Ladies and gentlemen, thank you for standing by and welcome to the Sabra Health Care REIT fourth quarter 2020 earnings conference call. At this time, all participant lines are in a listen-only mode. After the speakers' presentation, there will be a question and answer session. To ask a question during the session, you will need to press star one on your telephone. Please be advised that today's conference is being recorded. If you require any further assistance, please press star zero. I will now hand the conference over to your speaker today, Michael Costa, Executive Vice President, Finance, and Chief Accounting Officer. Thank you. Please go ahead, sir.
Thank you. Before we begin, I want to remind you that we will be making forward-looking statements in our comments and in response to your questions concerning our expectations regarding our future financial position and results of operations, including the expected impacts of the ongoing COVID-19 pandemic, our expectations regarding our tenants and operators, and our expectations regarding our acquisition, disposition, and investment plans. These forward-looking statements are based on management's current expectations and are subject to risks and uncertainties that could cause actual results to differ materially, including the risks listed in our Form 10-K for the year ended December 31st, 2020, that was filed with the SEC yesterday, as well as in our earnings press release, included as Exhibit 99.1 to the Form 8-K we furnished to the SEC yesterday.
We undertake no obligation to update our forward-looking statements to reflect subsequent events or circumstances, and you should not assume later in the quarter that the comments we make today are still valid. In addition, references will be made during the call to non-GAAP financial results. Investors are encouraged to review these non-GAAP financial measures, as well as the explanation and reconciliation of these measures to the comparable GAAP results included in the financials page of the investor section of our website at www.sabrahealth.com. Our Form 10-K, earnings release, and supplement can also be accessed in the investor section of our website. With that, let me turn the call over to Rick Matros, Chairman and CEO of Sabra Health Care REIT.
Thanks, Mike. Good day to everybody. Thanks for joining us. I appreciate it. First, let me start by once again thanking our operators who have just done an amazing job showing resilience and dedication. Here we are a year later, who would've thought? Finally, they're at a point where we really see the light at the end of the tunnel, and have some real positivity, which I'll talk about in a few more minutes. I also want to thank the workforce, all the caregivers, and other frontline employees in the facilities who continue to show up every day and execute on the mission of providing care to the elderly. I'd also like to express my continued appreciation to state and federal government for continuing to provide support, primarily to the skilled sector, but also to the senior housing sector, the assisted living sector as well.
Finally, I want to call out the Texas operators who on top of everything else, shouldn't have had to go through what they went through recently with the weather and all the difficulties that that caused. Fortunately, all the facilities have emergency backup generators. There was minor to moderate damage, if any, they're fine from a physical plant perspective. Only one of our facilities had to evacuate, that was for a very short period of time. There were a few facilities that had short lockouts, they didn't last for very long. The bigger problem really was staff just being able to get in and drive on the roads and all that. We're past most of that right now. Again, on top of everything else, for them to have dealt with that was really difficult.
I want to express my appreciation to all of our operators and caregivers in Texas. I also want to thank the Sabra staff, who are still working from home almost a year later. They just don't miss a beat. Productivity's been fantastic. We've actually onboarded seven new team members during the pandemic, which was challenging working from home, but we all made it happen. We provided enhanced benefits to our staff, and we've done, I think, some interesting things to improve connectivity and just really stay in touch with each other and try to maintain the culture that we worked so hard in developing here. Finally, a couple of other things that pertain just to the company, note that we've had some significant board changes. Since December, we've added three new board members, Cliff Porter, Ann Kono, and Katie Cusack.
This goes to all of our efforts to enhance the diversity of our board, they bring some really unique and interesting skill sets that were lacking on the board before in the areas of healthcare policy, investment banking, data analytics, and ESG. Last but certainly not least, I want to congratulate Mike Costa for being promoted to Chief Accounting Officer. Mike's been with us since the beginning of the creation of Sabra and has always done an amazing job and has developed a great team. We couldn't be more pleased having had the opportunity to work with Mike all these years and now to see him get promoted to Chief Accounting Officer. I noted ESG with one of our new board members a second ago. We are going to be releasing in the next few months our inaugural ESG report.
We started working on this initiative well before the pandemic. The pandemic certainly slowed some things down, but in the next few months, we will have our first report released. Rating agencies. We're really pleased with all the work that we've done through the pandemic, and to have Fitch come out and affirm our ratings and remove the negative outlook with the pandemic still something that we're all dealing with, was really a fantastic outcome. S&P also affirmed our ratings as well. We feel really great about that, and Harold will talk more about that. Now on to some of our tenants. Everybody has seen that there was an announcement on Enlivant that the CEO, Jack Callison of Enlivant, is moving over to become the CEO of Sunrise. Dan Guill is the new CEO of Enlivant. He's been the COO.
He's been there really since the beginning with Jack rather. We have fantastic relationship with Dan. Jack did a great job building a really deep bench. We feel more than comfortable. We feel very strongly that Dan is going to do a great job as CEO. We don't expect there to be any changes that are noticeable to anybody on the outside. He was instrumental in building the culture there. That will continue all along the lines that Jack established. We also expect a potential resolution to the JV this year. There's not really details to share at this point other than TPG has let us know they'd like to resolve it this year. We'll be working with TPG and be making a decision on whether we retain or buy their 51% out, or we exit the portfolio.
For us to be able to buy out the 51% that's owned by TPG, I think as everybody knows, pandemic notwithstanding, we really like the portfolio. We like the assets. The team is great. It's taken a hit during the pandemic. It's going to take time to recover. This just has to work for us economically. We're not going to do it just to do it. Whether we can get there with TPG and have a transaction that is beneficial to our shareholders remains to be seen. Stay tuned for more on that, and Harold will talk a little bit more about that as well. In terms of the stimulus, I want to point out that there's still $33 billion left in the HHS fund that hasn't been distributed, and that's a GAO number, so that's a very specific, accurate number.
The $33 billion is actually going to increase because there's quite a number of hospital providers that are in the process of returning funds that were not needed back to HHS. The $33 billion is actually going to increase, we think, relatively significantly. Stay tuned on that as well. There are ongoing discussions, but we don't know what's going to happen with allocation yet on that. It certainly makes us feel pretty good that there's that level of money sitting there still. As you all probably know, the Public Health Service Act was extended for another quarter. We're actually optimistic that the Public Health Service Act will be extended through the year. Technically, it can only be extended in quarterly increments. That's the dialogue that's going on. That, of course, carries with it sequestration, the continued waiver of the three-day stay, and FMAP.
