“On one hand, the market fundamentals continue to show signals of progress due to the availability and widespread distribution of the COVID-19 vaccine among America’s seniors—on the other hand, staffing challenges and wage pressures are continuing to put strain on NOI for many operators. These data from the Wave 25 survey support trending improvement in the pace of move-ins and in occupancy rates across each of the care segments. However, staffing shortages that were experienced by many operators prior to and exacerbated by the pandemic persist. Currently, two-thirds of organizations report staffing shortages within their portfolio of properties. Adding to the challenge, nearly all respondents to the Wave 25 survey were paying staff overtime hours, and four out of five organizations were tapping agency/temp staff. The Wave 26 survey currently collecting data will explore strategies operators are implementing to attract staff.”

–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 25 survey includes responses collected March 22 to April 4, 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 25 Summary of Insights and Findings

• According to Wave 25 seniors housing and care survey respondents, on average, nine out of ten residents (92%) of their respective properties—including all care segments across their portfolios—have been fully vaccinated. From late January to the present, resident uptake of the vaccine has steadily increased. Staff uptake of the vaccine, however, leveled off between Waves 22 and 24 and has just recently increased slightly from over half (55%) to nearly two-thirds (63%) of staff.

• As a result of the vaccination rates, one-half of organizations are currently testing staff at least once a week for COVID-19, and one-half are testing residents only if symptomatic. Notwithstanding the need to test staff more frequently, and the costs associated with testing, one-half of respondent organizations indicate they probably will not or definitely will not make the COVID-19 vaccine mandatory for staff (53%); however, one-quarter probably will or definitely will (27%). The share of organizations considering making the vaccine mandatory for staff has increased since Wave 22 (11%).
• Staffing shortages that were experienced by many operators prior to and exacerbated by the pandemic persist in Wave 25. Currently, two-thirds of organizations report staffing shortages within their portfolio of properties (68%). And NOI continues to be pressured. Nearly all respondents to the Wave 25 survey are paying staff overtime hours (97%), up from a prior peak of 92% in the Wave 19 survey conducted December 28 to January 10. Furthermore, four out of five organizations are currently tapping agency/temp staff (82%). Both factors are at a time series high.

• The Wave 25 survey revisited the ways organizations are supporting property staff and their families to see what changes, if any, have occurred since early in the pandemic. As shown in the chart below, substantially fewer organizations are still offering additional paid sick leave and remote work. However, flexibility in work schedules is enduring: three-quarters of respondents (75%) are still offering staff flexible work hours.

• The shares of organizations reporting acceleration in the pace of move-ins has increased for independent living, assisted living and memory care since Wave 23, and reports of acceleration in move-ins in independent living is at the highest point in the time series. It is encouraging to see the pace of move-ins increasing in independent living, now, after lagging the higher levels of care that presumably saw earlier penetration of the vaccine due to the generally higher age and more acute health care needs of residents in assisted living, memory care and nursing care.

• Many operators have been eagerly anticipating a boost in occupancy due to the COVID-19 vaccine availability, and these survey data from Wave 25 support continued trends in improvement in the pace of move-ins and upward changes in occupancy rates across each of the care segments. More than one-half of organizations responding to the Wave 25 survey noted an increase in prospect interest specifically related to the vaccine (56%)—up from 25% in Wave 21. A similar proportion of survey respondents (57%) expect their organizations’ occupancy rates to recover to pre-pandemic levels sometime in 2022.
• Increased resident demand was cited by nine out of ten respondents (90%) as a reason for acceleration in move-ins in the past 30-days (the highest point in the survey time series), and about one-quarter of respondents in the Wave 25 survey reported that their organizations had a backlog of residents waiting to move-in (23%). The share of organizations currently offering rent concessions remains around 50% since the Wave 12 survey, conducted mid- to late-September.
• The Wave 25 survey data continue to show a trend in the shares of organizations noting an increase in occupancy across all four care segments, and each of the care segments are at or near the respective time series high points in terms of reports of occupancy increases.

