What changed in this filing

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Item 1. Business

2022-02-18 compared with 2021-02-19 · 114 added, 112 removed, 248 unchanged (48% of the section changed)

National HealthCare Corporation, which we also refer to as NHC or the Company, began business in 1971.

Our principal business is the operation of skilled nursing facilities, assisted living facilities, independent living facilities, homecare programs and a behavioral health hospital.

Our business activities include providing sub–acute and post–acute skilled nursing care, intermediate nursing care, rehabilitative care, memory and Alzheimer’s care, senior living services, and home health care services.

We have a non–controlling ownership interest in a hospice care business that services NHC owned health care centers and others.

Our principal business is the operation of skilled nursing facilities, assisted living facilities, independent living facilities, homecare and hospice agencies, and a behavioral health hospital.

In addition, we provide management services, accounting and financial services, as well as insurance services to third party operators of health care facilities.

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We operate in 10 states, and our owned and leased properties are located in the Southeastern, Northeastern, and Midwestern parts of the United States.

Description of the Business  

The following table summarizes our operations by ownership status as of December 31, 2021:

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Percentage of total

Homecare locations

We also operate a 16-bed behavioral health hospital.

This hospital specializes in geriatric behavioral health.

We have a 75.1% non–controlling ownership interest in Caris Healthcare, LP (“Caris”), a business that specializes in hospice care services in NHC owned health care centers and in other settings.

Caris provides hospice care to over 1,000 patients per day in 28 locations in Georgia, Missouri, South Carolina, Tennessee, and Virginia

Homecare Agencies

Hospice Agencies

We also operate a 16-bed behavioral health hospital that specializes in geriatric behavioral health.

We currently have a 64-bed behavioral health hospital and a 16-bed behavioral health hospital under construction that are set to open in early 2022.

Net Patient Revenues.

The services we provide include a comprehensive range of health care services.

In fiscal 2020, 95.0% of our net operating revenues were derived from such health care services.

In fiscal 2021, 89.9% of our net operating revenues and grant income were derived from such health care services.

Highlights of health care services activities during 2021 were as follows:

Skilled Nursing Facilities.

The most significant portion of our business and the base for our other health care services is the operation of our skilled nursing facilities (“SNF’s”).

In our facilities, experienced medical professionals provide medical services prescribed by physicians.

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Rehabilitative Services.

We provide therapy services through Professional Health Services, a subsidiary of NHC.

Our licensed therapists provide physical, speech, respiratory and occupational therapy for patients recovering from strokes, heart attacks, orthopedic conditions, neurological illnesses, or other illnesses, injuries or disabilities.

We maintained a rehabilitation staff of over 1,500 highly trained, professional therapists in 2021.

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Medical Specialty Units.

All our skilled nursing facilities participate in the Medicare program, and we have expanded our range of offerings by the creation of center–specific medical specialty units such as our memory care units and sub-acute nursing units.

Our trained staff provides care for Alzheimer’s patients in early, middle and advanced stages of the disease.

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thus, these facilities offer an expansion of our continuum of care.

We believe these independent living units offer a positive marketing aspect to all our senior care offerings and services.

In 2021, the rate of occupancy was 88.1% compared to 92.1% in 2020.  

We have one independent living facility which is a "continuing care community", where the resident pays a substantial entrance fee and a monthly maintenance fee.

The resident then receives a full range of services, including skilled nursing and home health, without additional charge.

Homecare Programs .

Behavioral Health Hospitals.  

Our comprehensive continuum of care includes behavioral health services to both adults and geriatric patients with psychiatric, emotional, and addictive disorders. 

Currently, we operate a 16-bed hospital to adult and geriatric patients who require inpatient hospitalization due to mental disorders, including cognitive illnesses. 

We are completing construction, and will open in early 2022, two additional behavioral health hospitals (64-bed hospital and 16-bed hospital) that will provide the same level of comprehensive care for adults and geriatric patients with psychiatric, emotional, and addictive disorders. 

We also will be offering intensive outpatient programs with individualized treatment plans based on the patient's clinical needs.  

Homecare Agencies .

Our home health care programs (“homecares”) assist those who wish to stay at home or in assisted living residences but still require some degree of medical care or assistance with daily activities.

