NIC’s Skilled Nursing COVID-19 Tracker, featuring the most up-to-date CMS data as of February 14, 2021, shows that the per-resident rate of new COVID-19 infections in skilled nursing facilities continued to fall and reached a pandemic record-low point on February 14 (0.34%). This was 0.20 percentage points below the previous nadir of 0.54% reached eight months ago on June 21, 2020 and was down 2.69 percentage points from 3.03% at its peak on December 20.

Regionally, the lowest rate of new infections was seen in the Midwest at 0.22% – a pandemic low, followed by the West (0.23% – a pandemic low), the South (0.41% – a pandemic low), and then the Northeast (0.43%).

As of February 14, 2021, about 16 million Americans have received 2 doses of the COVID-19 vaccines in the U.S, and about 1.7 million people have been fully vaccinated in the Federal Pharmacy Partnership Program for Long-term Care.

Recent F.D.A. authorization of the Johnson & Johnson single-shot vaccine gives more hope and suggests that the worst of the pandemic maybe behind us. The characteristics of this new single-shot vaccine are a game changer and should increase vaccination numbers significantly.

Exhibit 1 below shows that weekly confirmed cases within skilled nursing facilities are down 89% from the December 20 peak, while U.S. new cases declined by 59% over the same period.

Exhibit 1 – Weekly COVID-19 Cases in Skilled nursing (SNF) vs. U.S.

As shown in Exhibit 2 below, weekly fatalities are down 75% in skilled nursing facilities since the launch of the Long-Term Care vaccination program on December 20. Sadly, U.S. weekly COVID-19 fatalities increased by 17% over the same period, according to the CDC. However, U.S weekly fatalities on February 21 fell more sharply than at any previous point—down 38% from the week ending February 14, 2021.

New fatalities in skilled nursing facilities as a share of total fatalities in the U.S. measured approximately 10% on February 7 and 7% on February 14 (data for the week ending February 14 is preliminary). These shares are the lowest recorded since CMS began reporting data in late May 2020.

Exhibit 2 – Weekly COVID-19 Fatalities in Skilled Nursing (SNF) vs. U.S.

“The week-over-week improvement in infections and death rates since late December is certainly welcome relief to the pandemic battle, we have been fighting for nearly one year,” said NIC Chief Economist, Beth Mace. “And the introduction of a third vaccine provides even further promise and hope that we may be nearing the end of the worst parts of this crisis. That said, the seniors housing and nursing care sectors have forever shifted and many of the protocols put into place during the past 12 months are likely to remain in place.”

Positive signals are palpable in Wave 22 results from the latest NIC Executive Survey Insights, which collected survey results from February 8 – 21, 2021. The survey results show that 50% of organizations with nursing care beds reported increasing occupancy rates in the past 30 days.

To gain in-depth insights and track the week-over-week change rate for new resident cases and fatalities of COVID-19 within skilled nursing facilities at the state and county levels, visit NIC.org. You can also access the Skilled Nursing COVID-19 Tracker along with a rich trove of analysis and insight on the NIC COVID-19 Resource Center.

For more reading on the effects of vaccines in skilled nursing facilities, see the following blogs:

New COVID-19 Cases in Skilled Nursing Continue Decline, Far Steeper than U.S. Overall Cases (Published on February 23, 2021)

Rate of New COVID-19 Infections in Skilled Nursing Facilities Continues to Plummet* (Published on February 17, 2021)

COVID-19 Case Counts Falling in Skilled Nursing Properties Following Vaccine Rollout (Published on February 9, 2021)

NIC is committed to provide timely data, analyses and insights that increase transparency and understanding of the sector, especially in this difficult time of COVID-19. We strongly support all actions and efforts that prioritize distribution of COVID-19 vaccines, testing, and availability of PPE to protect frontline workers and residents.

With all-too-frequent headlines of “nursing home deaths,” federal and state deficits, increased competition from home health agencies, and historic low occupancy levels while wage pressures continue – how will the nursing home industry emerge from the pandemic? In the latest NIC Leadership Huddle event, expert panelists, and then attendees in small groups, joined a spirited discussion on the skilled nursing sector’s short-term and long-term operational challenges and the impact on property valuations.

The event titled “Is There an Investment Case for Skilled Nursing in the Intra-and Post-Pandemic World?” began as always with expert commentary from experienced leaders in the space. In a short presentation, Colleen Blumenthal, MAI, chief operating officer/partner, HealthTrust pointed to some pre-pandemic slides indicating that demand was declining before COVID-19 hit the U.S. She also pointed out that a search in Google for “nursing home deaths” now yields over 150 million hits. She said, “It feels like there’s been a complete barrage of headlines, starting with Lifecare Center of Kirkland back in March, and it’s still continuing to this day.” She continued, “It’s a stigma that’s going to impact everyone in the nursing home sector, not just those that did not provide the standard of care that we expect.”