We want to note that we're very pleased with President Biden's nominations of Xavier Becerra for HHS Secretary and Chiquita Brooks-LaSure for CMS Administrator. We look forward to having a productive relationship with those folks, assuming that their nominations are confirmed. Moving on to vaccine update stats. Since this started at the end of December, the numbers have improved really dramatically. In the aggregate, we're close to about 80% of our patients and residents having received at least one, if not two shots of the vaccine. If they've only received one, obviously, they're scheduled to receive the second. Staff, which was under 40% in the aggregate, is now up to about 60%.
I think we're seeing with staff what we would have expected to see, and that is as they saw residents and patients that they provide care for and their colleagues who got the vaccine, when they saw that they were okay and there weren't any side effects, it increased their confidence. Those numbers have picked up dramatically, and we continue to expect those numbers to improve. We have a number of operators that are actually over 90% on residents, patients, and employees. That's just all good news. As cohort restrictions for facilities are eased due to the vaccine rollout, this will provide additional impetus for occupancy improvement. Due to these restrictions, admissions are limited simply due to the lack of availability of beds in facilities with so much isolation that's been necessary.
We've always focused on surgeries and the hospitals being at capacity and not having regular admits for our admission flow hampering occupancy, and certainly, those are huge factors. The cohort restrictions have been maybe not equally significant, but very significant as well because of the number of rooms that have two beds, but we can only use one bed for those isolation protocols. As that normalization starts to accelerate with all the uptake in vaccines, we should see a normalization of the environment in the facilities, having more group activities. That's going to also lessen the amount of labor that we have and should automatically start improving the margin even ahead of occupancy improvement. In terms of communities that have been impacted by COVID, that's improved dramatically since early January and the peak of the recent surge.
Only two new facilities have had positive COVID tests last week and only two the week before. Just dramatic improvement for that mortality and cases has come down dramatically as we've seen nationwide in long-term care facilities. We see the same in our portfolio as well. Really all good news there. Now I just want to mention home health because it's come up a lot on some of the earnings calls and it's been part of the narrative that's out there. One, in terms of the home health impact and whether or not home health benefits offset skilled nursing and senior housing. One, I would point out that there's nothing new in this narrative. This is a narrative that's been in existence for well over a couple of decades. It's been impacted by the difference the pandemic has had on home health and SNF occupancy.
Clearly home health has benefited during the pandemic, particularly with hospitals admitting lightest to care patients. They get discharged and go back to home. Frankly, we think it's a good thing if home health can take more patients because we do have a demographic crisis looming. We have a decline in supply in skilled, there are already access issues that are going to be exacerbated throughout the country in terms of skilled nursing. We actually, as a society, as a country, need home health to be taking more than they've taken historically from an acuity perspective. However, that said, the paradigm isn't going to change. There are huge acuity differences between the settings. In home health, you've got, by definition, interim visits by nurses and therapists, and in skilled nursing facilities, it's called 24/7. It's very intense, we see the same in assisted living.
Obviously not as intense as skilled nursing, but much more intense than home with the rise in acuity over the last 10 years for assisted living. You've got nurses around the clock, therapists in there every day. The paradigm doesn't change, and we expect to see things normalize more as everything else normalizes, and we move past the pandemic. On guidance, Harold will talk in detail about guidance, but we determined that it was best only to put out Q1 primarily because of managed portfolio. Genesis is out there. We're not sure how that's going to resolve either, so we can talk more about that. Those were really the two issues. We do think that based on the most recent statistics, that we are close to bottom on managed occupancy coming down.
We completed $168.4 million in investment activity in 2020 with a blended cash yield of just under 8%. Our acquisition pipeline currently stands at about a billion and a half. It's primarily senior housing, but actually some interesting opportunities that we're looking at there. We're seeing more behavioral and addiction opportunities, and we are just starting to see some skilled opportunities. Not a whole lot there still, but we're starting to see some. Now moving to some operating statistics. Skilled occupancy dropped about 1,200 basis points from February 2020 through the end of 2020. Skilled mix, however, improved 530 basis points during that time, which was a very important mitigate for our operators.
To this point in 2021, the occupancy decline has almost effectively stopped, and our top seven operators bottomed out actually at the end of December and are up 210 basis points through the second week of February from the end of December. The SNF industry in the aggregate was actually down 1,850 basis points from February 2020 through year-end. The industry in general has recovered 200 basis points in the two months since they hit bottom as well. It's kind of too early to really project, but we've got aggregate data points for the industry and for our top operators, both improving by about 100 basis points a month. We'd love it obviously if we can stay on that sort of track, because we'd be in really good shape by the end of this year.
As some of you know that we've talked to in the conferences that we've had, we projected that skilled would be back more around the first quarter of 2022 or pretty close to back. We'll see if we can actually beat that. Our senior housing lease portfolio held up actually really quite well during that period, with occupancy dropping 620 basis points, and that's really a function of having small operators in very specific markets within the 65 facilities that are in that leased category. They actually held up pretty well. Senior housing leased EBITDA coverage flipped from 1.31- 1.25 and unlike the skilled coverage, EBITDA coverage, which improved to 1.93, that was obviously in large part due to all the assistance that we've gotten.
On the senior housing lease side, there was much less assistance than in the skilled space, so we would have expected that to drop some. Still at 1.25 EBITDA, that portfolio in the aggregate is in pretty good shape as well. None of our operators have required any permanent rent restructurings to this point, and our rent collections have been 99.9% of forecasted rents throughout the pandemic, and we don't expect that to change. Finally, I want to point out our specialty hospital coverage and occupancy have been unaffected by the pandemic and contribute a meaningful 11% of our NOI. With that, I'll turn it over to Talya.