• However, the degrees of occupancy increases vary. As shown in the chart below, the largest degrees of upward changes in occupancy rates were reported in the nursing care segment with 32% reporting upward changes of 5 to 10 percentage points. Reports of occupancy increases in organizations with independent living residents is at the time series peak, but the degree of change is weaker than the other care segments with one-quarter reporting increases of 0.1 to 3.0 percentage points.

Wave 25 Survey Demographics

• Responses were collected between March 22 and April 4, 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 one-half of the sample (52%). Operators with 11 to 25 and 26 properties or more make up about one-quarter of the sample (25% and 23%, respectively).
• One-half of respondents are exclusively for-profit providers (54%), just over one-quarter (28%) are nonprofit providers, and 18% 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, 79% of the organizations operate seniors housing properties (IL, AL, MC), 33% operate nursing care properties, and 39% 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 26 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 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.

As the U.S. enters the fourth week of rising COVID-19 cases, nineteen states have reported increasing COVID-19 cases among the general population for the week ending March 21. According to the CDC, Michigan reported the highest increase in COVID-19 cases among the general population at 187%, up from 7,313 cases during the week ending Feb 21 to 20,982 on March 21. Interesting and in contrast, skilled nursing facilities in Michigan reported a 55% decline in newly confirmed cases among residents over the same week-over-week period.

Other states that saw significant increases in cases between the reporting weeks of February 21 and March 21 are Maine (57%), New Jersey (36%), Alabama (32%), Idaho (31%), Maryland (26%), while at the same time, all of these states reported falling COVID-19 cases within their skilled nursing facilities. This may suggest that at this point in this 13-month pandemic, older Americans may indeed be safer in skilled nursing properties than in the general population.

CMS data as of March 21 compiled by NIC’s Skilled Nursing COVID-19 Tracker show that six states reported no new COVID-19 cases within their skilled nursing facilities for the week ending March 21 – down 100% from February 21 levels. These states include Wyoming, Montana, South Dakota, Nebraska, Utah, and Delaware.

Furthermore, more than twenty states reported fewer than 10 newly confirmed cases among residents across all their skilled nursing facilities. However, two states (Minnesota and Connecticut) reported a very small uptick in newly confirmed cases among skilled nursing residents, but the increases remain relatively low. (See interactive tool below for more details).

NIC’s Skilled Nursing COVID-19 Tracker shows that more counties are “turning grey” on the Tracker map, i.e., they report no new COVID-19 cases for the week ending March 21 compared to three months earlier on December 20 and prior to vaccine rollout. The difference between the two maps above corroborates the success story of the long-term care vaccination program for skilled nursing facilities and the effectiveness of the vaccines against new variants. The level of concern across skilled nursing facilities is most likely lower now than three months ago. This can only suggest a positive near-term outlook and more confidence in the post-pandemic picture and the safety of skilled nursing properties.

NIC’s new analysis below shows that new cases of COVID-19 in skilled nursing facilities account for just a fifth of 1% of U.S. cases overall on March 21, down from over 5% of cases in June 2020 and from over 2% in December 2020 and the launch of the long-term care vaccination program.

Per-resident rate of new COVID-19 infections continued to decline and reached a new pandemic low of 0.08% —only 8 in 10,000 residents of skilled nursing facilities tested positive for COVID for the week ending March 21, 2021 compared to 303 in 10,000 twelve weeks ago on December 20, 2020.

New Jersey weekly cases continue to accelerate since February 21, while weekly cases within skilled nursing facilities in New Jersey continued to decelerate and remained low. In fact, case counts within SNFs in New Jersey are down 92% from December 20 and 53% from February 21 through March 21 while weekly cases among the general population there are down 23% from December 20 but up 30% from February 21 levels. Choose specific regions or states from the dropdowns in the tool below to change the graphs. 