Blumenthal, explaining the impact of COVID-19 on the sector, pointed to CMS’s decision to limit visitations to nursing homes, among other factors. While likely saving lives, the policy negatively impacted many residents and their families, many of whom were left living in isolation for much of 2020. The policy also made it difficult for buyers and lenders to evaluate and transact on properties. Occupancy rates, which declined across the entire seniors housing and care industry, dropped more dramatically for nursing care than other sectors. Blumenthal observed that skilled nursing occupancy rates, which had been around 80% nationwide pre-pandemic, are now ranging from 55%-80%, with widely varying numbers across the fifty states.

Closing her self-described “Debbie Downer” introduction, Blumenthal pointed to pricing, which remained fairly steady, at around $100,000 per bed in 2020. That, she suggested, reflects sustained investor interest in the sector. With that, she asked panelists Wendy Simpson, chairman & CEO, LTC Properties, Inc., and Ben Reisman, senior vice president of Finance, TL Management, why they remain attracted to skilled nursing. They had similar responses. Both feel that the services provided by these businesses are needed and will continue to be supported by reliable government payers. In addition, according to Reisman, there are opportunities for investors to “stay ahead of the curve” by investing in new technologies, treatments, and other innovations.

2020 saw a pause in deal-making, as many investors focused on helping their operators weather the pandemic. This year, according to Reisman, deals are happening again. Simpson also is seeing an uptick in activity so far this year, saying, “We’re finding a relatively slow start to the year, but things are feeling a little bit better, as the spring comes along, than before.”

Both panelists pointed to difficulties finding lenders. Reisman said, “Lenders are going to look for very strong borrowers, which they always do, but will be more important now because they know, and we know that you can’t just say ‘there’s a vaccine’…to get back to pre-pandemic levels is going to take a long time.” That focus may result in fewer, and smaller, deals happening in the short term.
The deals that do get done may rest on the quality and reputation of the operator. “I think the industry is more interested in the operator now than necessarily the asset,” said Simpson. She continued, “You know, in real estate it’s ‘location, location, location,’ well, in investing it’s ‘operator, operator, operator.’” She indicated her company would like to help existing, trusted operators expand their portfolios.

Asked about the high numbers of prospective residents switching to home health care, neither panelist sees a long-term problem for skilled nursing. Rather, Reisman sees a temporary shift driven by the pandemic, followed by a return to congregate settings. Saying, “Isolation is a horrible thing,” he explained that current nursing home residents are isolated, but that, as group activities and visitation return, and people return to work and school, “that might flip.” He explained, “Even if people are reading the news and are scared today, in a few months or a couple of years, when they’re making a decision, talking to their doctor who’s recommending a nursing home as the best place for them to get better, I think a lot of that fear can easily go away, if we do a good job of communicating that.”

On the same question, Simpson pointed to skilled nursing’s investments in rehab facilities, as well as shortages of labor. She said, “Even before the pandemic, we didn’t have enough of an employee base, so if you take all of these people who are going to be able to see one or two patients a day, because of the travel between patients, and that person could see four to six people in a nursing home – I just don’t see how that math works.” She believes that home health will appeal to high income patients who can afford expensive round-the-clock nursing care at home, or strong families who can provide such care themselves. She argued, “that’s just not the United States.”

It should be noted here that in the follow-up discussion several attendees took a different view of the impact of home health care. Some small groups were unable to agree on whether the trend will be short term or have a lasting impact on long term care occupancy rates. If there was general agreement, it was on the fact that, for now, skilled nursing valuations are holding steady.

Another consideration for underwriters will be the relative health of state Medicaid systems, as well as the healthcare networks that refer patients. The panel discussed Texas, an example of a state with a rapidly growing population – but that has some of the lowest Medicaid reimbursement rates in the nation. In some smaller Texas markets hospitals have gone many months without referring rehab patients – a real concern for investors in an industry that often depends on those referrals for survival. Again, according to the panelists, they will be looking at the operator as they consider these and other investments.

Another potential source of trouble is rising insurance and liability costs driven by the pandemic. The panel suggested they will look at tort-reform laws and the litigation environment in any given state as part of their underwriting process.

The panel also discussed the trend towards reducing the numbers of beds in facilities, and the recent Ohio bed buy-back program. “Ohio may give up a thousand beds, but none of those beds were in service,” pointed out Simpson. She said, “I think there’s more value in the private room, if its available, but there’s always going to be need for at least double occupancy in properties.”

