“After increasing in February and March, occupancy was flat in April. Labor is still a serious challenge within the industry and some operators are still unable to admit new patients due to staffing shortages.”

– Bill Kauffman

NIC MAP Vision released its latest Skilled Nursing Monthly Report on June 30, 2022. The report includes key monthly data points from January 2012 through April 2022.

Here are some key takeaways from the report:

Skilled nursing occupancy was flat for the month of April. Skilled nursing property occupancy held steady at 77.3%. However, occupancy has increased 140 basis points since January 2022 as demand seemingly picked up after the Omicron variant subsided. In addition, occupancy has increased 524 basis points since the low of 72.1% in January 2021 and remains at the highest occupancy level since April 2020, in the beginning of the pandemic. Although occupancy has increased in recent months, it is still down considerably (8.9 percentage points) compared to February 2020 before the beginning of the pandemic. There are some positive signs given the increases in occupancy since the low, but many challenges remain including labor shortages, operating expense pressure, and the proposal to claw back Medicare reimbursement as it relates to the Patient Driven Payment Model (PDPM).

Medicare revenue mix declined in the month of April. Decreasing for a second month in a row, Medicare revenue mix declined 72 basis point to end April at 20.6%. After increasing to start 2022, from December 2021 (20.6%) to January 2022 (24.4%), it has now decreased 397 basis points from the 2022 high (24.6%) set in February. The increase to start 2022 was likely due to the elevated number of COVID-19 cases in January and suggests there was a significant uptick in the utilization of the 3-Day Rule waiver as COVID-19 cases increased. The 3-Day Rule waiver was implemented by Centers for Medicare and Medicaid Services (CMS) to eliminate the need to transfer positive COVID-19 patients back to the hospital to qualify for a Medicare paid skilled nursing stay, hence increasing the Medicare census at properties. As cases declined, the Medicare revenue share has declined as well. Meanwhile, Medicare revenue per patient day (RPPD) decreased for the third month in a row to end April at $568. This suggests that due to decreasing COVID-19 cases there was less additional reimbursement needed for COVID-19 positive residents, who require additional measures of care to be implemented.

Managed Medicare revenue per patient day (RPPD) continued its decrease in April. It decreased from $456 to $454 in April and is down 2.1% from last year in April 2021. It has decreased $111 (19.6%) from January 2012 and continues to create pressure on operators’ revenue as managed Medicare enrollment grows around the country. The persistent decline in managed Medicare revenue per patient day continued to result in an expanded reimbursement differential between Medicare fee-for-service and managed Medicare, which accelerated during the pandemic until January 2022. The difference between Medicare fee-for-service and managed Medicare RPPD in January 2022 was $123. Pre-pandemic, in February of 2020, the differential was $91. However, the difference has decreased since January 2022 to end April 2022 at $114. Meanwhile, managed Medicare revenue mix increased 14 basis points from March to end April 2022 at 10.8%. It is up 26 basis points from last year and has increased 269 basis points from the pandemic low of 8.1%. The increase from the pandemic low is likely due to growth in elective surgeries from 2020, which typically creates additional referrals to skilled nursing properties.

Medicaid patient day mix increased for the second month in a row. It increased 79 basis points in April to end the month at 66.0%. It has increased in a similar trend as Medicaid revenue as it also increased for second month in row. Medicaid revenue mix increased 243 basis points from March to end April at 50.7%. Some of this increase is related to what was mentioned above, regarding the decline in COVID-19 cases from January and patients have now moved from Medicare patient days back to Medicaid, after utilizing the 3-Day Rule waiver. Meanwhile, Medicaid revenue per patient day (RPPD) increased from March to end April 2022 at $247. It is up 3.3% from the pre-pandemic period (February 2020) as many states embraced measures to increase reimbursement related to the number of COVID-19 cases to support skilled nursing properties, in addition to fiscal year increases.

Get more trends from the latest data by downloading the Skilled Nursing Monthly Report. There is no charge for this report.

The report provides aggregate data at the national level from a sampling of skilled nursing operators with multiple properties in the United States. NIC continues to grow its database of participating operators to provide data at localized levels in the future. Operators who are interested in participating can complete a participation form. NIC maintains strict confidentiality of all data it receives.