NIC’s new interactive tool tracks the incidence of COVID-19 and provides a way to compare weekly infections of COVID-19 in skilled nursing facilities and in the U.S. and across regions, sub regions, and states. Data show

• weekly confirmed cases in SNFs vs. U.S. (sort by region, sub region, or state)
• per-resident rate of new COVID-19 infections within SNFs (all vs. specific region/state)
• weekly confirmed cases among skilled nursing residents as a share of U.S. weekly cases.
• Summary states table (choose any two weeks comparison to compute the percent change).

The data is displayed in an easy-to-use interactive dashboard that allows sorts down to state level, with data updated weekly. Check back each week to see and compare current data. 

Managed Medicare RPPD hit a new low.

NIC MAP® Data Service, powered by NIC MAP Vision, released its latest Skilled Nursing Monthly Report on April 1, 2021, which includes key monthly data points from January 2012 through January 2021. Here are some key takeaways from the report.

Occupancy continued to be challenged as the industry navigated the first month of 2021. Skilled nursing property occupancy fell to a new low of 71.2%, placing it 46 basis points below December 2020 (71.7%), 13.8 percentage points below pre-pandemic levels of February 2020 (85.0%), and 13.7 percentage points below year-earlier levels. The COVID-19 pandemic has significantly impacted census at skilled nursing properties due to many challenges including the vulnerable population living in the properties, local and state level regulatory restrictions, and a significant decrease in hospital referrals. The occupancy trend was consistent across geographies as both urban and rural occupancy rates declined from December (47 basis points to 72.2% in urban areas and 29 basis points to a record low of 69.4% in rural areas). While rural and urban areas continue to face very low occupancy levels, vaccination clinics in most skilled nursing properties and the recent relaxation of some CMS visitation guidelines may support some stability in occupancy in the coming months.

Medicare revenue per patient day (RPPD) declined from December 2020 to January 2021 ending the first month of the new year at $552. However, it is up since March 2020 when the RPPD was $549. There has been federal government support for Medicare fee-for-service reimbursement such as higher rates to help care for COVID-19 positive patients requiring isolation. However, that has been becoming less relevant as case counts have declined sharply at skilled nursing properties since the vaccine rollout in December. Medicare RPPD increased 0.3% compared to a year ago. Meanwhile, Medicare revenue mix continued to increase reaching its highest level since March of 2018. It increased 61 basis points from December to January, ending at 24.1%. Medicare revenue mix has held up relatively well since the pandemic began in March 2020, compared with other payor types. It is up 247 basis points since March compared to managed Medicare (down 16 basis points to 10.3%) and private (down 255 basis points to 5.8%).

Managed Medicare RPPD hit a new low of $458 in January. Early in the pandemic managed Medicare RPPD increased from March to May 2020 but has since resumed the trend of monthly declines. It is down 2.1% since January 2020 and has declined 16% since January 2012. Managed Medicare patient day mix increased from December, up 81 basis points and stood at 7.7% in January after hitting a low during the pandemic of 5.4% in May. In addition, it was up 82 basis points from year-earlier levels. The increase since May of 2020, and the increase in the first month of 2021, suggests managed Medicare is playing an increasing role in overall operations but this is all in the context of a significant decline in occupancy. Managed Medicare admissions likely continue to be significantly below levels prior to the start of the pandemic.

Medicaid revenue per patient day increased slightly from December ending January 2021 at $238. However, that represents a 3.5% increase since March 2020 when the pandemic started, and it is up 4.2% from one year ago as many states embraced measures to increase reimbursement related to the number of COVID-19 cases. However, covering the cost of care for Medicaid patients is still a major concern as reimbursement does not cover the basic cost of patient care and services in many states. In addition, nursing home wage growth is elevated relative to inflation and staffing shortages are a significant challenge in many areas of the country. Expectations are that wage growth will remain elevated as staffing challenges remain an operational hurdle due to turnover and competition for labor in other industries.