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In 2021, we served an average census of 3,165 patients and provided 342,313 visits.

Hospice Agencies .

We provide hospice care through Caris Healthcare, L.P.

(“Caris”), a wholly owned subsidiary of NHC.

Caris specializes in providing hospice and palliative care to over 1,250 patients per day in 28 locations in Georgia, Missouri, South Carolina, Tennessee, and Virginia.

Under the Medicare reimbursement payment system, Medicare pays a daily rate to cover the costs for providing services included in the patient care plan.

Medicare makes daily payments based on 1 of 4 levels of hospice care.

All hospice care and services offered to patients and their families must follow an individualized written plan of care that meets the patient’s needs.

Pharmacy Operations.

At December 31, 2020, we operated four regional pharmacy locations (two locations in Tennessee and one location each in South Carolina and Missouri).

 At December 31, 2021, we operated four regional pharmacy locations (two locations in Tennessee and one location each in South Carolina and Missouri).

These pharmacies primarily service our patients that are in an inpatient setting using a central location to deliver pharmaceutical supplies.

Our regional pharmacies bill Medicare Part D Prescription Drug Plans (PDPs) electronically and directly for inpatients who have selected a PDP.

Institutional Special Needs Plan (“I-SNP”).

Our I-SNP, which is called NHC Advantage, is a managed care insurance company that restricts enrollment to Medicare Advantage eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a skilled nursing facility.

Institutional Special Needs Plan ( “

I-SNP ”

We believe the I-SNP benefits our patients by providing nurse practitioners and care-coordination teams that continue to enhance the patient-centered experience and our quality of patient care.

The I-SNP receives a per member, per month premium from Medicare which covers the members same health care benefits as original Medicare, as well as additional benefits including preventive screenings and routine vision coverage.

At December 31, 2020, the I-SNP operated in the states of Tennessee and Missouri with over 900 members enrolled in the plan.

At December 31, 2021, the I-SNP operated in the states of Tennessee, Missouri, and South Carolina with approximately 1,000 members enrolled in the plan.

Other Revenues.

We generate revenues from management, accounting and financial services to third party operators of healthcare facilities, from insurance services to our managed healthcare facilities, and from rental income.

In fiscal 2020, 5.0% of our net operating revenues were derived from such sources.

In fiscal 2021, 4.2% of our net operating revenues and grant income were derived from such sources.

The significant sources of our other revenues are described as follows:

Management, Accounting and Financial Services.

We provide management services to skilled nursing facilities, assisted living facilities and independent living facilities operated by third party operators.

We typically charge 6% of the managed centers’

net operating revenues as a fee for these services.

 We provide management services to skilled nursing facilities, assisted living facilities and independent living facilities operated by third party operators.

We typically charge 6% of the managed centers’ net operating revenues as a fee for these services.

Additionally, we provide accounting and financial services to other healthcare operators.

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Insurance Services.

NHC owns a Tennessee domiciled insurance company that provides workers’

compensation coverage to substantially all of NHC's owned and managed healthcare facilities.

 NHC owns a Tennessee domiciled insurance company that provides workers’ compensation coverage to substantially all of NHC's owned and managed healthcare facilities.

A second wholly owned insurance subsidiary is licensed in the Cayman Islands and provides general and professional liability coverage in substantially all of NHC’s owned and managed healthcare facilities.

Rental Income.

The healthcare properties currently owned and leased to third party operators include nine skilled nursing facilities and four assisted living communities.

Government Stimulus Income.  

We received government stimulus funds during 2020 as part of the Coronavirus Aid, Relief, and Economic Security Act (the "CARES Act"). 

 The healthcare properties currently owned and leased to third party operators include nine skilled nursing facilities and four assisted living communities.

Government Stimulus Income.

We received government stimulus funds in 2021 and 2020 as part of the Coronavirus Aid, Relief, and Economic Security Act (the "CARES ACT"). 

The CARES Act provided $2.2 trillion of economy-wide financial stimulus in the form of financial aid to individuals, businesses, nonprofits, states and municipalities. 

The CARES Act appropriated $175 billion to the Public Health and Social Services Emergency Fund , which is referred to as the Provider Relief Fund. 