With the highly contagious omicron variant seemingly behind us and senior housing occupancy recovery continuing for the third consecutive quarter through Q1 2022, there is waning optimism regarding operating margins. In the Wave 42 survey, almost 60% of survey respondents expect margins to increase in the next six months, although this is down from 75% of respondents in the Wave 38 survey. Rising operating expenses limit the degree to which operating margins will grow in the next six months. Staffing challenges remain top of mind. Only 20% of respondents indicate that staffing challenges will improve in the next year, while 20% indicate it will take until 2024 to see improvement, and 30% signal staffing issues will not improve until 2025 or later. The most effective method cited for attracting new community staff is increasing wages (65%), followed by flexible schedules (15%), and hiring bonuses (5%). Staffing and a slowdown in lead conversions are affecting the pace of move-ins, which slowed for memory care and nursing care properties, but remained consistent for assisted living and independent living properties.

–Ryan Brooks, Senior Principal, NIC

NIC’s Executive Survey of senior housing and skilled nursing operators was implemented in March 2020 to deliver real-time insights into the impact of the pandemic and the pace of recovery. In its third year, the “ESI” is transitioning away from the COVID-19 crisis to focus on timely industry topics. While some standard questions will remain for tracking purposes, in each new survey “wave,” new questions are added.

This Wave 42 survey includes responses from May 31 to June 26, 2022, from owners and executives of 61 small, medium, and large senior housing and skilled nursing operators across the nation, representing hundreds of buildings and thousands of units across respondents’ portfolios of properties. More detailed reports for each wave of the survey and a PDF of the report charts can be found on the NIC COVID-19 Resource Center webpage under Executive Survey Insights.

In the Wave 42 survey, reflecting operator experiences in June 2022, the pace of move-ins in the past 30 days remained steady for independent living residences (44%) and assisting living residences (52%), but declined substantially for memory care residences (20%) and nursing care residences (37%). In the previous Wave 41 survey, 51% of memory care and 68% of nursing care reported an acceleration in the pace of move-ins.

With regards to operators reporting a deceleration in the pace of move-ins, it is the third consecutive wave with an increase in memory care properties reporting a deceleration in the pace of move-ins, up from 4% in Wave 40 and 8% in Wave 41 to 20% in Wave 42.

Of respondents indicating a deceleration in the pace of move-ins, 65% indicate the deceleration is a result of a slowdown in leads conversions or sales, 15% indicate resident or family member concerns, and 15% cite staffing constraints.


Most respondents reported no change in the pace of move-outs. Between 70% and 80% of organizations reported no change in the pace of move-outs, which may aid occupancy stability or improvements in the coming months. While few organizations observed an acceleration in the pace of move-outs, of those that did, fewer than one-half reported residents moving to higher levels of care (41%) —much lower than in the Wave 39 survey (73%). This appears to be reflected in the decreases in the pace of move-ins in care segments serving residents with the highest acuity.

Anticipated increases in operating margins have contracted since Wave 38. Just over one-half of respondents (58%) anticipate their organization’s operating margins to increase in the near future. This is down from 75% of respondents in the Wave 38 survey, the most recent survey to include this question. About one in five respondents (18%) anticipate operating margins to increase by greater than 10%, about one-third (35%) anticipate operating margins to increase by 6%-10%, and few (5%) anticipate operating margins to increase by 1%-5%.

In the Wave 42 survey, the share of respondents anticipating operating margins to decrease in the next six months grew. About one-quarter of respondents (27%) anticipate operating margins to decrease between 1% and 5%, and one-eighth of respondents (13%) anticipate operating margins to decrease between 6% and 10%. In the Wave 38 survey, only 5% of respondents anticipated operating margins to decrease in the next six months, and those decreases were anticipated to be between 1% and 5%.

Driving the contraction in anticipated operating margins is likely increased operating expenses. A significant 84% of respondents reported that operating expenses have increased since the beginning of 2022. About one in ten (11%) reported operating expenses have remained the same, and a meager 5% reported operating expenses have decreased since the beginning of 2022.

