Anticipating a surge in patients, hospitals need to free up beds and discharge those who do not need extensive care. Nursing homes are just as desperate to prevent the kind of outbreaks that have invaded at least 146 facilities in 27 states, including Life Care in the Seattle suburbs, where more than 30 people have died of covid-19.

Administrators in both institutions are navigating conflicting and fast-changing guidance from local, state and federal authorities, advocates and medical professionals in nine states told The Post. Testing shortages at hospitals and limited availability at nursing homes have only exacerbated their challenges.

It’s a tension that has thrown seniors into a dangerous limbo and placed strain on families already burdened by intense social distancing mandates.

“This is the most strained and anxious that I’ve seen the system and staff and families and patients,” said Alice Bonner, a registered nurse and adjunct faculty at Johns Hopkins who has worked in nursing homes for decades. “People are trying really hard to do the right thing and to do the best they can.”

When asked about this dilemma, the U.S. Centers for Medicare and Medicaid Services – the federal agency that regulates the nation’s 15,000 nursing homes – referred The Post to recently released guidance that outlines the process for accepting coronavirus patients or those who might have been exposed to the infection.

The guidance says that nursing homes can and should accept residents back if they’ve tested positive for the virus or potentially been exposed, but only if their facilities are equipped to prevent spread within the nursing home as mandated by the Centers for Disease Control and Prevention.

If a nursing home cannot comply with those CDC rules, which include creating isolation wings and using personal protective equipment, the new CMS guidance says a facility “must wait” to accept the resident until they have been without fever and respiratory symptoms and taken two negative tests 24 hours apart. If tests are not available, the CDC says a resident can come home after three days without a fever and improved respiratory symptoms and at least seven days after the person first got sick.

Further confusing the process, the CDC guidelines also say that residents do not need to meet that criteria before being discharged from the hospital.

What the guidance doesn’t address is whether nursing homes have the right to refuse their residents who leave or are hospitalized for reasons other than coronavirus.

Absent that kind of clarity, and because coronavirus can turn even an asymptomatic person into a vector, nursing homes are treating anyone who leaves the facility and returns – including for nonmedical trips – as a threat. Residents have been instructed to self-quarantine with family or remain at the hospital until they can prove they aren’t infected with the virus.

Doctors and advocates from around the country told The Post that nursing home and hospital employees have been working through these difficult conversations with residents since CMS mandated that all nursing homes close their facilities to visitors indefinitely in an attempt to keep the disease out.

One Alzheimer’s patient at a Pennsylvania facility was hospitalized for a respiratory illness and had to wait a week to get a negative coronavirus test before they were allowed back into the nursing home. In another case in the commonwealth, a resident who left their nursing home for dialysis and returned with a fever was told they could not come home for fear they had been exposed.

An emergency room doctor in Texas said one of his patients left their facility for a funeral and was told they had two options upon their return: self-quarantine outside the facility for 14 days or get admitted to the hospital for three days, then have a doctor write a letter certifying they weren’t infectious.

And advocates in New York are concerned that short term nursing home and rehab residents – those who need temporary care for an injury or illness – are being involuntarily discharged from their facilities before they are ready to make room for a new surge of patients because of coronavirus, said Susan Dooha, executive director of the Center for Independence of the Disabled New York.

More cases have been reported in long-term care facilities in California, Florida and Colorado, demonstrating the lengths facilities are going to fortify themselves against the infection.

Janet Snipes, the executive director of Holly Heights Nursing Center in Denver for the past 43 years, said she has a responsibility to try to keep everyone in her building as safe as possible. She has one resident who is currently hospitalized for a non-respiratory issue. When she returns to the nursing home, Snipes said she will need to be screened carefully and probably be quarantined for 14 days.

“While we want to be part of the solution and not have hospitals back up, we want to protect our current residents,” Snipes said.

One solution is robust testing, doctors say, but both the shortage of test kits and lag time for results is placing residents in more danger. Testing criteria remains a moving target. Guidance from health officials is still varying from state to state and hospital to hospital. Patients are being treated, but not tested, which means nursing homes aren’t getting the kind of official confirmation they need to trigger isolation measures that can save lives.

“This is hugely concerning,” said Karl Steinberg, a nursing home and hospice medical director in San Diego County in California. “It’s really frustrating for the providers to not even have a diagnosis.”

For those who are able to get a test, the waiting period for results can last up to 10 days. The longer someone sits in a hospital, the more likely they are to be exposed to the deadly virus – and the faster hospitals are forced to burn through their rapidly dwindling reserves of masks and gloves.

The Sarasota Memorial Health Care System is just one hospital in Florida experiencing this. As of Thursday morning, about 70 patients were being held in isolation awaiting test results, a spokesperson said.

It’s “triggering a cascade of events” that “backlogs the hospital system,” said Chief Medical Officer James Fiorica.

“There’s only so many isolation rooms, there’s only so much protective equipment,” Fiorica said. “It creates anxiety for everybody taking care of them.”

In California and New York, two of the states with the most cases in the nation, advocates and physicians have reported confusion over conflicting guidance from government officials.

On Wednesday, the New York State Health Department mandated that “no resident shall be denied readmission or admission to the [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19.” The directive also prohibited nursing homes from “requiring a hospitalized resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission.”

In a sharp rebuke, national nursing home advocates said Thursday the state’s edict contradicts federal guidance from CMS, which has stipulated that “such decisions to accept a patient be made with the understanding that the facility can safely care for such patients,” according to a statement from the country’s leading society for post-acute care.

“We find the New York State advisory to be overreaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles,” the statement said.

Last week in Los Angeles, county health officials gave nursing homes a similar mandate, prompting concern among administrators who felt unprepared to accept and isolate coronavirus patients.

In Colorado, advocates have called on the governor to mandate the process for transferring patients from hospitals to nursing homes and prioritizing those patients for testing.

“We’re in unprecedented times with profoundly difficult decisions wrapped in a fog of confusion and stress,” said geriatrician David Nace, who is president-elect of AMDA and the chief medical officer for a collection of senior living facilities under the University of Pittsburgh Medical Center.

Nace acknowledged how important it is to get residents back home to familiar surroundings and caretakers, but he said he does not believe that facilities that are still coronavirus-free should be forced to accept positive residents.

“The nursing home is often the adopted family. People want to get back, and it’s their home, and they view it as such,” Nace said. “The difficult part is making sure that that transition is safe.”

What advocates and doctors agree on is the importance of preparation, which includes following the federal government’s recommendations for creating isolation facilities for those awaiting tests that are not a hospital or nursing home. Long-term care facilities have also been advised to create coronavirus wings in anticipation of a positive test.

In Pennsylvania, Nace said, hospital and nursing home leaders in his region are trying to get ahead of the surge with planning calls, one of which revealed that a facility has already prepared a 15-bed isolation unit for coronavirus patients. Vivage Senior Living facilities in Colorado has offered to accept overflow patients who aren’t sick with coronavirus so the hospitals can prioritize space for those who test positive.

“This is a time for everybody to be working together,” said Steinberg, the California doctor. “It’s a fluid situation, and we just don’t know where it’s all going to go.”

“This whole conversation might be moot in a month,” he said.