During 2020, we received disbursements from the Provider Relief Fund that totaled $63,573,000.

Of the $63,573,000 of funds received, the Company recorded $47,505,000 of government stimulus income for the year ended December 31, 2020. 

As of December 31, 2020, amounts not recognized as income are $16,068,000 and are reflected in the current liability section of our consolidated balance sheet (provider relief funds).

Non–Operating Income.

The CARES Act appropriated $178 billion to the Public Health and Social Services Emergency Fund , which is referred to as the Provider Relief Fund ("PRF"). 

The Company recorded $63,360,000 and $47,505,000 of government stimulus income from the PRF for the years ended December 31, 2021 and 2020, respectively. 

As of December 31, 2021, government stimulus funds received but not recognized as income are $9,443,000 and are reflected in the current liability section of our consolidated balance sheet (provider relief funds).

Operating Income.

We generate non–operating income from equity in earnings of unconsolidated investments, dividends and realized gains and losses on marketable securities, interest income, and other miscellaneous non–operating income.

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Earnings from investments in entities in which we lack control but have the ability to exercise significant influence over operating and financial policies are accounted for on the equity method.

Our most significant equity method investment is a 75.1% non–controlling ownership interest in Caris, a business that specializes in hospice care services in NHC owned health care centers and in other settings.

Caris currently has 28 locations serving five states (Georgia, Missouri, South Carolina, Tennessee, and Virginia).

During the first five months of 2021, our most significant equity method investment was a 75.1% non–controlling ownership interest in Caris.

As of June 11, 2021, the Company acquired the remaining 24.9% equity interest in Caris. 

As of the acquisition date, Caris’

operations are consolidated into the Company's financial statements.

Quality of Patient Care

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Skilled Nursing

Springfield, MO

Behavioral Health Hospital

Osage Beach, MO

Skilled Nursing

Knoxville, TN

February, 2020

February 2020

Assisted Living

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Under Construction

Behavioral Health Hospital

Behavior Health Hospital

Knoxville, TN

Under Construction

 Business Segments

For the two behavioral health hospitals under construction, the two facilities are expected to begin operations late in the first quarter of 2022 or the beginning of the second quarter of 2022.  

Business Segments

The Company has two reportable operating segments:

(1) inpatient services, which includes the operation of skilled nursing facilities, assisted and independent living facilities, and the one behavioral health hospital, and (2) homecare services.

(1) inpatient services, which includes the operation of skilled nursing facilities, assisted and independent living facilities, and the one behavioral health hospital, and (2) homecare and hospice services.

The Company also reports an “all other”

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Changes in the laws or new interpretations of existing laws as applied to the skilled nursing facilities, assisted living facilities, home health, or other components of our health care businesses, may have a significant impact on our operations. 

Governmental and other authorities periodically inspect our skilled nursing facilities and home health agencies to assure that we continue to comply with their various standards.

Governmental and other authorities periodically inspect our healthcare facilities and home health and hospice agencies to assure that we continue to comply with their various standards.

We must pass these inspections to continue our licensing under state law, to obtain certification under the Medicare and Medicaid programs, and to continue our participation in the Veterans Administration program.

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These notices may require us to take corrective action and may impose civil money penalties and/or other operating restrictions.

If our skilled nursing facilities and home health agencies fail to comply with these directives or otherwise fail to comply substantially with licensure and certification laws, rules and regulations, we could lose our certification as a Medicare and Medicaid provider and/or lose our licenses.

If our skilled nursing facilities, home health agencies, or hospice agencies fail to comply with these directives or otherwise fail to comply substantially with licensure and certification laws, rules and regulations, we could lose our certification as a Medicare and Medicaid provider and/or lose our licenses.

Local and state health and social service agencies and other regulatory authorities specific to their location regulate, to varying degrees, our assisted living facilities.

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All but eight (seven owned and one managed) of our affiliated skilled nursing facilities participate in Medicaid.

All our homecare agencies participate in the Medicare and Medicaid programs, with Medicare comprising the majority of their revenue.

All our homecare and hospice agencies participate in the Medicare and Medicaid programs, with Medicare comprising the majority of their revenue. 

Our behavioral health hospital also participates in the Medicare and Medicaid program.