Staffing challenges remain a primary concern for respondents as well. Respondents are anticipating staffing challenges to remain much further into the future as compared to the Wave 41 results. Respondents anticipating improvement in staffing challenges in 2024 doubled, from 10% to 20%, and respondents anticipated improvement in 2025 or later tripled from 10% to 30% from Wave 41 to Wave 42.

In the Wave 42 survey, 20% of respondents report the severity of staffing shortages to be severe, 71% report them to be moderate, and 8% report them as minimal. One-fifth of operators have more than 20% of full-time positions open, while another one-fifth have between 16% and 20% of full-time positions open. One-third of operators have 11% to 15% of positions open and one-quarter have between 6% and 10% open. The most effective method cited for attracting new community staff is increasing wages (65%), followed by flexible schedules (15%), and hiring bonuses (5%).

Wave 42 Survey Demographics

• Responses were collected between May 31 and June 26, 2022, from owners and executives of 61 senior housing and skilled nursing operators from across the nation. Owner/operators with 1 to 10 properties comprise roughly two-thirds (67%) of the sample. Operators with 11 to 25 make up 20% and operators with 26 properties or more make up the remaining 13%.
• One-half of respondents are exclusively for-profit providers (52%), more than one-third operate not-for-profit seniors housing and care organizations (38%), and 10% operate both.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 70% of the organizations operate seniors housing properties (IL, AL, MC), 23% operate nursing care properties, and 36% operate CCRCs (aka Life Plan Communities).

This is your survey! Owners and C-suite executives of seniors housing and care properties, please help us tell an accurate story about our industry’s performance. The ESI 2022 questionnaire has been shortened from prior surveys. While some standard questions will remain for tracking purposes, in each new survey wave, new questions can be added based on respondents’ suggestions.

Wave 43 of the ESI is now live. The current survey is available and takes ten minutes to complete. If you are an owner or C-suite executive of seniors housing and care and have not received an email invitation to take the survey, please contact Ryan Brooks at rbrooks@nic.org to be added to the list of recipients.

NIC wishes to thank survey respondents for their valuable input and continuing support for this effort to provide the broader market with a sense of the evolving landscape as we recover from the pandemic.

The impacts of the pandemic and resulting workforce contraction affected healthcare industries differently. Nursing care facilities, continuing care retirement communities (CCRCs), and assisted living properties have experienced a longer workforce contraction compared with other adjacent healthcare industries.

In this blog, we provide context on jobs in the skilled nursing and senior housing sectors, by looking at employment patterns since March 2020, including workforce contraction and recovery, as well as wage increases, compared with other adjacent healthcare industry groups.

Total Employment in Skilled Nursing and Senior Housing Inching Back but Remains Far Below March 2020 Levels

According to the latest Bureau of Labor Statistics (BLS) data, the seasonally adjusted number of employees at skilled nursing properties dropped by 238,500 jobs or 15.1% over the period from March 2020 to March 2022. From March 2022, employment in skilled nursing edged up by 5,400 jobs and stood at 1,348,100 in May 2022, but still 233,100 jobs below pre-pandemic March 2020 levels (1,581,200), equivalent to negative 14.7%.

Similarly, the number of workers across CCRC and assisted living dropped significantly during the height of the pandemic, with a decline of 70,900 and 34,900 jobs respectively, equivalent to negative 13.9% for CCRC (from March 2020 to January 2022) and negative 7.5% for the assisted living workforce (from March 2020 to November 2021). The good news is total employment within the CCRC and assisted living sectors inched up in recent months by 0.8% (3,600 jobs) and 1.8% (7,700 jobs) from their pandemic related lows, respectively, but unfortunately remained far below pre-pandemic March 2020 levels, with negative 13.2% for CCRC (negative 67,300 jobs) and negative 5.8% for assisted living (negative 27,200 jobs).

These stats show that assisted living is experiencing a relatively fast workforce recovery compared with CCRC and skilled nursing. Notably and as background, NIC MAP Vision data shows that occupancy and demand levels (as measured by the change in occupied units) for assisted living have been recovering relatively fast also compared with skilled nursing and CCRCs.

