A look back at a year’s worth of data on COVID-19 case counts in U.S. nursing homes reveals some surprising insights, and some important questions. The data indicate that U.S. skilled nursing facilities (SNFs) are currently the safest places to be for frail older adults, who are most susceptible to the virus. In fact, case counts within SNFs are down 98% since the December 20^th launch of the long-term care vaccination program. By May 16, they accounted for about 0.3% of U.S. cases.

The drop in nursing home cases has outstripped the drop in case counts amongst surrounding populations, which in some areas were on the rise, even as vaccines become more readily available. In December 2020, new nursing home fatalities accounted for about 74% of overall fatalities for older adults over 85 years of age. By April 2021, that share dropped to 28%. Currently, more fatalities are occurring in the general population of older adults over 85 years of age than in those living in nursing homes.

At NIC, we’ve been analyzing and tracking Centers for Medicare and Medicaid (CMS) data throughout the pandemic, since March of last year. Our interactive “Skilled Nursing COVID-19 Tracker” (Tracker) tool is updated weekly with fresh CMS data. The tool can be used to compare weekly infections of COVID-19 in skilled nursing facilities, as well as in the U.S. general population, and can be geographically searched across regions, sub regions, and states.

Nursing Homes vs Local Populations 

The data clearly tracks with the nationwide effort to prioritize nursing home residents for vaccinations. Case counts began to steeply decline as the Pfizer, and then the Moderna vaccines began to be distributed to nursing homes across the country on December 20, 2020. Nursing home case counts remain low, particularly when compared to infection rates among the general population, which have roared back in recent weeks.  

In the Midwest, over three months into the U.S. vaccination program, Michigan reported the highest statewide general population increase in COVID-19 cases, jumping 612% from February 21 to April 11, reaching highs not seen since vaccines first became available. The state’s case count among residents in SNFs, however, declined 25% over the same period. Meanwhile, cases among staff increased 281%. Between the weeks ending March 21 and April 11, COVID-19 vaccines prevented at least 2,000 new infections among SNFs residents in Michigan.

Overall, COVID-19 cases among residents dropped to lowest point in pandemic, only 6 in 10,000 nursing home residents tested positive for COVID-19 for the week ending May 16, which, compared to over 300 in 10,000 back on December 20, 2020, reflects the magnitude of the impact of the U.S. vaccination program on nursing home residents. Five months into the vaccination program, 42 states and geographies were reporting 20 cases or less across their entire nursing home populations.

The Risk of Unvaccinated Staff 

Tracking back one year, from this month to last May, Tracker data reveals that despite the swift and immense impact of vaccinations, a troubling risk persists. At the height of the pandemic, new cases among skilled nursing residents were 20% higher than among staff. However, the trend has reversed in recent weeks: newly confirmed cases among residents were 74% lower than among staff on May 16. We already know that, even with the proper safety protocols and equipment, this vector represents a grave risk to the nursing home community.

Other NIC data sources, such as the Executive Survey Insights (ESI), a bi-weekly survey of senior living operators, help to support and explain some of the patterns we can see in the Tracker data. Yielding data on properties of every size, type, ownership structure, and across each care segment, every completed ESI questionnaire delivers information from the perspective of an owner/operator’s entire portfolio of seniors housing and nursing care properties. The ESI has been providing real-time insights on hundreds of buildings and thousands of units across the country every two weeks since near the beginning of the pandemic.

Roughly nine out of ten respondents in the Wave 22 ESI survey indicated that educating and motivating staff to take the vaccine was a challenge. This data, though anecdotal, may help explain why Tracker data is now showing that COVID-19 cases amongst staff, though significantly lowered, are failing to keep pace with the drop in resident infection rates. Already struggling with staffing shortages and high turnover rates, and often resorting to hiring temp agency workers, some nursing home operators may be unable to achieve a 100% staff vaccination rate, even when they have access to vaccines. Given the risks once COVID-19, and its variants, enters any congregate living setting, this dynamic represents a persistent threat that vaccine availability alone cannot remedy.

