By Elizabeth Koh, Jon Kamp and Dan Frosch

It seemed a curious day for the Life Care Center to throw a Mardi Gras party.

For one thing, Feb. 26 was actually Ash Wednesday, the day after Mardi Gras.

More crucially, the nursing home was under orders to be in scrub-down mode due to a raft of respiratory problems among its residents. That same day, managers had ordered staff members to close the two dining rooms immediately, wipe down all common spaces and halt group activities.

But the party went ahead. It was one of the facility’s biggest events of the year, spokesman Tim Killian later said. Only those residents with concrete respiratory symptoms were kept in their rooms. Meanwhile, dozens of residents, visitors and staff shared cake and clapped as a local band performed songs like “When the Saints Go Marching In.”

Within days, nurses were calling in sick, and calls to 911 were spiking for ailing residents. By March 9, 129 people were infected with the new coronavirus, including 81 residents, 34 staff members including health-care personnel, and 14 visitors, testing showed. As of Sunday, 35 deaths were tied to the home, around 7% of the national total.

Even as cases of coronavirus spread nationally, the Life Care Center of Kirkland remains the single deadliest concentration in the outbreak. The unsuspecting facility was hurt by the bustling social calendar meant to enrich residents’ days with themed parties, performances and a welcoming attitude toward visitors. It has turned into a deadly example of just how easily and quickly the novel virus can spread, and how it preys on the elderly.

“For us, the 26th is the date everything started escalating,” Mr. Killian said in an interview.

This account, pieced together through records and streamed news conferences along with interviews with first responders, public-health officials, family members of residents and comments from the company that runs the Life Care Center, provides the most detailed description yet of what happened on the three days leading up to that Saturday, when the public learned that the facility had contracted the coronavirus.

It reveals that the Life Care Center management missed opportunities. A more aggressive response to the respiratory illnesses in their midst could have made a difference, federal health officials say, even if no one there suspected the much more deadly coronavirus.

Mr. Killian said, “Anybody who thinks they would have known and acted differently simply was not in the situation we were in...and simply does not understand what you can do in a single long-term care facility.”

On Monday, the Centers for Medicare and Medicaid Services said there were major violations at the Kirkland home that created imminent danger, including not identifying and managing sick residents. Mr. Killian said the company was disappointed CMS didn’t take into account the unprecedented nature of the outbreak.

All day that Wednesday, Feb. 26, the place was abuzz with activity. The facility admitted at least one new resident. A local physical therapy student and professor came by. Visitors came and left. The facility’s visitor log was so loosely enforced that it proved insufficient for tracing the disease later on, local officials said.

Throughout the week, firefighters responding to medical calls entered and exited the facility without protection, having had no warning of widespread respiratory problems among the residents. Even after one fire official heard a patient and a staff member were being tested for coronavirus and the facility was supposed to be on self-quarantine that Friday, a nurse told him that day she didn’t know anything about it.

Mr. Killian said to his understanding Life Care staff didn’t know the patients were being tested for coronavirus at hospitals until they got the results on Saturday.

The Life Care managers’ response wasn’t out of line with what might be expected at any other long-term care facility in the country, unprepared for a global health emergency without precedent in modern history, public-health experts said in interviews.

“This could happen anywhere,” said Dr. Jeffrey Duchin, health officer for Seattle and King County’s public-health entity, which monitors communicable disease outbreaks, in a call with reporters.

Seattle-area nursing homes had little reason or direction to be on high alert. Though Washington state on Jan. 19 had its first identified case of Covid-19, the disease caused by the novel coronavirus, the patient had traveled to Wuhan, China, where the disease started. The Kirkland home’s vulnerable residents weren’t likely to have traveled abroad recently, much less to mainland China, where warnings from federal public-health officials were focused at the time.

“It just think it took them by surprise,” said Mike Weatherill, whose mother, Louise Weatherill, was a resident of the facility and died of pneumonia shortly after the first cases were announced. “I’m not going to blame anybody. It’s a real tragic and horrible thing that’s happened.”