During the fiscal years, we received payments from Medicare and, if participating, from Medicaid.

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Medicare is uniform nationwide and reimburses skilled nursing facilities under a fixed payment methodology called the Skilled Nursing Facility Prospective Payment System ("SNF PPS").

Effective October 1, 2019, CMS issued a new case-mix model under the SNF PPS, called the Patient-Driven Payment Model (“PDPM”), which focuses on a resident’s condition and care needs, rather than the amount of care provided to determine reimbursement levels.

The SNF PPS includes a case-mix model called the Patient-Driven Payment Model (“PDPM”), which focuses on a resident’s condition and care needs, rather than the amount of care provided to determine reimbursement levels.

PDPM utilizes clinically relevant factors for determining Medicare payment by using ICD-10 diagnosis codes and other patient characteristics as the basis for patient classification.

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physical therapy (“PT”), occupational therapy (“OT”), speech language pathology (“SLP”), nursing and social services and non-therapy ancillary services (“NTA”).

It also uses a sixth non-case mix component to cover utilization of skilled nursing facility (“SNF”) resources that do not vary depending on resident characteristics.

On July 31, 2020, CMS released its final rule outlining fiscal year 2021 Medicare payment rates and policy changes for skilled nursing facilities, which began October 1, 2020.

The fiscal year 2021 final rule provided for an approximate 2.2% increase, or $750 million, compared to fiscal year 2020 levels.

The final rule continues to reflect the commitment to shifting Medicare payments from volume to value, with the continued implementation of PDPM and value-based purchasing to improve interoperability, operational quality, and safety.  

The CARES Act temporarily suspended Medicare sequestration beginning May 1, 2020 through December 31, 2020.

It also uses a sixth non-case mix component to cover utilization of skilled nursing facility resources that do not vary depending on resident characteristics.

On July 29, 2021, CMS released its final rule outlining fiscal year 2022 Medicare payment rates and policy changes for skilled nursing facilities, which began October 1, 2021.

The fiscal year 2022 rule provided for an approximate 1.2% increase, or $410 million, compared to 2021 levels.

The net increase includes a 2.7% market-basket update that is offset by a 0.7% productivity adjustment and a 0.8% market-basket forecast error adjustment.

The Coronavirus Aid, Relief and Economic Security Act (the “CARES”

Act) and subsequent related legislation temporarily suspended Medicare sequestration beginning May 1, 2020 through March 31, 2022.

The Medicare sequestration policy reduces fee-for-service Medicare payments by 2 percent.

The CARES Act extends the sequestration policy through 2030 in exchange for this temporary suspension. 

On December 27, 2020, the Consolidated Appropriations Act of 2021 further suspended the 2.0% payment adjustment through March 31, 2021. 

Homecares ( “

HHAs ”

Medicare is uniform nationwide and reimburses homecare agencies under a fixed payment methodology, named the Home Health Prospective Payment System ("HH PPS").

Generally, Medicare makes payments under the HH PPS based on a standardized episodic payment, which is adjusted for case mix and geographical wage index.

Payment rates are updated at the beginning of each calendar year.

In November 2020, CMS released its final rule outlining fiscal year 2021 Medicare payment rates.

CMS projects payments to home health agencies in fiscal year 2021 will increase in aggregate by 1.9%, or $390 million.

The increase reflects the effects of the 2.0% home health payment update percentage and a 0.1% decrease due to reductions made by the rural add-on policy.

The rule also updates the home health wage index, limiting any decrease in a geographic area’s wage index value to no more than 5% next year.

Effective January 1, 2020, CMS set forth the implementation of the Patient-Driven Groupings Model (“PDGM”) and a 30-day unit of payment as mandated by the Bipartisan Budget Act of 2018 (“BBA”).

The new rule ended request for anticipated payments ("RAP"), or prepayments, and these will be completely phased out by 2021. 

Under PDGM, the initial certification of patient eligibility, plan of care, and comprehensive assessment remains valid for 60-day episodes of care, but payments for home health services will be made based upon 30-day payment periods.

These changes focus on providing value over volume of services to patients.

Home health payments will no longer be based on the number of visits provided, but rather the patient’s medical condition and care needs. 