Not All Nursing Homes Are the Same 

Tracking cases from the beginning of the pandemic to May 16, 2021, at which point nursing homes residents across the country were nearly universally vaccinated, it becomes clear that nursing home safety varies widely. In fact, nearly one third of U.S. nursing homes reported no more than 20 COVID-19 cases in total over that period, since CMS started reporting data. Sadly, fewer than 20 cases is a relatively low number. NIC looked more closely at this category of nursing home.

Data suggests that nursing home size may be a factor. Of all the nursing homes reporting fewer than 20 total cases throughout the pandemic, 44% were in the 50-100 unit size range. Six percent were in the largest category of 150+ unit facilities. Small nursing homes, with fewer than 50 units, performed slightly better, at 28% nationally, than those in the 100-150 unit size range, 21% of which reported fewer than 20 cases overall. The 50-100 unit size range outperformed the others.

Some nursing homes managed to completely block COVID-19 from infecting their residents. This was the case, even in geographic locations that saw significant community spread. Overall, about 4.5% of U.S. nursing homes reported 0 cases throughout the pandemic, from the time CMS began reporting data to May 16, 2021. This data indicates that there may be lessons to learn from those facilities, particularly as they kept out COVID-19 even before the vaccine was made available.

Questions on Safety 

According to CMS pandemic data through May 16, 2021, 25% of nursing homes are responsible for 54% of total resident cases. The remaining 75% are responsible for only 46% of overall cases. For the largest properties of over 150 units, 80% of cases were reported by only 56% of communities. 

Why did some nursing homes outperform others in keeping residents safe from COVID-19? Is there a ‘Goldilocks principle’ on the ideal size for a nursing home? Data suggests that communities of 50-100 units are safer than those that are bigger and smaller. But, as is so often the case, the data fails to provide all the answers. The questions that this data raises, however, may be the right ones to ask, as we work to ensure the safety of older adults, even as the pandemic continues.

The senior living industry has adapted and evolved through the COVID-19 pandemic. In the latest NIC Leadership Huddle, titled “Trends That Will Shape Senior Living Post-Pandemic,” subject matter experts discussed how the pandemic has shaped the industry, and how some changes will likely remain. They explored trends to watch for, both short term and long term – and identified best practices to help operators and their capital providers stay ahead of the curve.

Co-host Maria Nadelstumph, senior vice president, Center of Excellence, Brandywine Living, outlined three areas for the discussion. These included healthcare, housing, and business. She pointed out that healthcare has grown as part of the senior living model, as operators have increased clinical capabilities, brought in onsite healthcare partners, and beefed-up infection control. On housing, she said, “We’re past the real estate. We’re talking more lifestyle.” Housing has also seen a growing use of technology, as well as changes in the use of space and the environment within a property.

On the business side, explained Nadelstumph, “Of course, it’s occupancy.” Trends in this category include the increased use of digital sales platforms and processes. Retaining and recruiting quality staff is another area where trends have shifted through the pandemic. The regulatory environment has also seen major shifts.

Nadelstumph’s co-host, Joe Kiernan, chief strategy officer and senior vice president of Network Development, Ocean Healthcare, posed the first topic for discussion with subject matter expert Fee Stubblefield, founder and chief executive officer, The Springs Living. Kiernan pointed out that seniors housing used to be about lifestyle, rather than healthcare, which had been considered the territory of skilled nursing and post-acute care providers prior to the pandemic. Now, things have changed. s He stated that, “Clearly, healthcare is a huge component of what we do for seniors housing. It has to be a component of it.” He then asked Stubblefield what changes had to be made through the pandemic, and which of those would remain, even post-pandemic.

Speaking of that traditional separation, Stubblefield said, “We’ve all been thrown in this together, because we’ve had to all be part of the solution.” He said environmental systems are here to stay. Clinical initiatives that were once considered experimental learning programs have now accelerated in Stubblefield’s organization. He mentioned telehealth and onsite clinical partnerships, as well as MA plans, I-SNPs (Institutional Special Needs Plans), C-SNPs (Chronic Condition Special Needs Plans), concierge healthcare partnerships, and other healthcare-related innovations. “It’s here to stay, there’s no doubt about it,” he said.

