Most Read Skilled Nursing Stories for 2021

Several recurring topics crept up while chronicling Skilled Nursing News’ most-read stories of the year – occupancy, staffing, acquisitions and the industry’s place in value-based care – among others.

Of course, the COVID-19 vaccine rollout and subsequent mandate were top-of-mind the entire year as well. The Biden administration sought to boost lagging staff vaccine rates with a mandate tied to Medicare and Medicaid reimbursement.

Some states pushed back on the mandate, challenging the requirement in federal court. Currently, more than half of the 50 states are involved in one of these lawsuits; court injunctions have temporarily blocked the mandate for nursing homes in 25 states.


The Centers for Medicare & Medicaid Services (CMS) has since asked the Supreme Court to stay injunctions issued by the lower courts in Louisiana, Missouri and Texas.

Fallout from Genesis Healthcare’s New York Stock Exchange delisting and restructuring efforts were seen in real estate investment trust (REIT) transactions, while private equity buyers drove up SNF bed prices in a lively M&A environment.

Here’s a synopsis of our most viewed stories by month.


As Pandemic Drags On, Home Health Diversion Rates from Nursing Homes May Become Permanent

Nursing home occupancy continued to crater in 2021 as post-acute care stalled and census figures sat at historic lows in January, while home health agencies were running above their previous capacity as soon as June the previous year.

Suspended non-emergency surgeries at hospitals and an increased avoidance in institutional care settings continued to drive lower referral numbers into the new year – leaders in the sector had hoped the second half of 2020 would bring a return to normalcy and a reversal of both trends.

But as 2021 dawned, the coronavirus still raged out of control across the country and an analysis of post-acute referral patterns shows little sign of significant positive shifts.

Boston-based firm CarePort documented a rollercoaster ride of referral numbers across all post-acute care settings, falling to 69% of the previous year’s volume in April 2020 and then returning to 97% in October of that year.

Skilled nursing facility discharges had only crept back to 83% of historic volume during that time.

Warren Asks Genesis to Explain Former CEO Hager’s $5.2M Bonus in Wake of COVID Deaths, Federal Aid

Sen. Elizabeth Warren questioned Genesis HealthCare’s $5.2 million retention bonus paid to its former CEO George Hager, in the wake of dismal earnings reports for the second and third financial quarters of 2020.

Warren’s letter to newly appointed CEO Robert Fish described the move as “unfathomable greed amidst a public health tragedy and economic crisis,” citing Genesis’s accepted $300 million in state and federal aid under the CARES Act while claiming to be “on the brink of bankruptcy.”

Just two months later, the Kennett Square, Pa.-based nursing home giant announced plans to restructure and voluntarily remove itself from the New York Stock Exchange – while also receiving a $50 million capital infusion from ReGen Healthcare.

A slew of leadership changes followed, with Harry Wilson replacing Fish as CEO in March only to step down from the role after less than eight months. In November, Genesis announced the departure of its Chief Operating Officer Paul Bach, Chief Nursing Officer JoAnne Reifsnyder and Chief Financial Officer Tom DiVittorio. Genesis named new executives from both within the company and outside, including incoming COO Melissa Powell of The Allure Group.

Latest restructuring efforts take a page from the Ensign Group (Nasdaq: ENSG), Stifel analysts said, as Genesis also announced a shift toward a market-focused model “designed to build out a vertically integrated community-based health care system in every market, supported by centralized resources.”

Ensign now sits as the last major public nursing home operator left standing between the Nasdaq and the NYSE.

Welltower to Largely End Relationship with Genesis, Bolster ProMedica Joint Venture in $880M Deal

Real estate investment trust (REIT) Welltower (NYSE: WELL) breaks with Genesis as the operator grapples with restructuring, instead choosing to boost its relationship with ProMedica in an $880 million joint venture.

The Welltower exit marks the first major move by a REIT to substantially distance itself from the operator by divesting 51 of its Genesis assets.

Thirty-five were sold to a Welltower, Aurora Health Network and Peace Capital joint venture for $500 million; seven transitioned to a regional operator in conjunction with the Aurora joint venture until a purchase option becomes available in April 2023 for $182 million; and the remaining 9 assets folded into Welltower’s existing 80-20 ProMedica joint venture for $292 million.

In a separate deal, the Welltower-ProMedica JV shed 25 “non-strategic” facilities for $265 million.

CMS Proposes $444M Medicare Boost for Nursing Homes, Calls Out ‘Unintended’ $1.7B PDPM Gain

A year-plus into the implementation of the Patient-Driven Payment Model (PDPM), CMS raises the specter of potential adjustment to the payment model.

The agency was reeling from an unintended increase in PDPM payments – 5%, or $1.7 billion in 2020. The new payment model was intended to be budget neutral, CMS said, meaning the transition to PDPM was not supposed to cause an increase or decrease in skilled nursing spending.

CMS admitted the pandemic was a significant driver of the increase, although not immediately clear. The payment structure only generated a few months of pre-pandemic data before COVID.

Coupled with potential PDPM changes, CMS in April suggested a $444 million Medicare boost for nursing homes, or 1.3% increase. CMS called for adding new measures to the value-based payment (VBP) program and temporarily suppressing the 30-day all-cause readmission measure in 2022 due to the pandemic.

For Nursing Homes, I-SNPs Remain ‘Only Model’ for Them to Enter Value-Based Care

In June, operators sought recovery from a year-and-a-half dominated by a global pandemic. Many saw the institutional special needs plan (I-SNP) as a way to build a foundation in a post-pandemic world.

The I-SNP is a type of Medicare Advantage (MA) plan that restricts enrollment to people eligible for MA who, for 90 days or more, need or are expected to need the services of a SNF or another institution, according to CMS.