Thank you, Rick. In the fourth quarter 2020, our senior housing managed portfolio continued to experience occupancy pressures as a result of the pandemic and the surge that followed the Thanksgiving and Christmas holiday season. While government funding provided some mitigation from the financial pressures, adoption of the vaccine is the linchpin to getting the senior housing industry on the road to recovery. All our operators have been intent on implementing vaccine clinics at their buildings, educating and incentivizing both residents and staff to maximize participation, and using their clinics and documented safety record to demonstrate to potential residents that the fastest path to a normal lifestyle is to move into a senior housing community.
CMS data compiled by NIC shows that COVID cases in skilled nursing closely tracked cases in the general population from June 2020 until the launch of the Pfizer and then the Moderna vaccine in December 2020. In January 2021, this changed dramatically. Cases in skilled nursing began to decline just as cases in the U.S. spiked from the post-holiday surge. By early February, new cases in skilled nursing fell by 83%, and cases in the general population fell 47% compared to late December when the Pfizer vaccine was launched. After the launch of the vaccines, deaths in skilled nursing began to decline and have continued to do so dramatically, while deaths in the general population spiked and have plateaued since. With skilled nursing as a leading indicator of the impact of the vaccine in congregate living, we have reason to be optimistic.
As of the end of the fourth quarter 2020, approximately 14% of Sabra's annual Cash Net Operating Income was generated by our senior housing managed portfolio. Approximately 49% of that relates to the communities that are managed by Enlivant, and 37% relates to our Holiday managed communities. The balance includes our Canadian portfolio and five assisted living and memory care communities in the U.S. To start, I will provide highlights of the operating results of the managed portfolio, which includes both the wholly owned portfolio and Sabra's share of the unconsolidated joint venture on a same-store sequential book quarter basis to illustrate the trends in the industry. These results will exclude two recent acquisitions and one transition community in our wholly owned portfolio, consistent with the presentation in the supplemental information package.
Occupancy declined 280 basis points to 76.4% in the fourth quarter of 2020, in line with the 270 basis point decline experienced in the third quarter over the prior quarter. Revenue per occupied room, RevPOR, excluding government grants received, rose 1.6% this quarter compared with an increase of 1.7% in the previous quarter. Revenue decreased 5.8% in the fourth quarter of 2020 compared to the third quarter, inclusive of $1.1 million and $4 million respectively of government funds received by eligible assisted living facilities. If we exclude the grant revenue, same-store revenue declined 1.9%. Cash Net Operating Income for the quarter decreased sequentially by 24.9% to $14.8 million from $19.7 million. Excluding the government grants, Cash Net Operating Income would have declined by 12.5% on a sequential basis. Cash NOI margin decreased to 21.3% from 26.8% in the preceding quarter.
Excluding government grants, Cash NOI margin would have been 20.1% in the fourth quarter and 22.5% in the preceding quarter. In the fourth quarter, we saw the same occupancy and rate dynamic as we saw in the third quarter. Rising rates and continued decline in occupancy, resulting in a decline in revenue. In a business with high operating leverage, government funds received by eligible operators have had a disproportionate impact on Cash Net Operating Income, depending on the amount and the timing of receipts. The Enlivant joint venture portfolio, of which Sabra owns 49%, had a challenging fourth quarter as a result of lower occupancy and operating revenue that was only slightly offset by the receipt of approximately $484,000 in government grants.
Average occupancy for the quarter was 71.6%, reflecting a 4.2% decline on a same-store sequential quarter basis and a 10.6% decline on a same-store basis compared with the fourth quarter of 2019. RevPOR, excluding government funding, was 4,576 compared with 4,411, or 3.8% higher on a same-store sequential basis, and 3.6% higher on a same-store basis compared with the fourth quarter of 2019. Revenue was 8.6% lower on a same-store sequential quarter basis and 8.5% lower on a same-store basis compared with the fourth quarter of 2019. Excluding government funds, revenue decreased by 1.9% on a same-store sequential basis and 9.8% on a same-store basis compared with the fourth quarter of 2019. Same-store Cash Net Operating Income was $5.2 million, a 43% decrease on a sequential quarter basis, driven by lower government funds in the fourth quarter. Without those funds, same-store Cash NOI would have declined 22.3%.
Subsequent to the end of the quarter, January 2021 occupancy was 68.9%, 140 basis points lower than December 2020 occupancy. Since the pandemic began, nearly all of our Enlivant JV communities have had a resident or staff member test positive for COVID-19. By late February, only 10 communities had a resident or staff member with a positive test, compared with 35 at the end of January. That's a 70% decline. All the communities in the joint venture have completed their first vaccine clinic, and 50% have had their second clinic. Data so far shows that 94% of residents and 64% of staff received the vaccine, a significantly higher rate than industry average. January 2021 saw a rise in move-ins compared to the prior month, while move-outs remained at a reduced level, similar to move-outs before the holiday surge.
The gap between move-ins and move-outs started to narrow in January, and that momentum has continued into this month. The fourth quarter operating results for Sabra's wholly owned Enlivant portfolio of 11 communities had similar themes in its performance. Fourth quarter occupancy was 77%, a 4.2% decline compared to the prior quarter and a 12.5% decline compared with the fourth quarter of 2019. RevPOR in the fourth quarter, excluding government funding of $549,000, was $6,029, 4.7% higher than the prior quarter and 3.8% higher compared with the fourth quarter of 2019. Revenue was 3.3% lower on a sequential quarter basis and 5.1% lower compared with the fourth quarter of 2019. Excluding government funds, revenue was nearly flat on a sequential quarter basis and 10.7% lower compared with the fourth quarter of 2019.
Cash Net Operating Income was $1.9 million, a 32.2% decrease on a sequential quarter basis, helped slightly by the government grants. Without those funds, same-store Cash NOI would have decreased 32.6% for the same period. More recently, January occupancy was 68.4%, 510 basis points below the prior month. While only two of our wholly owned Enlivant communities currently have a resident or staff member who is positive for COVID-19, that's down from six at the end of January. All 11 communities were touched by COVID during the post-holiday surge. The combination of an increase in resident deaths and move-in restrictions resulting from the surge had an outsized impact on occupancy. Enlivant also incurred higher costs associated with the surge, including labor costs as well as increased PPE needs.
