48 States Saw Nursing Home Occupancy of 80% or Worse as 2021 Dawned — With Census as Low as 56%

Skilled nursing facilities are in the midst of a massive push to inoculate residents and staff against COVID-19, with the eventual hope of restoring routine visitations and opening more broadly to admissions from hospitals and the community.

But convincing both hospitals and family members that it’s safe to place patients and loved ones in long-term care is a task that will take months if not years. Hospital referrals to the skilled nursing setting plummeted over the course of the pandemic, and unlike referrals to home health, they have not recovered, a study from the consulting firm Avalere Health found in September.

The effects of the COVID-19 pandemic on SNF occupancy across the country are apparent in a data analysis conducted by the professional services firm CliftonLarsonAllen (CLA), which studied skilled nursing occupancy trends across the U.S. — drawing on data that SNFs are required to report to the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS).


CLA found that out of the 48 continental U.S. states, none are reporting occupancy higher than 80%, with New York the top state at approximately 79%; Texas has the lowest SNF occupancy at approximately 56%.

And while funds from the CARES Act and the Paycheck Protection Program (PPP) have allowed operators to navigate the challenges of maintaining their facilities during COVID-19, those reserves are declining, and occupancy is a “top 3 pain point for SNF operators,” CLA noted in its analysis.

“Given historically low margins, post-COVID occupancy at even 90-95% of pre-COVID levels will push most operators into a negative margin situation,” CLA principal and senior living segment leader Stephen Taylor and director Seth Wilson wrote.


Massachusetts had a notable drop in median occupancy from 2019 to 2020, going from 90% in the former year to 70% as of the end of May in the latter. New Mexico’s median occupancy went from the low 80% range to the low 70% range in the same time, with ongoing decline to a range in the low 60% area at the start of 2021.

CLA spotlighted Southern states as an example of the impact of COVID-19’s regional variations. Most of the South was hit with the first major COVID wave in the summer of 2020, well after the initial U.S. spikes in the Northeast, and most states in the South saw an occupancy decline of approximately 15% from 2019 to the beginning of 2021.

Source: CLA

The states covered in the chart, from left to right, are Florida, Mississippi, South Carolina, Alabama, Georgia, North Carolina, Louisiana, Tennessee, Arkansas, Oklahoma, and Texas.

Texas is the lowest in median occupancy of all 50 states at the start of 2021, at 55.7%, while Florida — whose median occupancy had typically trended above national median occupancy, according to CLA — had a median census of 75.8%.

“However, the Southern states as a group have consistently trended below national median occupancy throughout the COVID-19 pandemic,” Taylor and Wilson wrote. “COVID confirmed cases for the group of southern states were above [the] national median at the beginning of January 2021, which was also seen in the July, August, and September timeframes.”

Texas is facing a unique combination of challenges, CLA noted. The Lone Star State’s problems aren’t limited to just low occupancy, but low Medicaid rates and the typical increases in expenses related to infection control and staffing.

“Texas has one of the lowest Medicaid rates in the country, and at the start of 2020, Medicaid comprised approximately 69% payor sources, compared to approximately 63% median for the rest of the country,” Taylor and Wilson wrote.

Map showing median SNF occupancy in continental U.S. states
Source: CLA

The contrast to the median occupancy of SNFs in the Northeast region of the U.S. was shown in the fact that Massachusetts – despite its steep decline year-over-year – was still at roughly 70% to start 2021, a sharp contrast to Texas and Oklahoma, which had a median occupancy of just 55.8%. Arkansas was just barely above that, with a median occupancy of 58.4%.

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