Lorraine Sheppard moved into Potomac Valley Rehabilitation and Healthcare Center for physical therapy in mid-April, just as the nursing home reported its first coronavirus case.

Within three weeks, the largely healthy 92-year-old was dead.

Sheppard was one of at least three newly admitted short-term residents who contracted the coronavirus at Potomac Valley — a Rockville, Md., facility that continued to take new patients even as it struggled to contain a growing outbreak.

What happened to her points toward a thorny question faced by all nursing homes: Whether to continue taking new patients during a pandemic that has devastated the elderly and infirm, leaving many facilities short-staffed and overwhelmed.

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Governments in New York and other states have been lambasted for forcing nursing homes to accept COVID-19 patients to free up hospital beds, but less attention has been paid to the implications of nursing homes choosing to accept non-COVID-19 patients into their ranks.

For these facilities, closing the door to new residents means shutting off a precious source of revenue and turning away people in desperate need of care. But continuing admissions risks exposing new and existing residents to the coronavirus, especially if the facility is unable to properly isolate patients or lacks staff and protective gear.

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In Maryland, like across the country, such decisions are often left to the facility. State and local health departments sometimes impose admission bans, but not consistently.

The Washington Post contacted 103 Maryland facilities with at least 30 known coronavirus infections. Of the 46 that responded, 20 said they had stopped external admissions at some point since the pandemic started. The remaining 26 said they did not.

According to documents obtained by The Washington Post, Potomac Valley continued to admit patients who did not have COVID-19 from April to May, a span in which 92 residents and 52 staff tested positive for the virus. Over nine days in May, five new patients arrived, all short-term stay residents like Sheppard, records show.

Potomac Valley and its parent company, Vita Healthcare Group, declined to say how many short-term residents have been admitted since the pandemic started or how many of them contracted the coronavirus.

Administrator Kathryn A. Heflin said the 175-bed facility abides by federal guidance and takes pride in “help[ing] patients with complex needs.” She added that the facility is now “COVID-free” and has not reported new infections for several weeks.

Two Potomac Valley employees, who spoke on the condition of anonymity to avoid retribution, said nurses and nursing assistants asked administrators repeatedly in April and May to stop admissions, to no avail.

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“We have COVID everywhere, and yet we are accepting patients,” said one employee in early May. “Right now, I’d chop off my right leg before I’d send my parents here.”

Sheppard’s daughter, Tina Bell, said Sheppard died as Bell and her brother were trying to pull her out of Potomac Valley. They were alarmed by a Washington Post article in which employees described the facility as dangerously short-staffed and unable to isolate coronavirus-positive patients.

The discharge process was underway, Bell said, when she got the call saying Sheppard had COVID-19.

“I wish they hadn’t admitted her,” Bell said. “Here’s where the system failed.”

While nursing homes are known for treating elderly patients with medical conditions, they also serve as a pit stop for short-term patients, such as those in need of physical therapy or those recuperating from surgery.

When elective surgeries were canceled in mid-March, nursing homes lost many of those patients and, like hospitals, took a massive financial hit.

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The daily reimbursement rate for Medicaid recipients, who generally are the long-term residents who fill the vast majority of a nursing home’s beds, is $271.45 in Maryland, said Joseph DeMattos Jr., chief executive of the Health Facilities Association of Maryland. That is about 60% of what Medicare or private insurance pays for short-term-stay patients. DeMattos said that because Medicaid is underfunded, nursing homes have to take in different types of patients to finance quality care.

Richard Feifer, chief medical officer at Genesis HealthCare, which operates 25 facilities in Maryland, said admission bans are considered a routine part of infection control. Closing the doors of many facilities was among the first steps the organization took when the pandemic set in.

But DeMattos said nursing homes should not be blamed for trying to stay financially afloat by taking in new residents — especially if they can isolate coronavirus patients and have enough employees, gloves and masks to provide appropriate care.

“Our advice has consistently been, though, that you have to have the physical layout to have an observation space and the personal protective equipment and staffing to do it safely,” DeMattos said.

Erickson Living, a national chain that operates the Riderwood Senior Living Community in Calverton, Md., opted to stop all external admissions on March 20, said spokesman Dan Dunne.

Genesis stopped admissions at 215 of its 361 facilities nationwide when signs of COVID-19 appeared and did not resume until all residents and staff were cleared of the disease, Feifer said. According to an earnings report from the publicly traded company, the drop in admissions contributed to $14 million in losses in its first quarter, though most of that was offset by Medicaid reimbursements and changes in payer mix.

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“Any time any nursing home is not taking in admissions, and there are empty beds, there’s naturally likely to be a negative financial impact,” Feifer said. “But during a pandemic, you put patient safety first, and it is that simple.”

Any time any nursing home is not taking in admissions … there’s naturally likely to be a negative financial impact. But during a pandemic, you put patient safety first, and it is that simple.” — Richard Feifer, Genesis HealthCare

The Arden Courts of Towson near Baltimore, Md., stopped admissions in April. Allowing new patients during an active outbreak places them at risk of getting the disease, said Julie Beckert, a spokeswoman for the facility, especially because some residents have a tendency to wander. “These decisions are not financial,” Beckert said. “They are made because it is the right thing to do.”

Not all providers made the same choice.