Immediately following the panel discussion, attendees hopped onto a group Zoom video meeting to discuss further. After a general discussion, attendees were divided into smaller breakout groups, and asked to address two questions: Has the pandemic inherently eroded skilled nursing values? And, where do occupancy/census levels stabilize, and how long will it take to get there? As noted above, discussion was frank and spirited – and not everyone in attendance was in agreement. However, when everyone returned to the larger group discussion and reported out their findings, the general sense was that, despite all the bad news of the past year, and despite disagreements on how deep and lasting the impact will be, there is still plenty of value in skilled nursing – and there will likely be more in coming months and years.

“Positive signals are palpable in Wave 22 results, which reveal upward shifts in organizations reporting acceleration in move-ins and occupancy increases across each of the care segments in the past 30 days. Data compiled in NIC’s Skilled Nursing COVID-19 Tracker clearly illustrates that COVID-19 cases in skilled nursing communities are now falling at a faster pace compared to the U.S. since the launch dates of the Pfizer and Moderna vaccines in long-term care settings, and more organizations with memory care units and/or nursing care beds reported increases in occupancy than decreases since prior to the fall surge of the coronavirus. The Wave 23 survey, currently collecting data, will explore when operators expect their occupancy rates to return to pre-pandemic levels.”

 –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 22 survey includes responses collected February 8 to February 21, 2021 from owners and executives of 67 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. Additionally, the full range of time series data for each wave of the survey by care segment for move-ins, move-outs and occupancy rate changes can be found HERE.

Wave 22 Summary of Insights and Findings

• According to Wave 22 seniors housing and care survey respondents, roughly 80% of residents and 60% of staff of their respective properties—including all care segments across their portfolios–have received the first dose of the COVID-19 vaccine on average, and about 75% of residents and 55% of staff have received the second dose.

• The majority of organizations surveyed have not made the COVID-19 vaccine mandatory for residents and/or staff (81%). Whether or not the vaccine remains voluntary will continue to be monitored in Wave 23 of the survey, which asks how likely organizations will be to consider making the COVID-19 vaccine mandatory for staff members.

• Roughly nine out of ten respondents in the Wave 22 survey indicated that educating and motivating staff to take the vaccine was a challenge. To smooth the way, operators are implementing a variety of strategies to encourage and improve vaccine acceptance. In addition to education/communication campaigns for residents and staff (95%), community and corporate leadership have stepped up and publicly taken the vaccine themselves (87%) and have been personally available with one-on-one support for staff who have questions and concerns (79%). Few respondent organizations have incentivized staff to take the vaccine with financial benefits (15%).

• In Wave 22, the shares of organizations reporting acceleration in the pace of move-ins is higher than those organizations reporting deceleration for each of the care segments. Furthermore, organizations reporting deceleration in the pace of move-ins has shrunk in the memory care, assisted living and nursing care segments over the past three waves of the survey.

• Looking specifically at the assisted living care segment, nearly half of organizations with assisted living units in their portfolios of properties (47%) noted acceleration in the pace of move-ins—the highest in the survey to date. The fewest (13%) noted deceleration in the pace of move-ins in the past 30-days. Wave 22 survey respondents reporting of acceleration in move-ins for the memory care segment is essentially equal to the high reached in the Wave 12 survey (50% and 51%, respectively), reflecting operator experiences in mid- to late-August. It is interesting to note that the pace of move-ins for the independent living care segment has not changed much since the Fall surge of the coronavirus.

• One in five respondents in Wave 22 noted that their organizations had a backlog of residents waiting to move in (20%)—similar to the prior survey, which was lower than at any other time since the question was first asked in late July. Possible reasons may include the previously mentioned, recent increase in the pace of move-ins across each of the care segments taking up some of the slack in pent-up demand, typical seasonality experienced during the winter months, and potentially less turnover of inventory in some properties as the pace of move-outs slowed in the Wave 22 survey. Between 78% and 87% of organizations noted no change or deceleration in the pace of move-outs for each of the care segments, and roughly one-third with assisted living units noted the pace of move-outs decelerated in the past 30-days.

• The Wave 22 survey data shows an upward shift in the shares of organizations reporting increased occupancy across each of the care segments since the prior survey, and more organizations with memory care units and/or nursing care beds reported increases in occupancy than decreases. The shares of organizations with independent living and assisted living units with declining occupancy in the past 30-days (across their portfolios of properties) continued to exceed those reporting rising occupancy.