Nadelstumph described how some healthcare-related infrastructure and services had begun to move into senior living models prior to the pandemic. Operators had been keeping them in the background, to preserve the social and community aspects of their properties. Again, COVID-19 has changed operator models. “We have licensed nurses and clinical capabilities in our buildings, but we don’t want it to be in your face…putting in healthcare layers of support service, whether its telehealth, or onsite clinics, or physicians coming in-house, or therapy; whatever it might be; there’s a way to do both to make sure that it’s the right marriage.” She said operators must make sure their healthcare partners are fully aligned, to be a part of the team rather than transactional vendors.

Stubblefield agreed, but pointed out that operators have to align with the healthcare system as well. “As operators, we have to evolve and invest in the infrastructure because we’re going to have to improve the health outcomes for these residents. The delicate dance is that, while we have to become more integrated with the healthcare system, we don’t want to be the next nursing home.” He explained how assisted living, independent living, and memory care have evolved to meet customer demands, but that now, they must also prove how they are improving outcomes, both to their customers, and to the broader healthcare community. “And, do it in a way that the customer wants to be there,” he said.

“We’ve got to get better with data, with technology, invest more into infrastructure systems. I contend that has to connect with environmental information, not just personal health information…we have to do that not just for our residents but think about our staff. They have a healthcare need. They’re working one, two jobs at the entry level. How do they have time to get the healthcare access they need?” Stubblefield continued, “I think there are some opportunities for us not only to impact the healthcare system, the cost drivers, the quality for our residents, but also for our employees.”

Moving to the topic of housing, the panel first discussed the impact of COVID-19 on resident lifestyles, which were impacted by social isolation and safety protocols. Operators are looking at ways to reduce the social and community impacts of future pandemics. New technologies, such as air scrubbers and biological threat detection systems will likely become a part of new property design.

There was agreement that even while integrating new technologies and new health partnerships, the industry’s goal remains to offer the market a product that a new generation of elders will want to move into. Stubblefield pointed out the importance of attention from staff on a successful resident experience, and that staff are key to successful outcomes. Regarding property upgrades and new building construction, he said, “We’re really going to have to pay attention to the space for our employees and our staff, and create great environments to work in.” He said, “Our breakrooms are the size of a housekeeping closet, and there are these industrial looking lockers…our buildings are going to have to evolve to continue to attract talent that want to work there and create an environment that is supportive to them.”

Speaking further on the evolving housing model, Stubblefield asked, “What do we really do here? Do we rent apartments? No. We provide support. That’s really the need that we have to focus our new communities on.” After a discussion on the challenges around recruiting and retaining staff, Stubblefield said, “That’s our raw material; our labor. We’re not builders of buildings and communities, and real estate acquisition. We’re an HR company. We must become highly sophisticated in that.” He argued that the industry must improve in retaining staff, and that it will take help from regulatory partners, particularly around employment initiatives to solve the problem.

Moving into a discussion on the business aspects of the pandemic, Kiernan asked about the regulatory impact. Stubblefield compared the challenge of adhering to differing regulatory guidelines and interpretations, from one jurisdiction to another, to ‘herding cats.’ He said, “Really what it came down to…was how important communication was.” He said a key takeaway was that the industry would have to do more to partner and communicate with regulators and policy makers in the future.

“We’re going to have to make sure that we continue to tell our story very well, because it is a partnership.” Stubblefield said, concluding, “I think the inconsistency across the board for regulation was really, really challenging to manage. And we’re going to have to fix that now…we’re going to have to involve public-private partnerships.”

Back by popular demand, NIC’s Innovations that Work offer real world solutions via fast-paced presentations that will premier during the 2021 Fall season.

NIC is currently seeking submissions for innovations that add value, improve resident experiences, and drive better outcomes. This is your opportunity to share your success story with the NIC audience of seniors housing and care leaders. These brief, inspiring presentations are designed to share the latest solutions that deliver results in the real world.