By mid-February, all these communities had their first vaccine clinic, and half had already completed their second clinic, with 94% of residents and 64% of employees receiving the vaccine. While it will take time to rebuild occupancy back to the pre-pandemic levels of 90%+, in January, we saw a reduction of about 25% in move-outs, in tandem with an increase in move-ins of about 150% compared with the prior month. This momentum, along with vaccine clinics driving a rapid reduction in infections, lays the groundwork for occupancy to rebuild. Holiday Retirement operates 22 independent living communities for Sabra, one of which was transitioned to Holiday in the fourth quarter of 2019. Note that these properties were not eligible to receive government support distributed to assisted living providers. All the following operating results are presented on a same-store basis and exclude the transitioned property.
Holiday portfolio occupancy was 80.8% in the quarter, 1.7% lower on a sequential basis and 7% lower compared with the fourth quarter of 2019. RevPOR was $2,518, flat to the prior quarter and 1.3% higher compared with fourth quarter 2019. Revenue declined 2.2% compared to the prior quarter and 6.9% compared with the fourth quarter of 2019. Cash Net Operating Income was $6.1 million, a 3.4% increase on a sequential basis and 10.1% decline compared with fourth quarter of 2019. Subsequent to the end of the quarter, excluding the one transitioned community, January occupancy was 79.8% compared to 80.7% in December 2020, a 90 basis point decline. Over the last year, all 22 properties that Holiday manages for Sabra have had a resident, staff member, or private home health aide test positive for COVID-19.
As of mid-February, 17 communities have recovered and are in various stages of lifting restrictions, such as dining room use at reduced capacity, limited visits, and reopening of the beauty salon. Independent living communities were not eligible for government aid and prioritized on-premises vaccine clinics. In order to continue to keep its residents safe, Holiday has needed to be creative in organizing and negotiating vaccination strategies. Holiday currently has 13 of our communities with confirmed vaccination partners. Five of those communities have already held five initial clinics for residents and associates, with 78% and 37% vaccinated respectively. In the fourth quarter of 2020, Holiday saw a rebound in sales activity with leads, move-ins, and move-outs tracking between 95% and 99% of the fourth quarter of 2019.
We are now seeing a gap between move-outs and move-ins narrow significantly on the heels of vaccine distribution, reflecting the same trends that we spoke about at Enlivant. Sienna Senior Living manages eight retirement homes in Ontario and British Columbia for Sabra. In the fourth quarter, the Sienna portfolio had 79.5% occupancy, flat on a sequential basis, and 8.8% lower compared with the fourth quarter of 2019. RevPOR was $2,488, 2.5% lower than the prior quarter and 2.2% lower compared with fourth quarter 2019. Fourth quarter revenue was $4.5 million, 2.5% lower than the prior quarter and 11.9% lower compared with fourth quarter 2019, driven by occupancy declines. In the fourth quarter, Cash Net Operating Income was just over $1 million, a 1.3% decline on a sequential basis and a 44% decline compared with fourth quarter 2019.
More recently, January occupancy was 78.5%, a 30 basis point decline compared with the prior month. Only one of our retirement homes has had a confirmed case of COVID-19. While Canada experienced a surge in COVID cases after Canadian Thanksgiving in October, the impact on our portfolio has remained minimal. Both British Columbia and Ontario are in the early stages of rolling out vaccine clinics to retirement homes after prioritizing long-term care residents and staff. It is not yet clear when retirement homes will be receiving vaccines, although at least one of our Sienna homes in Ontario has already had 80% of staff vaccinated. Leads have ramped up to nearly double what they were in the fall. Even without the catalyst of vaccine distribution, move-ins are increasing to match move-outs, which remain driven by death and the need for higher level of care.
We have noted in prior quarters that senior housing rates appear inelastic. Our operators have consistently maintained rates because a prospective resident's decision to move in is being driven by qualitative rather than quantitative factors. They are seeking a change in lifestyle, whether out of need or desire. While we speak about pent-up demand and higher lead volume, the fact is that converting leads to move-ins is more challenging when potential residents are concerned about the lifestyle that they will have when they move in. Between February 2020 and January 2021, our senior housing managed portfolio, inclusive of non-stabilized assets, lost 10.1 percentage points in occupancy. Occupancy remains the largest variable driving the operating results of our senior housing managed portfolio. What our results in the fourth quarter point to is that the holiday surge in COVID cases has not had a uniform effect on our managed portfolio.
The largest occupancy declines were in assisted living, particularly in December 2020 and January 2021. Lower move-in rates during the holidays and higher death rates among more vulnerable residents drove that outcome. COVID infections that surged in the general community impacted our assisted living communities and the people who work there, resulting in increased labor, PPE, and related costs, particularly in those months. While our assisted living operators did receive some government support, it was significantly lower in the fourth quarter and didn't offset the simultaneous higher costs and lower revenue experienced in December 2020. Cash Net Operating Income margins, which are lower in assisted versus independent living, were even further compressed. The first step in reversing this trend is to maximize vaccinations, which is underway. Both our portfolio as well as broader statistics indicate that residents are eager adopters.
If skilled nursing is a reasonable precedent, we have visibility on stemming occupancy losses. COVID cases should decline within a month following the vaccine clinics, and in fact, we have shared that we are seeing a steep decline in cases. With fewer cases will come fewer move-outs, again, something we have discussed, which will begin the return to pre-pandemic levels and extend length of stay. Achieving high vaccine adoption rates among staff will help reduce labor costs, which spike during an outbreak. These, along with normalized PPE expenditures, will help stabilize expenses and support net operating income. Rebuilding occupancy will take more time. It requires converting leads to leases and convincing potential residents of the value that senior housing brings to their life.
A vaccinated population will allow for fewer and fewer restrictions within the community, which will allow residents to gradually resume the lifestyle that brought them to independent or assisted living in the first place. Operators will now have evidence to show that living in their community is not only enjoyable but also safer, whether it is in the face of a pandemic or a natural disaster. I will now turn over the call to Harold Andrews, Sabra's Chief Financial Officer.