Interestingly and as Exhibit 1 below shows, employment across adjacent healthcare industry groups, including general medical and surgical hospital, home health care services, individual and family services, and offices or physicians dropped in the very early months of the pandemic, but the level of workers across these industries began to recover back in April and May of 2020. In fact, the latest BLS data shows that as of May 2022, total employment surpassed pre-pandemic March 2020 levels by 1% for home health (+15,800 jobs), 1.5% for individual and family services (+ 42,300 jobs), and 4.4% for offices of physicians (+118,000 jobs).

The relatively fast recovery across these healthcare industries suggests that (1) these sectors have been successful in attracting and retaining workers during the pandemic, some of whom may have been part of the senior housing and skilled nursing workforce prior to the pandemic, and (2) demand has been relatively strong compared with skilled nursing and senior housing.

The level of employment in home health care services and individual and family services took two years to fully recover and return to March 2020 levels while labor across skilled nursing properties, CCRC, and assisted living began to recover just recently and will likely take some time to fully recover.

There are many factors that will influence workforce recovery for senior housing and skilled nursing. These include broad macroeconomic market conditions, the continuing COVID-19 pandemic, the size and growth of the labor force, demand patterns, and more importantly competitiveness. The relatively fast workforce recovery for home health care services and other healthcare industries is a notable difference.

Further, the relationship between labor and demand for the senior housing and skilled nursing sectors has never been strong and will remain critical. In some instances, if labor isn’t available, new residents can’t be admitted. The pandemic has shown that both residents and staff are part of the success equation for a smooth recovery.

Exhibit 1 – Workforce Contraction and Recovery Across Select Healthcare Industries

Exhibit 2 below shows that from March 2020, average hourly earnings for all employees at skilled nursing properties rose by $3.73, or 18.2% percent, to $24.25 in April 2022, averaging $0.15 or 0.7% increase on a monthly basis. Over the same period, average hourly earnings for CCRC and assisted living have increased by 17.1% to $22.31 and 16% to $20.72, respectively. These percentage increases in skilled nursing, CCRC, and assisted living wages were the largest across the select healthcare industries in Exhibit 2 below.

At $24.25 per hour on average, workers within skilled nursing are paid 8.7% ($1.94) above CCRC ($22.31), and 17% ($3.53) above assisted living (20.72). Relative to other industry groupings, wages for skilled nursing are also competitive. In March 2020, skilled nursing workers were paid slightly less than those in home health care services. However, skilled nursing workers are now paid better than those in home health care services ($23.25) by $1 or 4.3%, and $4 more than those in individual and family services ($20.26), equivalent to 19.7%.

Despite the competitive wages in skilled nursing compared with other healthcare industry groups, the fast workforce recovery across home health care services and individual and family services, shows that the factors driving workforce recovery go beyond competitive wages.

Staffing has always been an issue for the senior housing and skilled nursing sectors. Now, however, staffing challenges have been exacerbated by a shrinking labor force and continue to be a major area of concern, both for the ongoing recovery and for the sectors’ future capacity to compete in the healthcare industry.

Exhibit 2 – Average Hourly Earnings of All Employees Across Select Healthcare Industries

These wage comparisons capture the average hourly earnings (mean) of all employees. In future commentaries and upcoming NIC Notes blogs, NIC Analytics will compile 2021 data from the Bureau of Labor Statistics to provide a detailed overview of occupational employment and wages for nursing staff (registered nurses, licensed practical and licensed vocational nurses, nursing assistants, and home health and personal care aides) by state, and pinpoint where skilled nursing facilities and senior housing properties (CCRC and assisted living) stood in 2021 compared with the competitive landscape (i.e., other industries & healthcare settings). 

Today, ATI Advisory released a research paper, commissioned by NIC, that is a resource for skilled nursing stakeholders, including policymakers. The COVID-19 pandemic reminded our country of the persistent weaknesses of the long-term care system and NIC believes that a study providing the facts — both past and present — would be of tremendous value to stakeholders and is aligned with NIC’s mission of providing access and choice. In addition, with 10,000 people a day turning 65 and living longer with multiple chronic conditions, the time is now to set forth the facts to enable the country to move forward and improve the system.

The paper includes

• an overview of the nursing home industry,
• a summary of policy events that have shaped the current environment,
• a closer look at nursing home capital market dynamics, and
• key opportunities for policymakers to consider in their approach to nursing home reform.