The COVID-19 pandemic has brought the seniors housing and care industry under intense scrutiny. This is an opportunity to take control of the narrative by highlighting the innovations and solutions that will help deliver better care and outcomes for the seniors of the future.

Deployed Solutions	Measurable Benefits
Innovative Answers	Willing Presenters

We invite proposals to be submitted no later than Friday, June 18, 2021. Simply complete the online submission and provide the required information. You will be notified by Friday, July 30, 2021 if your presentation is selected. If selected, you will be paired with a speaking coach to help develop your talking points in the desired format.

Click here if you would like to view some past Innovations that Work presentations.

“Executive Survey Insights results suggest that the seniors housing and care market fundamentals may have reached a turning point at the end of March 2021. According to survey respondents, leads volume continues to grow and the shares of organizations reporting accelerations in move-ins continues to trend positively. These leading indicators have been translating into higher occupancy rates since the Wave 25 survey, conducted in the latter half of March.”

–Lana Peck, Senior Principal, NIC

NIC’s Executive Survey of operators in seniors housing and skilled nursing is designed to deliver transparency into market fundamentals in the seniors housing and care space as market conditions continue to change. This Wave 28 survey includes responses collected May 3 to May 16, 2021 from owners and executives of 64 small, medium, and large seniors housing and skilled nursing operators from across the nation, representing hundreds of buildings and thousands of units across respondents’ portfolios of properties.

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.

Wave 28 Summary of Insights and Findings

•  Since early April, respondents were asked if their organizations had seen an increase in resident lead volume since the beginning of the year—and if they had—if lead volume is above pre-pandemic levels, As shown in the chart below, about nine out of ten organizations reported an increase in lead volume (89%). Additionally, one-third of organizations report lead volume currently above pre-pandemic levels (35%) compared to 20% in Wave 26 conducted just one month ago. Regardless of reports of notable improvement in lead volume, nearly two-thirds of survey respondents expect their organizations’ occupancy rates to recover to pre-pandemic levels sometime in 2022. This sentiment has remained consistent since first reported in late February (Wave 23).

• The strongest reports of move-ins increasing began generally in and around the Wave 25 survey conducted at the end of March (however, sooner for the nursing care segment). In other words, acceleration in the pace of move-ins became notable near the end of the first quarter of 2021.
• Interestingly, increased resident demand has been cited by nine out of ten respondents as a reason for acceleration in move-ins since the Wave 25 survey. And, since then, the average rates of resident and staff vaccinations have leveled off at around 90% of residents and 65% of staff.
• The chart below shows the shares of organizations reporting acceleration, deceleration, or no change in the pace of move-ins by care segment—across their portfolios of properties—since the COVID-19 vaccine began to be distributed in the latter half of December (survey Wave 18) to the present. (For a key to the specific dates of these survey waves, please click here.)

• Regarding trends in the pace of move-outs, the most recent and slight increase was mainly attributed to transfers to higher levels of care, followed by normal attrition according to survey respondents.

• The chart below depicts a compelling trend in the shares of organizations reporting higher occupancy since the Wave 25 survey conducted at the end of March. Roughly 50% to 70% reported upward changes in occupancy in the Wave 28 survey. (For a key to the specific dates of these survey waves, please click here.)

• The degrees of occupancy change variation are shown in the chart below starting with survey Wave 18. Stronger improvement in the change in occupancy rates in recent waves of the survey support the inference that signs of recovery now appear more solid trends as supported by the length and depth of the blue stacked bar segments.

• Three out of five respondent organizations were offering rent concessions to attract new residents. As shown in the chart, four out of five of them were discounting monthly rents (83% in Wave 28 vs. 73% in Wave 26). One-half of organizations in Wave 28 (50%) were offering free rent for a specified period, down from two-thirds in Wave 26 (65%). Rent freezes, which were written in by survey respondents as “something else” were quantified in Wave 28 with about one-third (36%) capping rents for new residents for a specific period (e.g., two-years). Other tactics include community fee discounts, waiving second person fees, and giving moving allowances.