Thanks, Talya. I'll give an overview of the numbers for Q4 and then provide additional color on our guidance for the first quarter of 2021. For the three months ended December 31st, 2020, we recorded total revenues, rental revenues, and NOI of $152.1 million, $110.7 million, and $124 million respectively. These amounts represent increases from the third quarter, primarily due to a third quarter $14.3 million write-off of straight-line rent receivables and above-market lease intangibles for Genesis and Signature as we moved those tenants to a cash basis for revenue recognition. Excluding this write-off, total revenues declined $5.5 million, rental revenues declined $4.2 million, and NOI declined $9.6 million in Q4 compared to Q3. These declines were due to a $3.7 million decrease in collections related to leases accounted for on a cash basis.
Note that the third quarter of 2020 had a $2.2 million increase over the second quarter in rents collected from cash-basis tenants. These fluctuations in collections stem from a handful of cash-basis tenants that are in some phase of transition or stabilization period and pay rent based on cash flow available for payment. This can fluctuate quarter -to -quarter due to fluctuations in cash flows at the operator level. Tenants with this type of arrangement represent just 2% of our total revenues during the fourth quarter, and we do not see the reduction of cash collections this quarter as a new trend. Total revenues and NOI were also impacted by a $1.2 million reduction in revenues from our wholly owned senior housing management portfolio compared to the third quarter, including a $0.6 million reduction in government grant income.
NOI was further impacted by the results of the Enlivant joint venture, which was lower compared to the third quarter by $4 million, including a reduction in government grant income of $2.5 million. We recognized $1.1 million of government grant income during the fourth quarter, $0.6 million related to our wholly owned portfolio that was recorded in revenues, and $0.5 million related to the Enlivant joint venture that was recorded as part of loss from unconsolidated joint venture. Finally, COVID-19 related costs in our senior housing managed portfolio totaled $3 million for the quarter, a $0.5 million increase compared to the third quarter, lowering our NOI in the fourth quarter compared to the third quarter. Of the current quarter expense, $2 million related to the Enlivant joint venture, while $1 million was incurred in our wholly owned portfolio.
FFO for the quarter was $87.5 million, and on a normalized basis was $88.4 million or $0.42 per share. This compared to normalized FFO of $98.8 million or $0.48 per share in the third quarter of 2020. AFFO, which excludes from FFO certain non-cash revenues and expenses, was $87.2 million, and on a normalized basis was $86.9 million or $0.41 per share. This compares to normalized AFFO of $95.1 million or $0.46 per share in the third quarter of 2020. These declines in normalized FFO and normalized AFFO are primarily related to the reduction in NOI of $9.6 million previously discussed. For the quarter, we recorded net income attributable to common stockholders of $37.1 million or $0.18 per share. G&A costs for the quarter totaled $8.1 million compared to $7.2 million in the third quarter.
G&A costs included $2.3 million of stock-based compensation expense for the quarter, compared to just $0.9 million in the third quarter. This increase is due to updating our performance-based vesting assumptions on management's equity compensation in the third quarter, which resulted in lower expense in that quarter. The current cash G&A cost of $5.8 million was 4.7% of NOI for the quarter and in line with our expectations. We continue to have a strong liquidity position as of December 31st, 2020, with over $1 billion of cash and availability on our line. This puts us in an excellent position to take advantage of acquisition opportunities that present in 2021 and beyond. As we have consistently reported, maintaining our target leverage of below 5.5 times continues to be a key priority for us.
We were very pleased to see that the recent changes in our Fitch Ratings going from a negative outlook to stable, as well as the reaffirmation of our ratings in S&P. Maintaining leverage is a critical component of our current ratings. We have continued to manage this through the pandemic-induced declines in earnings on our managed portfolio during 2020. To that end, we issued 3.6 million shares of common stock under our ATM program during the quarter at an average price of $16.81 per share, generating gross proceeds of $60.1 million before $0.9 million of commissions. Additionally, we utilized the forward feature of the ATM program in preparation to fund certain upcoming investments, and 1.1 million shares with an initial weighted average price of $17.44 net of commissions remains outstanding under the forward sale agreements.
Our leverage remains below our target at 4.88 x, excluding the JV debt, and increased slightly to 5.49x from 5.48 x, including our share of the Enlivant joint venture debt. At the end of 2020, we have $235 million available under the ATM program. We were in compliance with all of our debt covenants as of the end of the year and continue to have strong credit metrics as follows. Our interest coverage is 5.32x , fixed charge coverage 5.14 x, total debt to asset value 35%, and unencumbered asset value to unsecured debt 282%, secured debt to asset value just 1%. On February 2nd, 2021, the company's board of directors declared a quarterly cash dividend of $0.30 per share. Dividend will be paid on February 26th to common stockholders of record as of February 12th.
The dividend represents a payout of approximately 71% of our AFFO and 73% of our normalized AFFO per share. For a couple of comments on Q1 2021 guidance. As noted in our press release issued yesterday, the financial effects of the COVID-19 pandemic have made it more difficult to accurately forecast our future earnings, primarily within our senior housing managed portfolio. We have limited our guidance to the first quarter of 2021. We expect the following amounts per diluted common share for the quarter ending March 31st, 2021. Net income, $0.16-$0.17, FFO, $0.39-$0.40, and AFFO, $0.38-$0.39. The above estimates are based on certain key assumptions spelled out in our supplemental. I would like to bring attention to just a few.
The estimates above do not include any anticipated funds from the Provider Relief Fund for our senior housing managed communities. While we expect to receive some meaningful amounts, predicting the amount and timing is very difficult. As we assume continued pressure in the early part of the first quarter, we expect our senior housing managed portfolio average quarterly occupancy to fall within the following ranges: wholly owned, 75.4%-77.4%, and unconsolidated joint venture, 66%-68%. We expect to close investments totaling $39 million with an weighted average initial cash yield of 8.2%. We anticipate funding investments using the revolver, along with match funding the equity component using the ATM program.
In the aggregate, we expect to issue approximately $100 million of equity under our ATM program to fund acquisitions and meet our goals of maintaining leverage at 5.5 x, which would include the unconsolidated joint venture, based on expected annualized adjusted EBITDA of approximately $480 million as of March 31st, 2020. Finally, I'd like to point out that our calculation of net debt to annualized adjusted EBITDA is based on a trailing 12-month adjusted EBITDA. March 2021 will be the 12th month impacted by the pandemic. This is important to our management of leverage because as each quarter passes since the start of the pandemic, we are dropping off a quarter of higher pre-pandemic EBITDA generated by our managed portfolio and replacing it with a significantly reduced EBITDA that has been negatively impacted by the pandemic.