While not without its challenges, SNF operators saw I-SNPs as a way to survive an increased focus on outcomes and value.

“When we look back on 2020, it confirmed [the I-SNP] model for us, and highlighted the components that we think are critical, including integrated care management, being connected with the plan and with the plan operations and with the facility, and not being a fragmented, outsourced delivery system,” Hank Watson, chief development officer at American Health Partners, told Skilled Nursing News.

The pandemic ended up presenting one of the strongest arguments in favor of the I-SNP, with clinical benefits to residents outweighing financial and operational struggles tied to COVID cases.

“As an operator, it was a lifesaver,” added J. Mark Traylor, president at Traylor Porter Healthcare. “We had one of the worst homes in the state as far as outbreaks go. It’s a very large home. They wound up with just shy of 50 patients at one given time in the building with COVID, and then we had about 60-plus employees who contracted COVID.”

Acquisition Market Continues to be on Fire for Nursing Homes

Despite low occupancy rates and federal funding uncertainty, skilled nursing acquisitions continued to be on fire in July. Most active buyers throughout the year were in private equity, with REITs taking a wait-and-see approach to the industry.

Price per bed was pushed by aggressive PE buyers, and private capital on the landlord-side – a prime example brings us back to Genesis, which accepted $50 million from private firm ReGen Healthcare upon its plan to leave the NYSE.

Larger operators like Symphony Care Network found opportunities this year to buy smaller, single operators exhausted by the pandemic – the Chicago-based operator in July purchased two skilled nursing facilities and one supportive living facility in Chicago for $48.95 million.

“I think that you’re running into situations where a family-owned operator got hit with COVID-19 and are saying to themselves that they’d like to attach themselves to a larger organization or that it’s time to get out and that’s part of the frenzy in the market,” Michael Munter, Symphony Care Network chief operating officer, told Skilled Nursing News.

Other operators like Charleston, W. Va.-based Stonerise decided to start from scratch this year, citing the continued shift to private rooms in future.

DigitalBridge’s $3.2B Portfolio Sale Includes 83 SNFs, Other Health Care Assets

In a September M&A shakeup, DigitalBridge Group, Inc. (NYSE: DBRG) decided to sell its wellness infrastructure business, including 83 skilled nursing facilities, among other health care assets.

The transaction, valued at $3.2 billion, is expected to be completed in early 2022.

DigitalBridge sold its assets to a familiar real estate investment firm – Aurora Health Network – along with Highgate Capital Investments. Aurora was involved in Welltower’s divestiture of 42 of 51 Genesis assets in March.

The sale is the final step in the Boca Raton-based REIT’s digital transformation and increases corporate liquidity to over $1.5 billion on a pro forma basis, while at the same time reducing consolidated investment-level debt by $2.6 billion and subsidiary-level debt by an additional $294 million.

Nursing Home Staff Must Be Vaccinated, Biden Administration Says

The Biden Administration’s vaccine mandate more or less dominated the news cycle here at SNN from August on, with nursing homes singled out first before CMS expanded the mandate one month later to include any health care provider that received Medicare and Medicaid funding.

Only 60% of staff per facility were vaccinated, CMS reported, when President Joe Biden first announced the mandate Aug. 18. By December, that statistic jumped up to 77.3%. Several states including Massachusetts and New York implemented their own vaccine mandate for health care workers, reaching successful staff vaccination rates of 96.2% and 95.58%, respectively.

Some operators viewed the mandate, especially the initial move to focus on nursing homes, as a punishment to the industry. The expansion eventually included hospitals, home-health agencies, ambulatory surgical settings and dialysis centers, among others.

CMS: Nursing Home Staff Must be Fully Vaccinated by Jan. 4

Vaccine guidance was finally issued in November after months of anticipation – CMS regulation gave operators, along with most other health care providers, a deadline to get their staff vaccinated.

The agency gave leadership 30 days to get a plan in place to vaccinate their staff. A first dose of the Pfizer or Moderna two-dose vaccines, or the one-shot J&J vaccine, was required by Dec. 5 in order to have staff fully vaccinated by Jan. 4.

CMS left it up to operators to develop a process or plan for religious or medical exemptions as well.

CMS worked with the Occupational Safety and Health Administration (OSHA) to develop guidance. OSHA also issued its vaccine mandate guidance for employers with more than 100 employees on Thursday.

Unlike the OSHA rule, however, CMS doesn’t give health care workers a test-out option.

Federal Judge Freezes COVID Vaccine Mandate for All Health Care Workers

We leave 2021 on a bit of a cliff-hanger, with federal courts issuing injunctions effectively blocking the vaccine mandate in select states.

All within the same week, three federal rulings came down on the mandate – the first from a federal judge in Florida who would not temporarily pause the mandate while the case was being litigated, while two others in Missouri and Louisiana issued injunctions.

The Louisiana ruling granted a nationwide injunction, extending reach beyond the 14 states involved in the federal lawsuit.

CMS suspended its vaccine mandate while it appealed all injunctions, eventually garnering a partial win mid-December – the 5th U.S. Circuit Court of Appeals in New Orleans, La. revived the health care worker vaccine mandate in 26 states. The three judge panel ruled that the lower court injunction only had the authority to block the mandate in the 14 states involved in the lawsuit.

Between the two injunctions, the mandate is temporarily suspended in the following states: Alabama, Arizona, Georgia, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Montana, Ohio, Oklahoma, South Carolina, Utah and West Virginia (Louisiana lawsuit); Missouri, Nebraska, Arkansas, Kansas, Iowa, Wyoming, Alaska, South Dakota, North Dakota and New Hampshire (Missouri lawsuit).

In a separate lawsuit, Texas became the 25th state to temporarily block the mandate. The injunction was issued mid-December.

Federal lawsuits challenging the mandate now involve more than half of the 50 states.

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