Beginning April 1, 2022, the sequestration reductions will then be 1% from April 1, 2022 through June 30, 2022. 

The full 2% reduction is scheduled to go back into effect July 1, 2022.  The CARES Act extends the sequestration policy through 2030 in exchange for this temporary suspension, which the sequestration reduction for 2030 has been increased up to 3%. 

Medicare is uniform nationwide and reimburses homecare agencies under a Patient-Driven Groupings Model (“PDGM”).

Under PDGM, Medicare provides homecare agencies with payments for each 30-day period of care provided to beneficiaries.

If a beneficiary is still eligible for care after the end of the first 30-day payment period, a second 30-day payment period can begin.

There are no limits to the number of periods of care a beneficiary who remains eligible for the home health benefit can receive.

While payment for each 30-day period of care is adjusted to reflect the beneficiary’s health condition and needs, a special outlier provision exists to ensure appropriate payment for those beneficiaries that have the most expensive care needs.

The payment under the Medicare program is also adjusted for certain variables.

In November 2021, CMS released its final rule outlining calendar year 2022 Medicare payment rates.

CMS projects payments to home health agencies in 2022 will increase in aggregate by 3.2%, or $570 million.

The increase reflects the effects of the 2022 home health payment update percentage of 2.6%, an estimated 0.7% increase that reflects the effects of the updated fixed-dollar loss ratio, and an estimated 0.1% decrease in payments due to the changes in the rural add-on percentages for 2022.

Additionally, CMS is expanding the Home Health Value-Based Purchasing (“HHVBP”) model nationwide with the first performance year of the expanded HHVBP Model to occur in 2023.

Quality performance data from 2023 will be used to calculate payment adjustments under the expanded Model in 2025.

Medicare payment rates are calculated as daily rates for each of four levels of care we deliver.

Rates are set based on specific levels of care, are adjusted by a wage index to reflect healthcare labor costs across the country and are established annually through federal legislation.

The following are the four levels of care provided under the hospice benefit:

Routine Home Care .

Care that is not classified under any of the other levels of care, such as the work of nurses, social workers or home health aides.

General Inpatient Care .

Pain control or acute or chronic symptom management that cannot be managed in a setting other than an inpatient Medicare-certified facility, such as a hospital, skilled nursing facility or hospice inpatient facility.

Continuous Home Care .

Care for patients experiencing a medical crisis that requires nursing services to achieve palliation and symptom control for a minimum of eight hours of care within a 24-hour period.

Inpatient Respite Care .

Short-term, inpatient care to give temporary relief to the caregiver who regularly provides care to the patient.

Medicare payments are subject to two fixed annual caps, which are assessed on a provider number basis, and are broken into an inpatient cap amount and an overall payment cap.

These cap amounts are calculated and published by the Medicare fiscal intermediary on an annual basis.

In July 2021, CMS released its final rule outlining fiscal year 2022 Medicare payment rates.

CMS issued a rate increase of 2.0%, or $480 million, effective October 1, 2021.

The increase is the result of a 2.7% market basket increase reduced by a 0.7% productivity adjustment.

The fiscal year 2022 hospice payment updates also include an update to the statutory aggregate cap amount, which limits the overall payments per patient that are made annually.

The cap amount for fiscal year 2022 is $31,297.61 compared to $30,683.93 for FY 2021.

Medicaid Legislation and Regulations

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Changes in federal funding coupled with state budget problems and Medicaid expansion under the Affordable Care Act have produced an uncertain environment.

Some states will not keep pace with post-acute healthcare inflation.

Most states will not keep pace with post-acute healthcare inflation.

States are currently under pressure to pursue other alternatives to skilled nursing care such as community and home–based services.

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Effective July 1, 2021 and for the fiscal year 2022, the state of Tennessee implemented specific individual nursing facility increases.

We estimate the resulting increase in revenue for the 2021 fiscal year will be approximately $1,500,000, or $375,000 per quarter

Effective October 1, 2020 and for the fiscal year 2021, the state of South Carolina implemented specific individual nursing facility rate changes.

We estimate the resulting increase in revenue for the 2022 fiscal year will be approximately $3,500,000 annually, or $875,000 per quarter.