In order to keep our net debt to annualized adjusted EBITDA below our target of 5.5 x, we expect to issue additional equity during the first quarter of 2021 to again account for the lower trailing 12-month adjusted EBITDA we expect as of the end of the quarter. To summarize this impact this has had on our equity issuance, based on our Q1 2021 guidance, we will have issued approximately $150 million of equity since the beginning of the pandemic to offset the loss of EBITDA from our managed portfolio as compared to the trailing more adjusted EBITDA one year earlier or as of March 31st, 2020.
However, on a very positive note, while we move through the trough in occupancy and begin to rebound, the expected increase in EBITDA from our managed portfolio will begin to naturally further de-lever the company and provide us with an even stronger balance sheet and the potential for outsized growth in earnings per share as we continue to manage leverage in a prudent fashion going forward. With that, I will open it up to Q&A.
As a reminder, to ask a question, you'll need to press star one on your telephone. To withdraw your question, press the pound key. Please stand by while we compile the Q&A roster. Our first question comes from Josh Burr with Scotiabank. Your line is open.
Hey, thanks. Could you provide some more insight into the current acquisition pipeline and what investment opportunities Sabra sees today? Just looking at Q1 guidance, it looks like you guys are going to raise over $100 million from the ATM program, have some availability on the line of credit, and $40 million will be used for investment. Is that remaining capital being raised just meant to de-lever and kind of keep leverage levels where you want them?
Most of the raise is to maintain our balance sheet where we want it to be, but it also pre-funds potential acquisitions as well. You have to think of it sort of in both ways. If there's an opportunity now to raise money on the ATM, that's going to keep our leverage down and give us room for leverage to go up slightly and still be below our target as we match fund acquisitions that come in. Talya, did you want to note some of the specific kinds of things we're looking at in the pipeline?
Sure. We're looking at senior housing assets that we can buy at reasonable prices at this time. We've spoken in the past about the population of assets out there that have had their lease-up projections delayed, if you will, because of COVID. There's an opportunity to acquire newer assets that have some upside to them. That's a lot of what we're seeing because people need liquidity at various times for various reasons. We're seeing that kind of opportunity where, as Rick said earlier, we're seeing opportunities in other sectors as well, including behavioral and a little bit in skilled nursing.
Got it. That's helpful. How are you guys comparing the Enlivant JV, buying out the other portion compared to just traditional acquisitions? I know it looked like that portfolio had some more occupancy challenges in Q4, and you guys are also factoring in some more occupancy loss in Q1 versus the wholly owned portfolio. How are you guys underwriting that occupancy NOI recovery and comparing that with other acquisition opportunities?
Yeah. One really has nothing to do with the other. We're already in the JV, that's just going to be a negotiation with TPG. As I mentioned in my opening remarks, it's going to have to be something that works for us economically. We're not going to do a deal just to do it. That's going to be dilutive to our earnings. It's just a completely separate thing than how we look at others. We know that portfolio really well, we have a lot of confidence in the team and everything that they have in place from an infrastructure perspective to rebound. What's been unfortunate for them is, unlike all of our other operators, they really have a national footprint. The surge was so bad, they just couldn't catch a break.
Every time you'd have one area that started getting a little bit better, they'd get hit with it in another geographic area. Over half their states hadn't lifted any restrictions, the cohort restrictions either. It's a completely separate thing, how we look at it. When we look at the individual senior housing opportunities that we're currently looking at, we just look at where they're at, what the current NOI is, and what their lease-up looks like, we underwrite everything on a balance sheet neutral basis, then we just see if it works.
Okay, thanks.
Did I answer your question?
Yep.
Thank you. Our next question comes from Juan Sanabria with BMO Capital Markets. Your line is open.
Hi. Good morning, thanks for the time. I was just hoping you could talk a little bit, Rick, about the occupancy recovery, both in skilled nursing and seniors housing. You seem to imply maybe a longer recovery in seniors housing, for the TPG stake, at least. You seem to be a little bit more optimistic about skilled nursing, if you could just give us some benchmarks on how long you think you can get back to pre-COVID levels for those two major food groups, that'd be great.
My thinking has been that by the first quarter of 2022, we'd be back on skilled nursing to a little pre-COVID-19 or pretty close enough that you feel comfortable you're going to get there. I think it's probably not before the middle of 2022 that you're there on the senior housing piece. Obviously, it's going to take a little bit longer, particularly with the Enlivant portfolio, because of what happened during the surge. Their pent-up demand is still their pent-up demand, and a lot of the same dynamics that help the skilled space should help the senior housing space, including Enlivant as well, with the easing of restrictions and all the isolation protocols and such, and being able to have real tours and group activities and all those kinds of things. I do think it'll take longer.
If you've got on the skilled side, it's intensely need-based. We also expect that as occupancy picks up, people will be sicker than they would have otherwise have been because they've had a delay going into hospitals first. That goes to senior housing as well. AL, and certainly the operators that we have seen their acuity tick up pretty dramatically over the past number of years. It's much more a needs-based model than it ever did, which is why we have the confidence that it's going to rebound. It's just going to take time. I'd also point out, I know we talked about this before, we think the safety factor for senior housing is going to be a big deciding factor in terms of admissions coming back in at a pace that we'd like to see.
In the case of a couple of our tenants, just by way of example, Enlivant and Holiday, they've done really an incredible job from a safety perspective. Enlivant's infection rate is 2%, and the cohort in assisted living is 4%-7%. In independent living, which you would expect to be lower because they're healthier, it's less than 1% at Holiday. I think those statistics are going to be really critical from a marketing perspective and help those portfolios to recover. Was that what you ?
Maybe just a quick follow. It did. Thank you, Rick. Maybe just a quick modeling question for Harold. Cash rent payments from those three tenants that are on a cash basis, what's the assumption in the first quarter guidance relative to the fourth quarter payment?
Yeah. It should be pretty consistent with fourth quarter for vast majority of our cash flow. I'd say all of them, but one or two. I'm actually expecting an uptick in collections in the first quarter over the fourth quarter for those two. My expectation is going to be slightly up, not dramatically, but slightly up over fourth quarter.