First signs

Exactly when or how the virus first arrived at the Kirkland home, a beige and blocky one-story complex surrounded by residential condominiums, is still unclear. The facility had around 120 residents in mid-February, according to Life Care.

It is among more than 200 elder-care facilities spanning 28 states owned by Life Care Centers of America, a privately held company based in Tennessee that is one of the nation’s largest nursing-home operators. The Kirkland facility rated five out of five stars on Medicare’s Nursing Home Compare quality-ranking site, although it had a three-star health-inspection rating.

Staff members had begun to notice enough respiratory cases by Feb. 10 to take some precautionary measures, Mr. Killian said, including putting up printed-out signs in hallways and by doors to warn of the illness within the facility.

Mr. Killian said in a recent news conference that such respiratory illness symptoms were common. Residents are often near the end of their lives. “We see between three and seven deaths in a normal month,” he said.

Pat Herrick, 61, said she suspected nothing at the facility where her mother, Elaine Herrick, had lived for seven years until she came by for her weekly visit on Sunday, Feb. 23.

Ms. Herrick said she noticed some staffers wearing masks in the Baker wing, where her mother lived in room 5. Ms. Herrick had occasionally seen staff members don masks before, when flu cases popped up. She asked a staffer if there was a flu going around.

“Some people are just being cautious,” she recalls being told.

At 1:34 a.m. on Feb. 24, Baboucarr Lowe, a Life Care nurse, called 911 about a 73-year-old woman in room 26 who had been on antibiotics for pneumonia.

“She’s just having bad oxygen levels?” the 911 operator asked, according to recordings. “Difficulty breathing,” the nurse said. Her heart rate fluttered at nearly 200, he relayed. “She’s shaking too…she’s shivering.”

A woman matching that description was then rushed to the hospital, according to a subsequent report from the Centers for Disease Control and Prevention, where she registered a fever of 103.3 and needed intubation and mechanical ventilation the following day.

Again that Monday, the facility called 911—this time about a 54-year-old man with a traumatic brain injury. He, too, had a fever and was increasingly restless.

The next day, Fat Tuesday, a resident who would later test positive for coronavirus and die, transferred from the Life Care Center of Kirkland to the nearby Madison House assisted-living facility, another elder-care facility in Kirkland, a spokesman for Madison House confirmed. Some employees at the Life Care home in Kirkland also worked shifts inside several other facilities in the region before the outbreak was known, including Madison House, those facilities confirmed.

A resident who left the Life Care Center of Kirkland even earlier, on Feb. 19, was also found later to have had the disease.

Ash Wednesday

A memo signed by two Life Care Center of Kirkland managers, dated Feb. 26, spelled out the precautions staff members were to immediately implement “due to [the] increased number of Respiratory Symptoms.”

The Baker and Olympic dining rooms on opposite corners of the facility would be closed. Each patient would have meals served in their rooms instead, unless they needed feeding assistance. Group activities were to be put on hold.

A family member who shared a photo of the memo, recalled seeing it around noon on Ash Wednesday on the counter by the receptionist’s window in the lobby. At the bottom of the memo, wrapped in several asterisks, the memo said: “Let’s be Safe and Help Protect Our Patients.”

Mr. Killian described the memo as “business as usual, normal operating procedures” that the facility would take with any influenza-like outbreak.

A few hours later, at 2 p.m., the Mardi Gras party started up in the Baker dining room.

Several residents, seated in their wheelchairs next to each other, listened to the swing band, which played regularly at senior facilities in the area. Residents and guests drank Sprite or other soft drinks as they sang and clapped, said Patricia McCauley, who attended with her husband, Bob McCauley, and a friend they were visiting at the facility.

Though some staffers in the hallways were wearing masks, the only mask worn inside the party was a glittery masquerade-style one, Ms. McCauley remembered.

