A coronavirus outbreak at a skilled nursing facility in suburban Seattle has left as many as 23 people dead and sickened 70 workers at the facility, which is owned by Tennessee-based Life Care Centers of America. It has also led to 31 firefighters and three police officers being quarantined or isolated, with at least 18 showing symptoms of infection with the COVID-19 virus, which attacks the respiratory system. As of this week, the facility was the locus of infection for most of the U.S. residents who have died from the virus.

The stories emerging from the Life Care Center of Kirkland raise serious questions about the company's failure to take even the most basic steps to protect residents, workers, and first responders, who had been called to the facility seven times in January but 33 times in February and the first five days of March. Elderly people, who account for most nursing home residents, are particularly vulnerable to the COVID-19 virus. Relatives of patients at the facility reportedly tried to sound the alarm about conditions there for weeks.

Seattle NPR station KUOW reported that firefighters had learned through their chain of command that the facility's management said a resident and health worker had been tested for the virus. But when a firefighter showed up there, he encountered a charge nurse wearing just scrubs and no protective gear:

"Hey, you guys are supposed to be in self-quarantine," the firefighter said.

"No, we're not," the nurse replied.

"Well, our chain of command talked to your management, and they say something different."

The nurse insisted; she hadn't heard anything, she said.

The firefighter looked down the hall and saw two caregivers in scrubs — no mask or gown.

"What the hell?" the firefighter thought. "Who is not telling you that you have two suspected coronavirus cases?"

Later the nurse and firefighters would learn that it was more than just two suspected cases: Two people from Life Care had died the week before from coronavirus. Eight more who had spent time at Life Care would die in the following week.

Based in Cleveland, Tennessee, Life Care Centers of America was founded in 1970 by Forrest Preston, who at 86 remains its sole owner, chairman and CEO. The company is now the largest privately-owned long-term care facility chain in the U.S. and the third-largest overall, with more than 200 facilities in 28 states. The business has been good to Preston, who is now a billionaire and the richest man in Southeast Tennessee.

Preston is also a major Republican political donor, having contributed tens of thousands of dollars over the years to various GOP organizations and candidates, according to OpenSecrets.org. They include the National Republican Congressional Committee and the National Republican Senatorial Committee. In addition, Life Care is a significant lobbying force, having spent $280,000 on lobbying at the federal level in 2019 alone.

The long-term care industry's revenues come largely from government programs — particularly Medicaid, the health care program for the poor. Medicare, the health care program for older Americans, covers some services in nursing homes but not room and board. As of 2017, about 1.4 million Americans were living in nursing homes, with 64 percent relying on Medicaid to cover their care. In some impoverished states including Mississippi and West Virginia, Medicaid was the primary payer for three-quarters or more of nursing home residents as of 2015.

Life Care has been at the center of controversies in the past. In 2016, the company paid an unprecedented $145 million to settle federal claims of Medicare fraud for providing unnecessary rehab services. The settlement also resolved allegations brought in the separate lawsuit by the U.S. government that Preston, as Life Care's sole shareholder, was unjustly enriched by the fraud. That was the Department of Justice's largest-ever settlement with a skilled nursing facility chain.

In 2018, the U.S. Equal Employment Opportunity Commission sued Life Care Centers of America for pregnancy discrimination. According to the lawsuit, the company and its affiliate — South Hill Operations, doing business as Life Care Center of South Hill in Puyallup, Washington — violated federal law when it denied light duty to a pregnant employee and then in effect fired her. Last December the company agreed to settle the suit by paying the former employee $170,000.

Preston reportedly avoids the public spotlight, concerned about the risk it places on his family. He does not appear to have made any public statements since the COVID-19 outbreak at the facility near Seattle. But on March 7, the Life Care Center of Kirkland broke its silence with a press conference. A spokesperson said all of the facility's residents are being confined to their rooms while symptomatic employees are being asked to stay home. Visitors are also being turned away. The company has also released a statement in which it says it's now "taking necessary precautions to protect our residents from COVID-19."

Nursing homes have experienced difficulties keeping residents and workers safe in past disasters. In 2016, the federal Centers for Medicare and Medicaid Services issued a new rule on emergency preparedness for providers including nursing homes that covers pandemics, citing among other things the 2009 H1N1 influenza outbreak. The rule mandates that care providers participating in the Medicare and Medicaid programs establish written procedures, protocols, and policies ahead of an emergency event. That planning appears to have fallen short at the Life Care Center of Kirkland.

Meanwhile, the U.S. Department of Justice earlier this month announced the formation of a National Nursing Home Initiative, which will target "grossly substandard care" in nursing homes. Negligent owners and operators could face both criminal and civil penalties.