These sections of the paper are meant to collectively inform the policy decision making process, regarding the factors to consider when making policy.

The current nursing home industry is struggling as it is increasingly serving a more complex patient population, facing a continuing staffing crisis which could become more difficult with new staffing mandates, and continuing to struggle with reimbursement as a result of growing Medicare Advantage penetration and value-based payment models.

A main takeaway from the paper is, given the current state of the industry, the current public-private partnership for skilled nursing facilities is failing. To meet the long-term care and housing needs of extremely frail older adults, America needs a modern and high-functioning skilled nursing industry. The government alone cannot meet the needs of this population and without reinventing the public-private partnership, federal and state governments will fail in meeting the needs of the extremely frail population who require 24-hour care. Partnerships to meet the capital funding needs of the skilled nursing sector must be rethought and restructured to better serve patients and the staff that care for them.

In order for public-private partnerships to succeed, the system needs to encourage much-needed innovation that would improve facilities and their operations for patients and staff. The policy changes over many years have resulted in operators seeking alternative sources of capital. For example, Medicaid reimbursement rates are no longer required to cover the cost of providing care, causing SNFs in many states to rely on higher reimbursement from Medicare patients to subsidize Medicaid shortfalls. Furthermore, within the current system it is not encouraged for private capital sources to invest in modernization of existing infrastructure or operational improvements that would drive quality care for patients by supporting frontline staff.

New and innovative private investments in modern skilled nursing models must be encouraged and policies to improve skilled nursing facilities should incentivize investments for better patient outcomes and support staff, if America’s long-term care system is to succeed.

Visit our website to download the paper in its entirety, including the executive summary.

NCREIF Performance Report Q1 2022

The total investment return for the senior housing sector was a positive 1.08% in the first quarter of 2022. This marked the seventh consecutive quarterly gain after one quarter of pandemic-related negative returns in the second quarter of 2020 (negative 1.00%). Short-term total returns for senior housing remain low compared with the broader NPI, which saw total returns of 5.33% in the first quarter. Appreciation returns for the NPI dwarf those of senior housing, as the NPI was boosted in part by outsized returns in industrial properties (10.96%). Many investors have reduced their appreciation expectations for seniors housing as the impact of the coronavirus has weighed heavily on their view of the sector.

The income return in the first quarter was 0.91%, its best showing since late 2020. This was stronger than industrial and nearly on par with apartments, and slightly less than the NPI (0.99%). The appreciation (capital/valuation) return was 0.18%, the third consecutive quarterly increase after seven quarters of declines that began in late 2019. The appreciation return was below the other main property types. The appreciation return is the change in value net of any capital expenditures incurred during the quarter.

On a longer-term basis, the ten-year return for senior housing was the strongest of the main property types, except for industrial. For this time frame, the income returns for senior housing (5.47%) surpassed the NPI (4.83%), while the appreciation return (4.49%) was slightly less than the NPI (4.61%).

Note that the performance measurements cited above for senior housing reflect the returns of 175 senior housing properties valued at $9.54 billion in the first quarter. This was the highest property count and market value in the NCREIF time series for senior housing. It’s also notable that the number of properties tracked by this index has grown significantly since the beginning of the pandemic, having been 134 properties in the first quarter of 2020, valued at $6.3 billion. The additional properties may be influencing the overall performance returns of the index.

First quarter 2022 market fundamentals data for senior housing showed improved demand patterns compared with the pandemic-related losses and moderate growth in inventory in the 31 Primary Markets, according to NIC MAP® Data powered by NIC MAP Vision. The occupancy rate for senior housing stood at 80.6% in the first quarter, up 2.5 percentage points from its low point, but still 6.7 percentage points below its pre-pandemic level of 87.2% in the first quarter of 2020. The average masks the wide range of occupancy rates by property, however, with 30% of properties having occupancy levels at or above 90%. While these statistics are promising, future occupancy improvement will be shaped by local patterns of inventory growth and demand, and will be influenced by the broad economy, consumer confidence, inflation pressures, rising interest rates, the ease of development, COVID-19 variants, and vaccination rates.

Total Returns