The four ambulances arrived in quick succession Monday morning, filing into the parking lot of the long-term care facility in Kirkland that has become a focal point in the United States’ response to the novel coronavirus illness.

For Life Care Center, COVID-19 has brought seven resident deaths out of nine total in the state – and nation – by Tuesday evening. It has also brought a cluster of illnesses, a wave of questions from family members with relatives inside Life Care and scrutiny over how prepared the care facility and others are for an outbreak.

Health experts warn that nursing homes and other assisted living facilities are especially vulnerable, not only because they largely serve elderly residents, but also because many have been cited for health violations.

Ambulances have arrived each day at Life Care, with emergency workers wheeling away the sick on a stretcher. In some instances, a white sheet is held up to shield the patient from cameras. Of the 27 total COVID-19 cases to emerge statewide as of Tuesday evening, 14 have been linked to Life Care, according to officials. Some 50 people among the facility’s 100-plus residents and 180 staff were being monitored for signs of the illness, officials said over the weekend.

“We don’t really know what has led to this, but we know generally speaking that it’s very common for nursing homes to have very lax systems for control in place,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a nonprofit that advocates for residents of nursing homes and other assisted living centers.

Life Care said in a statement it was following all the proper protocols for dealing with the outbreak and stemming its spread. Visits from family members, volunteers and vendors were being halted as a precaution, Ellie Basham, the center’s executive director, said in the statement.

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“We are doing everything that the CDC [Centers for Disease Control and Prevention] and the State of Washington recommends and we are in regular contact with them,” Basham wrote in a separate email to family members of its residents.

But even as the center halted visits, one family member of a patient told The Seattle Times in an interview she was allowed to walk right in Sunday evening to see her 89-year-old mother.

Kim Frey drove 230 miles from Twisp to visit her mother, who last month was hospitalized with a severe respiratory illness at nearby EvergreenHealth and nearly died. When she went to Life Care Sunday, the only thing on her mind, she said, was “What if she dies and she’s in there all alone?”

Frey said she didn’t anticipate being allowed into the facility, but an employee noticed her standing outside her mother’s window and let her in. Frey made a sign to hold up to her mother. It read, “We can’t come in, but Jesus can … you’re not alone! Drink a lot of water.”

Staff at Life Care were caring for Frey’s mother well, she said. They were “smiling and reacting to her pleasantly, not making me feel rushed at all. I was very encouraged by what I saw.”

And the mood inside the facility was “actually pretty peaceful,” she said, no buzzing alarms or people rushing around.

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But now that she’s out of the facility, Frey said, she questions whether visiting her mother was the right thing to do. Frey said she wore a mask when she saw her mother, and took a shower and washed her clothes. Still, she wonders whether she might be carrying the disease – and whether she may inadvertently pass it to her 88-year-old father.

The center declined to respond to questions  about Frey’s account of the visit.

Failures to follow requirements for preventing infections are the most commonly cited violations among nursing homes nationally, according to a Seattle Times analysis of inspection data from the federal Centers for Medicare and Medicaid Services. Such violations often consist of a staffer’s failure to wash hands or properly dispose of sanitary gloves and don’t affect a large number of patients.

In this regard, the Life Care Center in Kirkland was neither an exception nor an outlier. Health inspectors cited the facility last April for failures to prevent infections, the only such finding in recent years, the federal data shows. CMS rates the facility three out of five stars for health inspections, and five stars overall.

Authorities have cited other nursing homes more often for infection-prevention deficiencies.

At Life Care Center, though, the lapses by staff to guard against infections had the potential to affect many patients, according to state and federal records.

During a series of unannounced visits last March and April, investigators documented a range of infection-related concerns, from how staff treated wounds to a broken exhaust fan in the laundry room. In one case, inspectors said they saw a nurse go into resident’s room without personal protective equipment, despite a sign outside warning staff and visitors to wear a mask, gown and gloves when entering. The resident had a suspected respiratory infection and was being kept in isolation. Investigators also noted that the resident’s oxygen device was tangled with the bed sheet and socks, instead of being bagged to prevent infection.

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Separately, the investigators observed a kitchen employee use the same gloves to load dirty dishes into the dishwasher and then stack clean dishes.

There were two influenza outbreaks on the facility’s infection-control report that month, and at least 17 residents and seven caregivers fell ill, according to the investigators. The facility said it trained staff and corrected the mistakes. When investigators conducted a follow-up visit in June, they found the facility was in compliance.

Since Saturday, Life Care Center has not responded to requests for interviews or comment. But in a statement Monday, the facility said staff members are following all proper hand-washing and other hygiene protocols, which include wearing masks, gowns and gloves, while tending to residents with symptoms of the illness. Those symptoms include fever, cough and shortness of breath.

Staff is also required to be screened as they enter and leave the property, Life Care said, though the facility’s statement did not describe the extent of the screenings.

Meanwhile, visits from families, volunteers and vendors have been halted, with Life Care urging relatives to call if they have specific questions about a resident.

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As the days pass and COVID-19 cases mount, friends and family of residents at the facility have described frustration over a lack of communication as they seek updates. Meanwhile, Gov. Jay Inslee said at a press conference on Monday that a team of about 20 people from the Centers for Disease Control and Prevention had arrived to respond to the cases at Life Care Center.

On Thursday evening, a health care worker at Life Care checked into Overlake Medical Center. A day later the Bellevue hospital notified local health officials that the woman in her 40s had tested positive for the virus – the first confirmed case with ties to the long-term care facility.

She was placed in isolation, her condition stable.

Inside Life Care, meanwhile, there were only hints for residents of what was to come.

A respiratory illness was spreading among the residents at the facility, where staff and aides had started wearing disposable masks early last week in an apparent attempt to contain it, according to Bonnie Holstad, the wife of a resident. But she believed at the time it was either a cold or flu-like illness when she visited the facility on Wednesday.

That same day, residents and staff gathered for a belated Mardi Gras celebration, passing around plates of Cajun cuisine and cake to the tune of a live band. Staff handed out purple, green and gold hats and masks.

Patricia McCauley, of Kirkland, said she and her husband, who aren’t residents at Life Care, had attended the party with a friend who is staying at the facility. Two days later, they returned to visit him but her husband, who was first to arrive at the door, was told by a staff member that he would have to wear a face mask to enter because an illness was spreading inside the facility.

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“That’s when he got really upset,” she said. “He said they shouldn’t be letting anybody in.”

The couple left, and has since inquired repeatedly without receiving a response about any precautions they should take in the event they had been exposed to the virus, McCauley said.

She said that she and her husband were not showing any COVID-19 symptoms.

By Friday, Life Care staff decided to confine residents to their rooms.

Holstad, grew so fed up that she stood outside the facility with a handmade sign Saturday, asking staff to take her husband’s temperature.

Her husband, who lives with Parkinson’s disease, wasn’t able to recall on the phone with her whether he’d had his temperature taken. The couple’s conversations have growing increasingly intermittent, because he often forgets where he put his cellphone and staff are not helping him find it.

Holstad said she hasn’t been able to reach anyone on staff consistently. The last they spoke, her husband did not have a fever, she said, though she could hear him coughing on the phone.

“I truly, truly want to believe they’re doing all the medical things properly,” Holstad said.

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