Maybe just one last one for Rick. What's the view on these dual capacity rooms you referenced in skilled nursing coming back? Do you sense any hesitancy by the regulators or whatnot to kind of do away with those, given some of the lessons learned from the pandemic?
No. Well, a couple different things in terms of the point you're making. One, there's a difference between the semi-private rooms and the wards that have three beds and four beds. I think over time, you're going to see states want to see They're going to want to see those go away. That's actually already happened in Massachusetts, so I think we'll see that elsewhere as well. There'll be corresponding reimbursement changes as well to go along with those so that the operator can continue to run a viable business. In terms of what's happening current, so that's something to think about and look forward to going forward, which is also going to exacerbate the access issue that we're starting to see in different markets. Before the pandemic, the industry was projected to be essentially full by somewhere around the middle of the decade.
That's going to exacerbate that problem. In terms of what's happening today in the pandemic, no, I think that the vaccine changed everything in terms of the concern regulators had about easing restrictions. I also think it's fair to say that when you see the numbers in terms of cases and mortality dropping so dramatically, so quickly, Talya pointed out, it's the vaccine, but it's more than the vaccine. We still have a lot of patients that stay in skilled nursing facilities under Medicaid for long periods of time.
We think about short stay because of Medicare. We've got a lot of longer-term patients in there, and a lot of the patients and residents in these facilities, both skilled and senior housing, have already had COVID and were aware of it, or they've had it and were unaware of it because there was so little testing through the first number of months. There's still not enough testing as far as antibody testing in facilities. The buildup of those antibodies with the existing population combined with the vaccine, I think, is why we saw such a dramatic improvement in cases of mortality dropping. I think if it was just the vaccine, it wouldn't have happened that quickly. There are conversations ongoing, more specifically to your point, Juan, with CDC about having national guidelines for restrictions easing once a certain percentage of the population has been vaccinated.
There are discussions so that hopefully it can be addressed on a more uniform basis, because right now, as you can imagine, it's quite different from state to state, and even within states, different regulatory localities.
Thanks, Rick.
Thank you. Our next question comes from Nick Joseph with Citi. Your line is open.
Thanks. Just wondering what the timing is on a decision in terms of Enlivant, at least current expectations for any timing?
I'm guessing here a little bit, Nick, because TPG is really driving the process. If I was going to guess, I would say we arrive at a decision in the next several months. Then, in terms of closing the deal, whether you're out or you're in, it's usually 180-day period because of all the regulatory approvals.
Thanks. If you just think about more broadly, I guess, pricing for senior housing, particularly like a national portfolio like that, how do you think about it versus pre-COVID values?
Well, look, we all know how PEs have driven pricing over the past few years. I think, for us, and certainly if you're going to buy something before it's recovered, it's got to have a much higher yield than the six handles that everybody got used to. I think for us, it's going to be a very specific exercise in looking at their current NOI, being as conservative as possible in terms of recovery. There may be some other mechanisms that can be built into a transaction that gives the portfolio more time to recover without us being out of pocket. I don't want to get ahead of myself here because those are negotiations that we have to have with TPG.
Thank you.
Thank you. Our next question comes from Rich Anderson with SMBC. Your line is open.
Thanks. On Enlivant, how binary is the decision? Is it in or out, or is there a rainbow of opportunities within being in or completely out? Could it involve third parties? What's on the table, or is it pretty straightforward binary?
Harold, do you want to take that?
Sure. Rich, I would say, look, if a decision is going to be made to do something, it's pretty binary between buying or not buying. That's not to say that you couldn't structure a deal that provided some level of earn-out or some other mechanism to kind of bridge the gap, if you will, between where NOI is today and where NOI is expected to be in the future. All those things are on the table. Who knows where it might land? I don't think that there's an opportunity from our perspective to bring in another investor alongside us.
I also think that it's just going to come down to TPG getting the price that they require for it or not, and whether that's us or somebody else, that's to be seen, and how we can structure it to bridge the gap is something we'll be working on within.
Okay. When you compare the occupancy level of the JV, which is a lot more than the 11 wholly owned assets, is there any reason why there shouldn't ultimately be a full recovery? Are the 11 assets that you own on a wholly-owned basis sort of outlier positive assets and that a real occupancy number, kind of steady state for the JV is something below those 11?
Talya, do you want to take that?
It's a couple of things. I'd start with big picture. The 11 wholly owned are in a very small geographic area. They're kind of Pennsylvania, Delaware. That already changes the profile versus a portfolio of 158 that are spread from East Coast to all across the country to the West Coast.
Sure.
That's the first thing. The second thing is there is much more memory care in the wholly owned than there is in the joint venture. That also affects, well, it affected COVID spread within the building, because I'm sure others have spoken at greater length than we have about memory care and how it's much harder to manage COVID spread in memory care. Also far fewer people are moving out just because of a lifestyle out of memory care. That also changed the bias. Given that the 11 wholly owned had performed at such a high level in terms of occupancy, 90+, in fact, we even hit 95% occupancy several quarters ago. I expect that that rebound, I think that 90-ish area is probably going to be where it heads back, because the loss was quite specific and quite specific in timeframe.
I think the joint venture, it's just different, and it's going to be a balance of the local markets and the environment and what's happening with respect to COVID vaccines, et cetera, and the competitive landscape in those areas across the country.
Okay.
Yeah. It's a matter of time, Rich. It's not a matter of the end result. We don't see any reason that the JV is not going to be back to where it was.
Yeah. Okay, then quick for you, Harold, the $100 million of equity for the first quarter. I'm getting like an implied cap rate on your stock around eight-ish or so. I see you're comfortable with that and the interest could de leveraging. Are you going to be kind of quick to get into that ATM to capture that pricing and take the risk off the table? What happens if, God forbid, some disruption in the stock and now you have to rethink the equity raise component of the story for first quarter?
Look, we'll get into it when it makes sense for us. I would point out, Rich, that it is our intent to do that. We do have cushion. We've got cushion in our leverage metrics. While we'd like to get it done and keep it right where we're at, if we're a little bit behind on that, it's not going to be a big deal relative to our raise with Fitch and S&P. We're going to get in there and do it as quickly as we can. Also keep in mind that we want to monitor the performance of the managed portfolio, because if performance starts to pick up and we can see a pathway to improve EBITDA more quickly than we might be thinking today, then we can temper that as well.