“My parents were touching tables, chairs, pushing wheelchairs. It was a big germ fest,” said Cheri Chandler, the McCauleys’ daughter, who wasn’t at the party that day.

“We have the same questions of how prudent that was in hindsight,” Mr. Killian, the nursing home spokesman, said, but he stressed that the facility still believed it was dealing with a run-of-the-mill flu outbreak. “We did not have a Covid positive test at that point.”

While the party was still going on, around 3 p.m., Lori Spencer brought her mother, Judie Shape, to be admitted to the facility. Mrs. Shape, 81, was recovering from a recent surgery for a blood clot at a nearby hospital and needed additional care after developing an infection, Ms. Spencer said.

No one at the facility informed the two women of a possible respiratory outbreak, Ms. Spencer said. She recalled no signs on the walls and said she wouldn’t have proceeded with enrolling her mother there if she had.

Mr. Killian said he could not speak to individual memories of signs at the facility, but said that signs noting respiratory illnesses were posted throughout the month.

A student training to be a physical therapist assistant and a professor from Lake Washington Institute of Technology were also in the halls that day. Sixteen more students in the school’s nursing program and two additional faculty members would visit during the rest of the week. A fourth faculty member visited a relative at the nursing home. All would subsequently be self-quarantined.

Also on that Wednesday, for the first time, Life Care reached out to state and county public-health officials to alert them to a respiratory outbreak, Mr. Killian said.

There were two deaths tied to Life Care that day, which officials would later trace to the coronavirus: a female resident in her 80s who was never hospitalized and the 54-year-old brain-injury patient who was taken to Harborview Medical Center in Seattle two days earlier. The facility wouldn’t learn about those coronavirus cases until early March.

On the other side of the continental U.S. that day, a man from Wake County, N.C., began to show Covid-19 symptoms, which state health officials later linked to his visit to Life Care. On March 3, he would become North Carolina’s first presumptive case.

Just before midnight on that busy Wednesday, Life Care had to call 911 again. Another woman was struggling with respiratory problems. She was 92 years old and had pneumonia. She was transported to EvergreenHealth Medical Center.

Feb. 27

On Thursday morning, the public-health office for Seattle and King County received a message from the Kirkland facility, notifying them of the respiratory illnesses.

The notification felt routine and without urgency, a spokesman for the health agency said.

It wasn’t until the regional health unit’s communicable disease program received a similar call from EvergreenHealth later that day—about two patients with unexplained pneumonia—that suspicion stirred, according to a timeline later provided by the health unit.

The regional health staff member who took the message noticed that one of those two patients had come from Life Care, hospitalized since Feb. 24. Public-health staffers asked the hospital for specimens as quickly as possible for coronavirus testing.

That evening, Lt. Dick Hughes of the Kirkland Fire Department responded to two calls from Life Care that had troublingly similar symptoms: a 74-year-old woman with “labored breathing,” around 5:30 p.m., and a woman in her late 80s, just shy of 8 p.m., who was “sweating, clammy, having a hard time breathing,” 911 recordings show.

Nurses seemed more worried than usual, Lt. Hughes recalled, as they frantically asked for help.

He and his team fitted patients with oxygen masks, giving them nebulizer treatments to help them breathe. He recalled the patients coughing up fluid that would splatter on the firefighters.

“Something is not right here,” Lt. Hughes said he and his crew agreed at one point that night. They decided to don masks, gowns and protective glasses the next time they were called into the facility.

Feb. 28

Lt. Hughes’s next call from Life Care came just after 4 a.m. Friday, for an 84-year-old woman who an employee said was diagnosed with pneumonia a couple of days earlier. A 911 log for the call included the language: “FLU SYMPTOMS—PPE FOR RESPONDERS ADVISED,” meaning protective gear such as masks and gowns.

After he returned to the firehouse from the trip to Life Care, Lt. Hughes typed up an email to the city’s Emergency Medical Services Captain Joel Bodenman, noting the three distress calls for respiratory problems at the facility during his shift. “They don’t meet any of the King County public health criteria of reporting potential COVID-19 but all had similar symptoms and it’s an anomaly to have that many resp. distress calls in a day.”