To get more trends from the latest data you can download the Skilled Nursing Monthly Report here. 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 in order to provide data at localized levels in the future. Operators who are interested in participating can complete a participation form at https://www.nic.org/skilled-nursing-data-initiative. NIC maintains strict confidentiality of all data it receives.

The first Friday of the month at 8:30 ET is widely anticipated as the Labor Department presents a fresh gauge of the most recent economic performance in its release of the labor report for the prior month. Today’s number was even more closely watched since it indicates how quickly the economy is bouncing back from the year-long pandemic. In its release, the Labor Department reported that nonfarm payrolls rose by 916,000 in March and that the unemployment rate edged lower to 6.0% from 6.2% in February. The jobless rate remains 2.5 percentage points above the pre-pandemic level of 3.5% seen in February 2020, but well below the 14.7% peak seen in April. Despite the February increase, job levels are 8.4 million (5.5%) below the pre-pandemic levels of February 2020. The consensus estimates for February had been for a gain of 660,000.

Private service-producing jobs increased by 780,000, led by a rise of 280,000 jobs in leisure and hospitality payrolls as pandemic-related restrictions began to be relaxed and restaurants re-openings occurred. The resumption of in-person learning translated into a combined 190,000 increase in state, local government, and private education employment. Health care added 11,500 jobs in March. Within healthcare, nursing care facilities gained 1,700 jobs in March.

The number of long-term unemployed (those jobless for 27 weeks or more) was little changed from February at 4.2 million but is 3.1 million higher than year-earlier levels, suggesting that this continues to be a very challenging time for many Americans. Long-term unemployed persons account for 43.4% of the total number of unemployed persons.

The underemployment rate or the U-6 jobless rate was 10.7% versus 11.1% in February. This figure includes those who have quit looking for a job because they are discouraged about their prospects and people working part-time but desiring a full work week.

Average hourly earnings for all employees on private nonfarm payrolls fell by $0.04 in March to $29.96, a gain of 4.2% from a year earlier. This was down from an annual gain of 5.2% in February.

The labor force participation rate, which is a measure of the share of working age people who are employed or looking for work was steady at 61.5% in March, up from 61.4% in February.

The change in total nonfarm payroll employment for January was revised up by 67,000 from a 166,000 to 233,000 and the change for February was revised up by 89,000 from 379,000 to 468,000. Combined, 156,000 jobs were added to the original estimates. Monthly revisions result from additional reports received from businesses and government agencies since the last published estimates and from the recalculation of seasonal factors.

The March data is promising and reflects a re-opening of the economy. The ongoing drop in COVID cases, the widespread distribution of vaccines, and a shift in consumer confidence will allow for a more complete re-opening of the economy and a fuller recovery in jobs in the coming months. The next round of fiscal stimulus will provide a further boost to economic activity and allow the second half of 2021 to be very strong.

New cases of COVID-19 in skilled nursing facilities account for just a quarter of 1% of U.S. cases overall, down from over 5% of cases in June 2020. NIC’s new interactive data visualization tool shows a divergence as case counts among the general population rise in some parts of the U.S., while those in skilled nursing facilities continue to decline.

U.S. weekly COVID-19 infections are rising again across several states despite ongoing vaccination efforts. Although we are on the road to herd immunity and case count data in skilled nursing facilities (SNFs) suggest that vaccines are indeed effective, the recent uptick in U.S. cases indicates that it is still important to remain vigilant and continue to be cautious regarding enthusiasm about beating the pandemic. It is too early to let our guards down.

This new interactive tool tracks the incidence of COVID-19 and provides a way to compare weekly infections of COVID-19 in skilled nursing facilities and in the U.S. and across regions, sub regions, and states. Data show

• weekly confirmed cases in SNFs vs. U.S. (sort by region, sub region, or state)
• per-resident rate of new COVID-19 infections within SNFs (all vs. specific region/state)
• weekly confirmed cases among skilled nursing residents as a share of U.S. weekly cases.

