After already losing 20 nursing homes over the course of the last year-plus, one in four facilities remain at risk of closure in Massachusetts, according to a long-term care trade group in the state.

Citing a new report from advisory firm CLA, the Massachusetts Senior Care Association late last week warned that 95 of the state’s nursing homes — or about a quarter of the total still in operation — are at risk of closure.

“A majority of the Commonwealth’s nursing facilities are operating in the red, particularly those facilities that have a high reliance on state Medicaid funding,” Tara Gregorio, president of the trade group, said in a statement. “The CLA report clearly shows the situation is dire and the causes are clear.”

CLA made waves earlier this year when its annual nursing home cost report revealed a nationwide median operating margin of -0.1% for 2018, a figure that the report’s authors described as “an alarming metric.”

“Given the multi-year trend of declining industry margins, this calls into question the long-term financial viability of lower-performing SNFs,” CLA observed in its national report.

But in the Bay State, that number has been underwater for some time, according to Michael Slavik, chief practice officer for CLA’s northeast region in Quincy, Mass. In 2014, Massachusetts operators had a median margin of -1.2%, a figure that fell to a nadir of -4.1% in 2017 — rising only slightly to -3.5% in 2018.

While shocking in isolation, those numbers probably don’t come as any surprise to providers with a presence in Massachusetts, a state where Medicaid rates for nursing homes haven’t been updated since 2007. Operators received a $50 million funding boost under the state’s most recent budget, but advocates say it isn’t enough to stanch the bleeding — prompting a group of providers to work toward placing a funding-reform initiative on the ballot in 2020.

“All of these things converge and put a lot of pressure on the Medicaid system, and the Medicaid system hasn’t kept up with the funding needs of the industry, as we’ve seen,” Slavik said. “And that’s evident, looking at the negative operating margins that these facilities have had over the last five years.”

Medicaid is also just one of the factors weighing down operators in the Bay State: A rising minimum wage, a decline in the proportion of private-pay residents, and overall payment reform efforts have all contributed to nursing home operators’ woes, Slavik noted.

“In skilled nursing, when our labor costs go up, we have to rely on a rate increase that will compensate us for the increased cost,” Frank Romano, CEO of operator Essex Group Management and a leader in the effort to bring a funding question to Massachusetts voters, told SNN earlier this month. “In assisted living, I can increase rates to offset the costs of labor, and you can’t do that in skilled nursing.”

About three-quarters of every dollar that Massachusetts nursing homes spend goes toward wages, Gregorio noted in her group’s statement on the CLA report — drawing a direct line between Medicaid funding and quality outcomes.

“In order to protect this state safety net service, we need to continue to build upon recent state investments in quality nursing home care and promote quality jobs in our nursing facilities,” she said.

CLA’s 95-building figure marks a steep increase from the Mass Senior Care Association’s prediction earlier this year of 35 nursing homes at risk. Since raising that initial alarm in April, several properties in the Bay State have indeed closed, including five facilities that had previously been operated by the now-defunct Skyline Healthcare chain.

Massachusetts, of course, isn’t the only state with Medicaid headaches: Low rates that haven’t kept up with 2019 expenses have been blamed for closures across the country. In Wisconsin, for instance, 27 facilities have closed since 2016, with operators predicting that the demand for nursing home services could soon exceed supply in some markets as soon as next year.

That said, Slavik allowed that all 95 facilities aren’t necessarily hovering on the brink of imminent closure. CLA used a variety of metrics — from margin to days’ cash on hand to debt service ratios — to analyze the health of these properties, but Slavik noted that certain intangibles may have been lost in the analysis: For instance, the owner of a non-profit operator might have an endowment that didn’t show up on an individual facility’s cost reports, while a national for-profit chain could shift funds from elsewhere to help its struggling SNFs in Massachusetts.

But he also emphasized that the cohort of facilities have serious issues that require immediate attention.

“It accurately shows facilities that aren’t performing, and are probably at risk for some need of intervention — or potentially closure,” Slavik said.