Also that morning, the county’s public-health offices received word of another suspicious case, from a second nearby hospital. The patient was a Life Care employee.

When a county public-health employee called the nursing home to follow up on the facility’s report of a respiratory outbreak, Life Care said about 20 residents were ill—six with pneumonia. Eighteen employees also were sick. And though about 30 residents had been tested for the flu, going back two weeks, tests were returning negative.

Visitors to the Life Care Center, including Mr. and Mrs. McCauley, who had attended the Mardi Gras party just days earlier, discovered by midday that they could visit residents only if they wore masks. Signs were posted on the entrance doors to the facility’s lobby, warning prominently of the respiratory outbreak.

The McCauleys subsequently self-quarantined and were eventually tested, but the tests returned negative.

Lt. Hughes, on duty again Friday, heard that afternoon from the local EMS captain that county health officials were having a Life Care patient and staff member tested for coronavirus, and that the facility was self-quarantining.

When Lt. Hughes returned to the facility on a call at 9:20 p.m., he saw no sign of a quarantine. Nurses were moving from room to room with no extra protective equipment that he could see.

When he asked the charge nurse on duty, he recalls her saying that she didn’t know anything about a quarantine.

Lt. Hughes, unnerved, called his EMS captain to confirm Life Care was supposed to be on quarantine. He said it was.

When Lt. Hughes returned to the nursing home later that night to check, nothing had changed. This time, the nurse told Lt. Hughes that she had spoken to her supervisor, who told her they were having a flu outbreak and staff were not to call 911 unless the patients were very sick.

“They were running it like it was a normal Friday night a year ago,” he said.

After driving away from Life Care, he got a call from his captain. The coronavirus tests had returned positive, and a patient had died.

Lt. Hughes and his crew were being put into quarantine. Lt. Hughes developed symptoms but a coronavirus test came back negative, a city spokeswoman said.

Mr. Killian said management had issued no orders to go into quarantine at Life Care that day because no one there knew the patients were being tested until they received results Saturday.

A man in his 80s who died inside the facility that Friday would posthumously test positive for the coronavirus and not be announced as another of its victims until March 18.

Feb. 29 and beyond

Just minutes after midnight on Saturday, Feb. 29, the facility was told a test on a hospitalized resident was positive for coronavirus. This was the 73-year-old woman rushed to the hospital five days before, the CDC later said.

Later in the morning, local officials held briefings announcing new cases. Life Care said it was closing its doors to new visitors—though some were allowed in regardless.

Mr. Killian said that there was some question about whether the facility had the authority to bar people from seeing their family members, something it later determined only the government had the authority to do.

Last week, the CDC issued a study saying that nursing-home facilities in the Seattle area, including the Kirkland facility, contributed to their vulnerability in many ways, including failing to implement infection controls such as using alcohol-based hand sanitizer and wearing proper gear. Staff members would also work while symptomatic, the CDC said, a practice that was shut down by the Life Care Center on Feb. 29.

Mr. Killian said he didn’t read the CDC study “as a condemnation of our practices at all,” but rather as a summary “of what we’ve learned since that happened.”

After the Kirkland home received its first positive test, it wouldn’t get enough testing kits for the bulk of the residents for another week, Mr. Killian said. Moreover, all employees couldn’t be tested for another two weeks due to a lack of tests, he said.

As of Friday, 42 residents remained inside the facility: 11 negative for Covid-19, 31 positive. One of them is Mrs. Shape, who was diagnosed earlier this month.

Her daughter broke the news of her positive test to her over the phone. Mrs. Shape and Ms. Spencer haven’t been able to be in the same room since the contagion at the nursing home was announced.

At some point there has to be an apology from the Life Care Center, Ms. Spencer said.

“You can understand a lot about crises, but I will never understand the death count at Life Care,” she added.