• In the Wave 28 survey, the share of organizations experiencing staffing shortages in their properties has leveled off at a very high 90%. Before the pandemic, operators were challenged with labor shortages due to widespread and generally low unemployment rates. During the pandemic, the problem was exacerbated by employees leaving the workforce.

• To attract community staff, most respondent organizations are increasing wages, offering referral bonuses, and more than half are offering hiring/sign-on bonuses. Staff wages and benefits are typically the most significant operating expenses for seniors housing and care providers. NOI has been squeezed by the efforts to replace workers who left the labor force during the pandemic, coupled with months of receding occupancy rates that had fallen to historic lows in the first quarter of 2021.

Wave 28 Survey Demographics

• Responses were collected between May 3 to16, 2021 from owners and executives of 64 seniors housing and skilled nursing operators from across the nation. Owner/operators with 1 to 10 properties comprise 61% of the sample. Operators with 11 to 25 and 26 properties or more make up 39% of the sample (25% and 14%, respectively).
• More than one-half of respondents are exclusively for-profit providers (61%), roughly one-quarter (27%) are nonprofit providers, and 11% operate both for-profit and nonprofit seniors housing and care organizations.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 81% of the organizations operate seniors housing properties (IL, AL, MC), 21% operate nursing care properties, and 34% operate CCRCs (aka Life Plan Communities).

Owners and C-suite executives of seniors housing and care properties, please help us tell an accurate story about our industry’s performance. Now, more than ever, we need your response so that we can track firsthand the inflection point on occupancy. This will be a turning point and we want all of our industry stakeholders to know when this important moment occurs.

The current survey is available and takes 5 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 click this link, which will take you there.

NIC wishes to thank survey respondents for their valuable input and continuing support for this effort to bring clarity and create a comprehensive and honest narrative in the seniors housing and care space at a time when trends are continuing to change in our sector

The NIC MAP^® Data Service, powered by NIC MAP Vision, an affiliate of NIC, tracks occupancy, asking rents, demand, inventory, and construction data for independent living, assisted living, memory care, skilled nursing, and continuing care retirement communities (CCRCs—also referred to as life plan communities) for more than 15,000 properties across 140 metropolitan areas. NIC MAP data currently tracks 1,208 not-for-profit and for-profit entrance fee and rental CCRCs in these 140 combined markets (1,134 in the 99 combined Primary and Secondary Markets).

The following analysis examines current conditions and year-over-year changes in inventory, occupancy, and same-store asking rent growth—by care segments within CCRCs (CCRC segments) compared to non-CCRC segments in freestanding or combined communities to focus a lens on the relative performance of care segments within CCRCs.

Current CCRC Occupancy by Payment Type and Profit Status

In the first quarter of 2021, CCRC occupancy fell 1.4 percentage points from the fourth quarter to 84.3%, another new low since NIC MAP began reporting in 2006. The cumulative drop in CCRC occupancy was 7.2 percentage points year over year—3.8 percentage points higher than non-CCRCs.

Non-CCRC occupancy averaged 74.9% in 1Q 2021—a very wide 9.4 percentage points lower than CCRC occupancy (84.3%). Entrance fee CCRC occupancy (86.8%) was 6.7 percentage points higher than rental CCRCs (80.1%), and not-for-profit CCRC occupancy (86.1%) was 6.8 percentage points higher than for-profit CCRCs (79.3%).

CCRCs vs. Non-CCRCs: Care Segment Detail

The table below compares each of the care segments—independent living, assisted living, memory care, and nursing care—in the Primary and Secondary Markets. The table shows the 1Q 2021 total open units, occupancy and average monthly asking rent—and year-over-year changes for CCRCs and non-CCRCs.

The CCRC independent living care segment (which represents 55.6% of CCRC units) garnered the highest occupancy in the first quarter of 2021 (88.6%), as well as the least year-over-year drop in occupancy falling 4.3 percentage points. The current nursing care segment occupancy rate in non-CCRCs, which represents 51.5% of non-CCRC units, was much lower at 73.6%, and fell 12.7 percentage points year-over-year.

