert staff when an infected resident was sent to a Fargo dialysis center, according to a Minnesota Department of Health report.

The 64-page report released Wednesday, May 27, details multiple instances of staff and residents at the Moorhead Rehabilitation and Healthcare Center not following coronavirus prevention guidelines last month, putting all 43 facility residents, staff and personnel from outside entities at risk.

Along with the three deaths, almost half of the residents tested positive for the virus, and seven were hospitalized, according to the report.

Moorhead Rehabilitation, at 2810 2nd Ave. N., disagrees with many of the health department's findings and plans to appeal the report, nursing home spokesman Jon Austin said in a statement.

"The safety and well-being of our residents, staff and families remains our highest priority," he said. "We will continue to coordinate closely with state and local health authorities and will take additional steps as needed to support that commitment.”

Story and narration by April Baumgarten / The Forum

The Moorhead nursing home was among four in Minnesota that put its residents in “immediate jeopardy,” the health department said. The other three were Parkview Home in Belview, Sauer Health Care in Winona and the Villa at Bryn Mawr in Minneapolis.

Inspectors noted that residents, nursing staff and other facility employees did not routinely wear face masks before the facility confirmed its first case on April 2. That was more than three weeks after Minnesota reported its first positive test and two weeks after the first Clay County resident tested positive for coronavirus.

The facility handed out masks after that, but there were reports that residents improperly wore the face coverings. Staff did not advise them to adjust the masks, the report said.

One resident who moved around the facility without a mask tested positive for coronavirus, the report said.

The facility also failed to document coronavirus screening, consistent monitoring and isolation for some residents who showed symptoms, the health department said.

A resident who tested positive for the virus was in a Fargo dialysis center for an hour before staff were alerted he or she was infected, the report said. The nursing home also failed to inform the transportation company about the resident’s condition, and he or she rode in a vehicle with another resident while infected, the health department said.

The report did not name the dialysis facility or the transportation company involved.

The Centers for Medicare and Medicaid Services, part of the U.S. Department of Health and Human Services, has the final say on whether nursing homes that do not follow guidelines will face civil penalties. It's unclear whether Moorhead Rehabilitation could face such punishment.

Scott Smith, a Minnesota Department of Health spokesman, said the agency is working closely with long-term care facilities to prevent the spread of coronavirus. The agency plans to hold nursing homes "accountable for implementing and maintaining the proper infection control practices to ensure the maximum protection for their residents and staff," Smith said in a statement.

"These facilities and their residents are particularly vulnerable to outbreaks, which makes it very important for facilities to take swift and sustained actions to limit the potential for introduction and spread of the infection," he said.