WINONA -- On March 24, a week after a statewide stay-at-home order went into effect, two residents at Sauer Health Care tested positive for the COVID-19 virus.

By the time health inspectors visited the Winona nursing home April 14, 33 residents and 22 staff members there had tested positive for the virus -- with at least five of them dying from it.

A report released by Minnesota Department of Health concludes the facility filed to control the outbreak. It was one of 200 facilities inspectors visited last month as the outbreak spread in congregate care facilities. So far, about 81 percent of the more than 900 COVID-19 deaths across the state have been people living in congregate care facilities.

According to the 19-page report generated from an April 14 inspection at Sauer Health Care, and a review of the facility's records, at least one resident showing symptoms of the virus during the outbreak was moved into a room with a woman not showing symptoms. That woman later contracted the virus, the report states.

According to the report, the woman was admitted March 11 to a room on the west wing. Her medical records showed no symptoms of illness such as cough, sore throat or elevated temperature from the time of her admittance through April 1.

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The report states another woman, identified as “R3,” had been coughing, complained of a sore throat and had a temperature of 99.6 March 29. Despite those symptoms, “R3” was moved from her east-wing room to the west-wing room on March 30. “R3’s” record did not show she had any illness symptoms March 31, but does show that by midday April 1, she had a temperature of 101.2, complained of not feeling well, and had a cough. She was then moved back to her previous room in the east wing. She was tested for COVID-19 the next day and results returned positive April 3.

On April 14, test results show the woman living in the west wing whom “R3” briefly shared a room with tested positive for COVID-19.

According to the MDH report, Sauer Health Care director of nursing said she wasn’t aware “R3” showed any symptoms of illness before moving her. The director also told inspectors the facility’s infection preventionist left around the end of January or the beginning of February.

The newly hired infection preventionist conducted some staff training, but not all staff attended. The infection preventionist was also pressed into service for daily resident care instead of performing infectious disease surveillance, tracking and trend analysis duties described in the position.

Staff also failed to properly wear or remove personal protective equipment and wore or carried protective gear used in areas where COVID-19 patients were being treated into other areas of the facility, according to the MDH report.

Messages requesting comment from Sauer Health Care were not returned.