Higher occupancy at CCRCs

The CCRC independent living care segment had the highest 1Q 2021 occupancy (88.6%), followed by CCRC assisted living and memory care (82.5%, respectively), and CCRC nursing care (76.5%). Among non-CCRCs, in the same order, the independent living care segment had the highest 1Q 2021 occupancy (79.0%), followed non-CCRC assisted living (75.3%), memory care (74.3%) and nursing care (73.6%).

The difference in 1Q 2021 occupancy between CCRCs and non-CCRCs was the highest for the independent living segment (9.6 percentage points), followed by the memory care segment (8.2 percentage points), the assisted living care segment (7.2 percentage points), and the nursing care segment (2.9 percentage points).

Occupancy declined from year-earlier levels for each of the care segments. However, CCRCs had lesser declines in occupancy than non-CCRCs. Among CCRCs, independent living care segment occupancy declined the least (-4.3 percentage points), followed by memory care (-7.5 percentage points), assisted living (-8.7 percentage points), and the nursing care segment (-12.6 percentage points). Among non-CCRCs, independent living and memory care segment occupancy declined the least (-8.3 and -8.7 percentage points, respectively), followed by assisted living (-9.9 percentage points), and the nursing care segment (-12.7 percentage points).

Higher annual, same store asking rent growth at CCRCs

Among CCRCs, the highest year-over-year asking rent growth was 1.6% in the independent living and nursing care segments; among non-CCRCs it was highest in the nursing care segment (1.5%). The lowest year-over-year asking rent growth was noted for CCRCs in the assisted living care segment (1.3%); in non-CCRCs it was noted for the independent living care segment (-0.6%). Note, these figures are for asking rates and do not consider any discounting that may be occurring.

Significantly weaker inventory growth at CCRCs

Non-CCRCs had higher rates of inventory growth (year-over-year change in inventory) by segment than CCRCs. The highest rates of inventory growth were reported for non-CCRCs in the memory care and independent living care segments (4.6% and 3.6%); the lowest were reported for both CCRCs and non-CCRCs in the nursing care segment (-0.6% and -0.3%, respectively). Negative inventory growth can occur when units/beds that are temporarily or permanently taken offline, or converted to another care segment, outweigh added inventory.

Occupancy rates vary by region and payment type

In the first quarter of 2021, the Mid-Atlantic, Pacific and Northeast regions have the strongest CCRC and non-CCRC occupancy rates ranging from 86.4% to 86.1% (CCRC) and 77.7% to 75.1% (non-CCRC). The weakest CCRC and non-CCRC occupancy is in the Southwest region at 78.6% and 68.3%, respectively. That said, the greatest difference in CCRC and non-CCRC occupancy was in the Mid-Atlantic region—an 11.3 percentage point difference.

Considering payment type, entrance fee occupancy was highest in the Pacific, Mid-Atlantic, East North Central, and Northeast regions (88.6% to 88.0%), whereas rental occupancy was the highest in the Pacific region (82.2%). The largest difference between entrance fee and rental occupancy was reported for the Mid-Atlantic and East North Central regions (8.2 and 8.1 percentage points, respectively).

Looking specifically at the independent living care segment, the highest CCRC occupancy was in the Mid-Atlantic, Northeast and Pacific regions (90.7% to 90.2%), but the largest difference between CCRCs and non-CCRCs was in the Mid-Atlantic region (14.0 percentage points).

Considering payment type, entrance fee occupancy was highest in the Pacific region (92.1%), whereas rental occupancy was the highest in the Northeast region (87.9%). The largest difference between entrance fee and rental occupancy was reported for the Pacific region (6.1 percentage points).

Look for future blog posts from NIC to delve deep into the performance of CCRCs.

Interested in learning more?

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*This blog was originally published in Ziegler Investment Banking, Senior Living Finance Z-News.