Okay. That's perfect. Thanks, everyone.
Thanks, Rich.
Our next question is from Steve Valiquette with Barclays. Your line is open.
Great. Thanks. Hello, everyone. Maybe just a question here for Rick, just on the COVID in the skilled nursing setting. You guys did mention the dramatic drop in COVID patients in SNFs in early 2021. I mean, that generally should be net positive in the big picture. I guess I'm curious if you can provide a little bit more qualitative color just around the notion that some SNFs actually do want to treat COVID patients in the SNF setting. Maybe just to help us frame this better quantitatively as well, do you know just roughly what percentage of the SNFs in your portfolio are actively seeking to treat COVID patients, presumably on a post-acute basis, versus what percentage of the SNFs really want nothing to do with COVID patients at all and are either isolating or discharging these patients to other care settings? Thanks.
Yeah. It's a relatively small percentage that are actively pursuing COVID patients, and trying to set up units and things like that. It's definitely not higher than 20%. I would say we have very few operators that just want nothing to do with it. The majority are comfortable with taking care of COVID patients. It's just that it's only a small percentage of those folks that are actively working with hospital partners. A lot of that was also driven by the hospitals in particular markets actively seeking out partners. Hopefully that's not a long-lived piece of the business.
I think for operators to do that on a longer-term basis, just under the assumption that you may always have a little bit of this from time to time, it's going to just depend on facility configuration and not prevent them from hitting their overall occupancy goals because of the isolation requirements.
Okay. That's definitely helpful. Appreciate the extra color. Thanks.
Yep.
Thank you. Our next question comes from Lukas Hartwich with Green Street. Your line is open.
Thanks. I'm just curious on the acquisition pipeline. Are those concentrated in any markets or are they kind of distributed?
They're all over the place.
Okay. The coverage metrics on page five of your stuff, I know the unstabilized assets are not in that. I'm just curious, do you have a rough number or percentage of total NOI or rent that's not reflected in those coverage metrics?
Yeah. It's less than 10%. It's non-stabilized, it's excluded from those figures.
Okay. Last one for me is just the specialty hospitals. Looks like occupancy's taken a nice uptick over the last few quarters. Is there anything kind of COVID related driving that or is it just unique issues at the properties? I'm just curious what's driving that.
No, there's nothing COVID driving it. They're relatively unaffected by COVID. They have very dynamic populations, we've always seen a lot of fluctuation up and down with those assets. A little bit different. We've got the behavioral assets in there. We've got children's hospital in there's a couple of different things, but a lot of it's driven by the behavioral facilities. It's just a dynamic population, but unaffected so.
Great. That's it for me. Thank you.
Thank you. Our next question comes from Josh Dennerlein with Bank of America. Your line is open.
Hey, guys.
Hey.
Rick, just curious on the Enlivant JV, have you guys also considered maybe selling your stake when TPG kind of looks to exit? Is that something that you've thought of?
I can take part of it. They have drag along rights with us, and so they have more control over the ability to sell. We've looked at obviously selling our interest before, but I just don't see that as being a potential outcome here.
Okay.
Yeah, we have looked at, Josh, you may not recall, but it seems like a decade ago now, but in the summer, early fall of 2019, we took a look at other potential JV partners to take out TPG, and really nothing really came of that. We thought about it and actually pursued it a while back.
Okay. You've thought about selling your stake in the past. It just hasn't worked. I wasn't sure because it does seem like on the SHOP side, like there is pretty good pricing and maybe where you guys are trading in, I don't know. Maybe it's potentially accretive. Okay.
With the drag along rights that they have, yeah, you just can't see somebody buying our interest and then having TPG sell them out and not be able to.
Oh, well, I thought maybe it'd be easier if someone could take the whole portfolio, right? Instead of just someone getting TPG's stake.
Well, the problem is it isn't just a matter of the whole portfolio because TPG has a management company as well. A lot of the parties that you would expect to come to the table for a new JV weren't necessarily interested in OpCo. Just complicated.
Oh, okay. I wanted to follow up on some of your comments earlier about the recovery to pre-COVID occupancy levels. Sorry if I missed it. What was your expectation for kind of a trough on senior housing occupancy? Not so much the level, but I guess timing. I am just trying to get a sense of how quickly the recovery comes after that trough to get to kind of the pre-COVID levels that you mentioned that you thought they would get to.
I think we're close to bottom on senior housing now, primarily because of the vaccine rollout. I think going into March, we pretty much should be at bottom and maybe just similar to what we've seen on the skilled side, we've had some period of time where we just sort of stayed flat before we started picking up. Maybe things are relatively flat in the month of March, and in April we start to see some pickup. Obviously I'm guessing, and my guess is no better or worse than anybody else's, but that's kind of what it feels like right now because we do think that the impact of the vaccine rollout in our senior housing, excluding independent living, should follow somewhat the same pattern that we're seeing on the skilled side.
Okay. Then do you think it's kind of a steady march higher, or do you kind of see like a big surge in the summer, the seasonal dynamics play out?
I think it's more of a steady march. I think skilled picks up a little bit more quickly. Skilled's dropped more than senior housing as well. Skilled, I think, picks up more quickly just because of the nature of the individuals that get admitted into skilled facilities. So many of them are in worse shape now because of the delays. I think for that reason, and even though you've got a needs-based model in assisted living, there is some choice there still as well, depending on who the operator is and how high the acuity is. Yeah, I think it's more of a steady march on senior housing.
Okay. Appreciate that. Thanks, guys.
Thank you. This concludes the question and answer session. I would now like to hand the call back over to Rick Matros for closing remarks.
Thank you all for joining us today. I know it went a little bit long. We'll do our best to shorten up the front end for Q1 as we start moving past this. We just wanted to provide as much detail as possible. Appreciate everybody hanging in there. We're available to have some offline conversations if there are some additional follow-up questions or modeling or anything else that y'all have in your mind. Have a great day. Thanks very much.
Ladies and gentlemen, this concludes today's conference call. Thank you for participating. You may now disconnect.