The data is displayed in an easy-to-use interactive dashboard that allows sorts down to state level, with data updated weekly. Check back each week to see and compare current data. 

Choose specific regions or states from the dropdowns in the tool below to change the graphs. 

Interactive Tool – Weekly COVID-19 Confirmed Cases | Skilled Nursing Facilities vs. U.S.

While skilled nursing residents make up less than 1% of the U.S. population, the analysis shows that newly confirmed cases among skilled nursing residents have shrunk dramatically. Remarkably, weekly confirmed cases within skilled nursing facilities accounted for only 0.26% of U.S. weekly cases on March 14, down 1.86 percentage points from December 20 (2.12%) and the launch of the long-term care vaccination program. This suggests that the incidence of COVID-19 has shifted to the younger adults. Recent data shows that hospitalized COVID-19 patients are getting younger across several states, including New Jersey, Pennsylvania, and Michigan.

New Cases in Skilled Nursing Facilities Fall Below 1,000

Additionally, newly confirmed cases within skilled nursing facilities continued to decline and fell below 1,000 cases for the week ending March 14 (preliminary data). The per-resident rate of new COVID-19 infections continued to decline and reached a new pandemic low of 0.09% – only 9 in 10,000 residents tested positive for COVID for the week ending March 14, 2021 compared to 303 in 10,000 twelve weeks ago on December 20, 2020.

Regional Differences

Regionally, the lowest rate of new infections among skilled nursing residents was seen in the Midwest at 0.06% – a pandemic low, where case counts are down 98% from 8,756 on December 20 to 150 on March 14. This is followed by the West (0.07% – a pandemic low), the South (0.10% – a pandemic low), and the Northeast (0.15%). Case counts within SNFs in the Northeast are down 94% since December 20 while the Northeast overall weekly cases fell only 53% over the same period. Notably, the share of newly confirmed COVID-19 diagnoses within SNFs in the Northeast decelerated from 2.44% to 0.30% for the reporting weeks from Dec 20 through Mar 14 (down 2.13 percentage points).

The positive effects of the vaccines continue to be notable across the four regions of the U.S., the rate of new COVID-19 cases among skilled nursing residents prior to vaccination rollout moved nearly in tandem with the rate of new cases within their respective regions. In recent weeks, following the vaccine rollout, new cases within SNFs have been sharply lower than the weekly cases in their respective region at any previous point.

Furthermore, SNFs weekly confirmed cases in the Middle Atlantic (New York, New Jersey, and Pennsylvania) are down 94% since the week ending December 20 and continued to diverge from the overall weekly cases within the sub region (down 47%).

State Differences

Drilling deeper into state infection rates, New Jersey weekly cases have accelerated since February 21, while weekly cases within skilled nursing facilities in New Jersey continued to decelerate and remained low. In fact, case counts within SNFs in New Jersey are down 91% from December 20 through March 14 while weekly cases among the general population there are down only 30%. Other states that saw an increase in the last few weeks include Maryland, Maine, and Texas – none of these states reported an increase in cases within their skilled nursing facilities as of March 14.

Vaccinations

As of March 14, over 40 million people in the U.S. have been fully vaccinated. Of this group, 7.6 million are in long-term care communities. The status of clinics shows that over 90% of skilled nursing facilities participating in the Walgreens and CVS vaccination programs have completed their clinics (data as of March 11). The U.S. is currently administering 2.8 million doses per day (as of March 31), and it is likely that the average vaccination rate will reach 3 million in the coming days. However, it is also important to consider vaccine hesitancy and put more efforts to promote vaccine literacy to more fully immunize those who are hesitant.

In summary, weekly COVID-19 cases within skilled nursing facilities continue to decline or flatten with relatively small increases across few states. Data suggest that vaccines are indeed effective, but it is important to keep track of the incidence of COVID-19 in skilled nursing facilities vs. U.S. since most of skilled nursing patients have been vaccinated.

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.

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.