Effective July 1, 2021 and for the fiscal year 2022, the state of Missouri implemented specific individual nursing facility increases.

We estimate the resulting increase in revenue for the 2022 fiscal year will be approximately $2,000,000 annually, or $500,000 per quarter.

We have also received from many of the states in which we operate a supplemental Medicaid payment to help mitigate the incremental costs resulting from the COVID-19 public health emergency.

For the year ended December 31, 2020, we have recorded $26,179,000 due to these supplemental Medicaid payments.

For the years ended December 31, 2021 and 2020, we have recorded $20,482,000 and $26,179,000, respectively, due to these supplemental Medicaid payments.

We have recorded these payments in net patient revenues in our consolidated statements of operations.

In most of the communities in which we operate health care facilities, we compete with other health care facilities in the area.

We operate 75 skilled nursing facilities located in nine states, all of which require a certificate of need prior to the opening of any new skilled nursing facilities. 

There are hundreds of operators of skilled nursing facilities in each of these states and no single operator, including us, dominates any of these state’s skilled nursing care markets, except for some small rural markets which might have only one skilled nursing facility.

In competing for patients and staff with these facilities, we depend upon referrals from acute care hospitals, physicians, residential care facilities, church groups and other community service organizations.

In most of the communities in which we operate health care facilities, we compete with other health care facilities in the area. 

There are hundreds of operators of post-acute healthcare services in each of these states and no single operator, including us, dominates any of the markets, except for some small rural markets which might have limited competition.

In competing for patients and staff, we depend upon referrals from acute care hospitals, physicians, residential care facilities, church groups and other community service organizations.

The reputation in the community and the physical appearance of our facilities are important in obtaining patients since members of the patient’s family generally participate to a greater extent in selecting skilled nursing facilities than in selecting an acute care hospital.

We believe that by providing and emphasizing rehabilitative, as well as patient-centered skilled care services at our facilities, we can broaden our patient base and to differentiate our facilities from competing skilled nursing facilities.

As we continue to expand into the assisted living and senior living communities, we monitor proposed or existing competing senior living communities.

Our development goal is to link our skilled nursing facilities with our assisted living facilities, thereby obtaining a competitive advantage for both.

Our homecare agencies compete with other home health agencies (HHA’s) in most communities we serve.

We believe that by providing and emphasizing rehabilitative, as well as patient-centered healthcare services, we can broaden our patient base and to differentiate our operations from competing operations.

As we continue to expand into the senior living communities and behavioral health hospitals, we monitor proposed or existing competing operations.

Our development goal is to link our skilled nursing facilities with our senior living communities and behavioral health hospitals, thereby obtaining a competitive advantage for both.

Our homecare and hospice agencies compete with other agencies in most communities we serve.

Competition occurs for patients and employees.

Our homecare agencies depend on hospital and physician referrals and reputation to maintain a healthy census.

Our homecare and hospice agencies depend on hospital and physician referrals and reputation to maintain a healthy census.

Human Capital

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The Company’s partners appreciate different perspectives and embrace the opportunity to work with those of diverse backgrounds.

At NHC, our values underpin our inclusive culture, drive our growth, nurture innovation, and inspire the great experiences we create for our patients and partners we serve. 

Our signature "Better Way" service culture encourages each partner to be responsive, respectful, and deliver great experiences to our customers, patients, partners, communities, and to each other. 

As a leader in health care, the Better Way culture seeks to do just what it says - continually searching for a better way to improve person-centered care and quality outcomes, while at the same time finding better ways to deliver care in a more efficient and effective way. 

The twenty "Better Way" promises align with our core values of integrity, care, respect, and compassion. 

These promises are embedded at all levels of our Company.  

Career Development

Our partners' career development is instrumental to our long-term success of attracting, rewarding, and retaining the best team members and a top priority of the Company. 

We actively seek to identify and develop talent throughout the Company and provide a variety of learning experiences for a diverse learning audience. 

This includes on-the-job training, effective performance evaluations and timely feedback, as well as formal programs such as:

An "Administrator in Training" program, which is 24 months in duration, that is for the professional training of administrators.

Presently, we have five (two female and three male) full–time individuals in this program.