• The chart above shows that in Wave 22, 50% of organizations with nursing care beds reported increasing occupancy rates in the past 30-days. However, as shown in the chart below, the majority of the increases were relatively small. The chart below describes the degree of those occupancy rate changes and illustrates that more organizations with nursing care beds in Wave 22 reported smaller increases than in the prior three waves of the survey. (The blue and orange-hued stacked bars correspond to the solid bars in the chart above indicating the degree of change by the saturation of color.) In the Wave 22 survey, 30% of respondents with nursing care beds reported occupancy increases of 0.1 to 3 three percentage points.

• One-third of organizations with memory care units and/or nursing care beds (32% and 33%, respectively), and one-quarter of organizations with assisted living units (24%) reported a week-over-week increase in occupancy. That said, similar shares of organizations with nursing care beds and/or assisted living units also saw decreases (30% and 26%, respectively).

Wave 22 Survey Demographics

• Responses were collected between February 8 and February 21, 2021 from owners and executives of 67 seniors housing and skilled nursing operators from across the nation. Owner/operators with 1 to 10 properties comprise two-thirds of the sample (66%). Operators with 11 to 25 properties make up 18% of the sample, while operators with 26 properties or more make up 16% of the sample.
• Just over one-half of respondents are exclusively for-profit providers (57%), one-quarter (26%) are nonprofit providers, and 16% 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, 74% of the organizations operate seniors housing properties (IL, AL, MC), 31% operate nursing care properties, and 28% operate CCRCs (aka Life Plan Communities).

Owners and C-suite executives of seniors housing and care properties, we’re asking for your input! By demonstrating transparency, you can help build trust. The survey results and analysis are frequently referenced in media reports on the sector including in McKnight’s publications, Mortgage Professional America Magazine, Senior Housing News, Multi-Housing News, Provider Magazine, and other industry-watching media outlets. The surveys’ findings have also been mentioned in stories by Kaiser Health News, CNN, the Wall Street Journal, and other major news outlets across the U.S.

The Wave 23 survey is available and takes 5-10 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 or send a message to insight@nic.org to be added to the email distribution list.

NIC wishes to thank survey respondents for their valuable input and continuing support for this effort to bring clarity and transparency into market fundamentals in the seniors housing and care space at a time where trends are continuing to change.

Skilled nursing facilities could be curbing COVID-19 sooner than we thought. Sadly, the impact on bereaved families will last forever.

“The decline in COVID-19 cases and fatalities within skilled nursing facilities is particularly notable and corroborates the effectiveness of the vaccine. The promising results of the Long-Term Care (LTC) vaccination program should be building confidence in COVID-19 vaccines among staff and the broader population to get vaccinated and help bring an end to the pandemic.” Beth Mace, Chief Economist, NIC

Seven weeks after the speedy vaccine rollout across U.S. long term care communities, CMS data unequivocally show that new infections in skilled nursing facilities have been, continue to be, and will likely continue to be, in a steep downward trend.

Data just published in NIC’s Skilled Nursing COVID-19 Tracker, for the week ending February 7, 2021, show that new confirmed cases of COVID-19 in skilled nursing facilities fell 83% over the last 7 weeks—from 32,563 on December 20, 2020 to 5,473 on February 7, 2021—while U.S. new cases fell 47% over the span of those same seven weeks.

Skilled nursing facilities reported a per-resident rate of new COVID-19 infections of 0.54% on February 7, a 2.5 percentage point drop since the December peak.

As of February 9, the status of vaccination clinics shows that about 88% of skilled nursing facilities participating in the CVS program have received their second dose of the COVID-19 vaccines. The status of clinics from Walgreens shows that 14 states have completed their second clinic in skilled nursing facilities (clinics through February 8). See exhibits 5 and 6 at the end of this blog for more details.

Exhibit 1 – Weekly new COVID-19 cases in SNF vs. U.S.

Data compiled by NIC’s Skilled Nursing COVID Tracker also show that fatalities are down 65% in skilled nursing facilities since the launch of the LTC vaccination program on December 20. Unfortunately, the U.S. weekly new COVID-19 fatalities increased by 17% over the same period, according to the CDC.

The new fatalities in skilled nursing facilities as a share of total fatalities in the U.S. appears to have varied between 21% and 43% on a week-over-week basis since CMS began reporting data in late May 2020. However, for the first time, the reported new fatalities within skilled nursing facilities accounted for approximately 14% on January 31 and 9% on February 7 (data for the week ending February 7 is preliminary).