Collingswood Rehabilitation and Healthcare Center in Montgomery County, Md., which as of July 1 had the second-highest nursing home death toll in the state, has continued to admit both COVID-19 and non-COVID-19 patients since March, said administrator Leah Whetzel.

Asymptomatic patients are isolated from symptomatic and COVID-19 patients, Whetzel said, and the facility has not struggled with shortages of staffing or protective equipment. As of Thursday, 41 residents and staff at the facility had died of COVID-19.

CommuniCare, another large operator in Maryland, chose to continue admissions at 16 of its 18 facilities, pausing them at two facilities only after being ordered to by health officials in Allegany and Carroll counties, said spokesman Fred Stratmann.

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The company’s Clinton Nursing and Rehabilitation Center in southern Maryland, where 196 staff and residents tested positive for the disease, has not ceased admissions at any point.

“Pandemic or no,” Stratmann said, “there are still people in need of skilled nursing care.”

Pandemic or no, there are still people in need of skilled nursing care.” — Fred Stratmann, CommuniCare spokesman

In Maryland, local health departments can order facilities to halt admissions, said DeMattos.

The same is true in Virginia, where local officials make recommendations for temporary admission bans “to ensure the facility can safely care for their current residents before accepting new resident admissions,” said Sarah Lineberger, a program manager in the health care-associated infections program of the state health department.

Lineberger said her agency does not track how many local admission bans have been put in place in Virginia, where nursing homes and long-term care facilities have reported 889 COVID-19 deaths — 55 percent of all fatalities in the state – as of last week.

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The Washington D.C. health department has not implemented admission bans at any of the city’s 19 nursing homes, but most voluntarily stopped taking new patients at the peak of the crisis in April and May, said Veronica Sharpe, president of the D.C. Health Care Association. As of June 28, there were 978 nursing home residents in D.C. who had tested positive for the coronavirus and 157 who had died.

In Southern Maryland, St. Mary’s County ordered all facilities to stop new admissions once there was a single coronavirus case, said county health officer Dr. Meena Brewster.

Montgomery County, Md., which leads the state in nursing home outbreaks, did not have a blanket rule barring admissions but instructed some facilities to do so on a “case-by-case” basis, said health department spokeswoman Mary Anderson. She declined to say whether Potomac Valley was among them, adding that the state Office of Health Care Quality “asked that counties not share specific information on facilities.”

Maryland Health Department spokesman Charles Gischlar said the only facility the state has barred from taking new admissions is Pleasant View Nursing Home in Carroll County, the site of Maryland’s earliest major outbreak.

The state fined Pleasant View $70,000 in May for lapses in infection control measures.

Lorraine Sheppard’s son, Mike Sheppard, said the lack of consistent state and county guidance on admissions was a mistake. “Why didn’t the state lock them all down?” he asked. “It didn’t take a rocket scientist to see that nursing homes were vulnerable.”

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Gischlar did not respond to questions about whether the state should have intervened earlier. As of Thursday, there have been 1,920 COVID-19 deaths linked to Maryland long-term care facilities.

When COVID-19 arrived at Potomac Valley, the facility was already grappling with major changes in personnel. The family-owned facility was sold last year to Vita Healthcare Group, a private company based in New Jersey. As the virus arrived in April, there was an exodus of senior staff members, including the director of nursing and longtime administrator.

The crisis peaked the following month. Nurses and nursing assistants became so busy caring for COVID-19 patients, they weren’t able to ensure that other residents were being fed daily or protected from symptomatic patients, said two employees, who spoke on the condition of anonymity because they feared retaliation at work.

Protective equipment was limited, two employees said. Isolating suspected and confirmed coronavirus patients was not possible.

“We’re already overwhelmed,” one employee said in May. “They’re bringing people in to get them sicker than they were.”

Lawrence Hartit, 74, was admitted in early March to recover from foot surgery, and discharged in late April with a high fever. Less than a day after returning home, Hartit was transported by paramedics to the hospital, where he tested positive for the coronavirus.

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It took him more than a month to recover, said his wife, Daryll Franklin-Hartit. “He came out of there worse than when he went in … What he went through – it was awful.”

In addition to exposing the new short-term residents to the coronavirus, Potomac Valley’s decision to keep admitting patients meant staff were further strained, said employees.

Family members of seven residents said their loved ones suffered from a lack of care in April and May. One woman said a harried nurse told her that her mother hadn’t eaten in two days; another man said he was not informed that his mother had COVID-19 until after she was intubated in a hospital.

Christopher Cofone, whose mother, Dorothy Piel, died in April, said communication from the facility was “dismal,” and he has spent months trying to reach administrators to learn more about how his mother died.

When Kay Buck, 85, suffered a stroke in May and needed to be moved to a nursing home to recover, staff at Howard County Hospital told her daughter, Suzanne Strayhorn, there were no facilities taking in new residents in Ellicott City, Md., where she lived.

Strayhorn said she was told Potomac Valley was the “only option.”

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Two weeks after Buck arrived, Strayhorn began trying to transfer her out of the facility. Family members were rarely able to get through to the nurse’s station or receive an update on Buck’s condition, she said.

In the “blips of time” when they were able to reach Buck, she would plead to leave Potomac Valley.

“I can’t sleep at night because I’m so worried,” Strayhorn said. By mid-June, Buck had been transferred to another facility.

“There was no way we could stay,” her daughter said. “It was just so dire.”