Two of our three regional senior vice presidents, four regional vice presidents, and 53 of our 75 health care center administrators are graduates of this program.

A robust educational tuition reimbursement program (through a Company sponsored not-for-profit Organization) that includes tuition and textbook reimbursement for continuing nursing education. 

This program currently supports approximately 200 partners in over 50 local communities.

An American Dietetic Association-approved internship program that trains qualified individuals to become dietitians, with an emphasis in geriatric nutrition. 

Accredited in 1982, the program includes rotations in hospitals and skilled nursing facilities, as well as community experiences.  

Certified Nurse Assistant training classes throughout the Company, as well as funding provided to local vocational programs, technical schools, and universities across the country to help increase the quality of education in the field of geriatrics.

Total Rewards

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Also, to foster a stronger sense of ownership, we offer an Employee Stock Purchase Plan where partners may purchase company stock through payroll deduction.

We face competition in employing and retaining nurses, technicians, aides, and other high-quality professional and non–professional employees.

To enhance our competitive position, we offer a robust educational tuition reimbursement program, an American Dietetic Association approved internship program, specialty designed nurse aide training classes, and there is financial scholarship aid available for various health care vocation programs.

We also conduct an "Administrator in Training" course, which is 24 months in duration, for the professional training of administrators.

Presently, we have five (two female and three male) full–time individuals in this program.

Both of our regional senior vice presidents, four regional vice presidents, one regional administrator, and 53 of our 75 health care center administrators are graduates of this program.

We regularly utilize third-party consultants to conduct anonymous surveys to seek feedback from our partners on a variety of topics, including but not limited to, confidence in company leadership, competitiveness of our compensation and benefits package, career growth opportunities and improvements on how we can continue to make our company an employer of choice.

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When the pandemic began, we ensured and continue to ensure that our partners have access to masks, thermometers, protective gloves, sanitizing supplies, and all personal protective equipment needed in order to protect themselves.

We closely followed the recommendations of the World Health Organization, the U.S.

Centers for Disease Control and local governments, and we took action to ensure our partners were safe.

Some of the preventative measures we implemented included:

We closely follow the recommendations of the World Health Organization, the U.S.

Centers for Disease Control and local governments, and we take actions to ensure the safety of our partners.

Some of the preventative measure we have implemented included:

increased hygiene, cleaning and sanitizing procedures at all locations;

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We have a long and proud history of investing in the communities where we live and work.

Through the National Health Foundation (the “Foundation”) and The Foundation for Geriatric Education (“TFGE”) we give back by providing grants and funding to various nonprofits, high schools, technical schools, and universities across the country.

We are proud to be recognized annually as a significant contributor to the Alzheimer's Association, where we also participate in the Alzheimer's Association annual Walk to End Alzheimer's. 

Through the National Health Foundation (the “Foundation”) and The Foundation for Geriatric Education (“TFGE”) we give back by providing grants to nonprofits and providing tuition reimbursement to partners to further their education in the field of geriatrics.

We also have a Compassion Fund which is used to help support partners in times of need.

Many of our partners make a positive impact in the communities in which they live by donating their time and talent by volunteering and serving on boards of charitable organizations.

Diversity and Inclusion

A diverse and inclusive workforce adds value to our Company and helps us succeed in an ever-changing environment. 

By embracing diversity and fostering inclusion, we aim to enable each partner to contribute fully to the Company. 

We believe diversity is important because varied perspectives expand our ability to bring unique experiences to our business. 

We also believe our workforce reflects the relative diversity of the available talent in the communities we serve.  

While we are making progress with our diversity and inclusion goals, we know we can do more. 

This year, the Company's Board of Directors ("the Board") approved amendments to the Company's Nominating Committee charter to directly address diversity. 

The Board also adopted Corporate Governance Guidelines that included a section on Board diversity and the Board recently adopted a Diversity Statement that included a best-efforts commitment to place at least one female on the Board by the 2022 shareholders' meeting.  

Environmental Sustainability

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Compared sentence by sentence after normalising whitespace, quotation marks, case and digits, so re-formatting and restated figures do not read as changed language. Wording changes appear as one removal and one addition. The current filing and the prior one are authoritative.

What changed 10-K

Item 1. Business