Although the number of people who have died from the novel coronavirus on a week-over-week basis has been declining in skilled nursing facilities, it is still high. Each number is a person, a family member, a friend, and a loved one. Sadly, the impact of the COVID-19 pandemic on bereaved families will last forever. A recent study published by the official journal of the National Academy of Sciences estimates that about 4.5 million people have experienced a family bereavement in the U.S. due to the pandemic. This provides some sense of the true scale of this pandemic tragedy but does not take into account those who have been infected and very sick, some with lasting symptoms.

Exhibit 2 – Weekly new COVID-19 fatalities in SNF vs. U.S

Exhibits 3 and 4 depict the drop in cases and fatalities within skilled nursing facilities across the four regions of the U.S.

Exhibit 3: New COVID-19 confirmed cases as a share of residents within skilled nursing facilities – By region

Exhibit 4: New COVID-19 Fatalities as a share of residents within skilled nursing facilities – By region

Source: NIC’s Skilled Nursing COVID-19 Tracker – CMS Data as of February 7, 2021

To gain in-depth insights and track the week-over-week change rate for new resident cases and fatalities of COVID-19 within skilled nursing facilities at the state and county levels, visit NIC.org. You can also access the Skilled Nursing COVID-19 Tracker along with a rich trove of analysis and insight on the NIC COVID-19 Resource Center.

For more reading on the effects of vaccines in skilled nursing facilities, see the following blogs:

Rate of New COVID-19 Infections in Skilled Nursing Facilities Continues to Plummet* (Published on February 17, 2021)

COVID-19 Case Counts Falling in Skilled Nursing Properties Following Vaccine Rollout (Published on February 9, 2021)

NIC is committed to provide timely data, analyses and insights that increase transparency and understanding of the sector, especially in this difficult time of COVID-19. We strongly support all actions and efforts that prioritize distribution of COVID-19 vaccines, testing, and availability of PPE to protect frontline workers and residents.

Exhibit 5: CVS – Status of clinics in skilled nursing facilities, assisted living and other LTC facilities

CLICK TO VIEW FULL PDF

Exhibit 6: Walgreens – Status of clinics in skilled nursing facilities, assisted living and other LTC

facilities

CLICK TO VIEW FULL PDF

The per-resident rate of new COVID-19 infections continues to plummet in skilled nursing facilities, with a two percentage point drop and a likely continued downward trend.

“There is light at the end of the tunnel, and we don’t think it’s a train,” said a participant in a recent NIC Community Connector™ Meetup.

NIC’s Skilled Nursing COVID-19 Tracker, featuring the latest CMS data updated as of January 31, 2021, shows that newly confirmed COVID-19 cases within skilled nursing facilities continued to plummet. For the week ending January 31, the per-resident rate of new COVID-19 infections dropped to July levels as skilled nursing facilities reported a two percentage point drop in infections from 3% on December 20 when the Long Term Care (LTC) vaccination program was launched to 1% on January 31. The chart below depicts this decline.

New COVID-19 confirmed cases within skilled nursing facilities continued to fall at a faster pace compared to the U.S overall new cases. Notably, new confirmed cases within skilled nursing facilities are down 49% from 32,521 on December 20 to 16,701 on January 24, while U.S. new reported cases are down 24% over the same period.

Since January 31, U.S. COVID-19 cases have continued to fall steadily. On February 16, the rolling daily average of new infections hit its lowest level since October. In addition, the count of people receiving two doses of the COVID-19 vaccines as reported to the CDC in the Federal Pharmacy Partnership for Long-Term Care (LTC) Program nearly tripled in the first two weeks of February, from 641,561 on January 31 to 1,711,846 on February 16.

This continuing decline in U.S. cases along with the increase in vaccine supply and administration spark hope and suggest that new coronavirus cases in skilled nursing facilities are likely to continue trending lower in the next two reporting weeks ending Feb 7 and Feb 14.

The Skilled Nursing COVID-19 Tracker also shows that the share of properties reporting new COVID-19 infections fell from 34.5% on December 20 to 24.4% on January 24. Additionally, newly confirmed cases among staff are declining at the same pace as the new cases among residents.

“The drop in new cases is becoming evident in CMS data since vaccines have been administered and distributed in skilled nursing properties. While data suggest that we are entering the beginning of the end of this pandemic, it is still important to realize that we need vaccinations in combination with other interventions, including more frequent testing, greater emphasis on physical distancing, and adherence to masking guidelines. These interventions continue to be an effective and vital weapon against the rate of mutation of the virus and the spread of current virus strain until vaccines are widely accepted and distributed and herd immunity is achieved,” said NIC Chief Economist, Beth Mace.

* Blog and graph updated as of February 19, 2021