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Real Property Acquisitions and Development
 9 Months Ended
Sep. 30, 2023
Real Estate [Abstract]  
Real Property Acquisitions and Development Real Property Acquisitions and Development The total purchase price for all properties acquired has been allocated to the tangible and identifiable intangible assets and liabilities at cost on a relative fair value basis. Liabilities assumed and any associated noncontrolling interests are reflected at fair value. The results of operations for these acquisitions have been included in our consolidated results of operations since the date of acquisition and are a component of the appropriate segments. Transaction costs primarily represent costs incurred with acquisitions, including due diligence costs, fees for legal and valuation services, termination of pre-existing relationships computed based on the fair value of the assets acquired, lease termination fees and other acquisition-related costs. Transaction costs related to asset acquisitions are capitalized as a component of purchase price and all other non-capitalizable costs are reflected in other expenses on our Consolidated Statements of Comprehensive Income.
The following is a summary of our real property investment activity by segment for the periods presented (in thousands):
 Nine Months Ended
 September 30, 2023September 30, 2022
Seniors Housing OperatingTriple-netOutpatient
Medical		TotalsSeniors Housing OperatingTriple-netOutpatient
Medical		Totals
Land and land improvements$58,049 $58,797 $72,992 $189,838 $199,892 $— $65,688 $265,580 
Buildings and improvements411,273 430,041 314,892 1,156,206 1,988,999 172 249,660 2,238,831 
Acquired lease intangibles25,617 — 45,936 71,553 109,049 — 33,978 143,027 
Construction in progress165,934 — — 165,934 108,141 — — 108,141 
Right of use assets, net16,539 — 927 17,466 169 — 3,852 4,021 
Total net real estate assets677,412 488,838 434,747 1,600,997 2,406,250 172 353,178 2,759,600 
Receivables and other assets16,789 — 545 17,334 10,410 — 460 10,870 
Total assets acquired(1)
694,201 488,838 435,292 1,618,331 2,416,660 172 353,638 2,770,470 
Secured debt(292,160)— (40,953)(333,113)(219,067)— — (219,067)
Lease liabilities(16,539)— (953)(17,492)— — (3,852)(3,852)
Accrued expenses and other liabilities(10,825)— (10,832)(21,657)(111,373)— (1,294)(112,667)
Total liabilities acquired(319,524)— (52,738)(372,262)(330,440)— (5,146)(335,586)
Noncontrolling interests (2)
— — (775)(775)(115,112)(4)(975)(116,091)
Non-cash acquisition related activity(3)
(171,667)— — (171,667)(25,795)— — (25,795)
Cash disbursed for acquisitions203,010 488,838 381,779 1,073,627 1,945,313 168 347,517 2,292,998 
Construction in progress additions450,205 25,646 297,862 773,713 343,000 64,091 75,460 482,551 
Less: Capitalized interest(28,289)(2,416)(5,447)(36,152)(16,464)(3,088)(1,177)(20,729)
Accruals (4)
3,447 (2,692)(7,604)(6,849)(2,809)— 4,452 1,643 
Cash disbursed for construction in progress425,363 20,538 284,811 730,712 323,727 61,003 78,735 463,465 
Capital improvements to existing properties261,935 17,933 54,222 334,090 232,618 39,526 43,691 315,835 
Total cash invested in real property, net of cash acquired$890,308 $527,309 $720,812 $2,138,429 $2,501,658 $100,697 $469,943 $3,072,298 
(1) Excludes $6,431,000 of unrestricted and restricted cash acquired during the nine months ended September 30, 2022.
(2) Includes amounts attributable to both redeemable noncontrolling interests and noncontrolling interests. For the nine months ended September 30, 2022, 1,227,000 OP Units were issued as a component of funding for certain transactions.
(3) Relates to the acquisition of assets recognized as investments in unconsolidated entities.
(4) Represents non-cash accruals for amounts to be paid in future periods for properties that converted, offset by amounts paid in the current period.
Effective on April 1, 2022, our leasehold interest relating to the master lease with National Health Investors, Inc. ("NHI") for 17 properties assumed in conjunction with the Holiday Retirement acquisition was terminated as a result of the transition or sale of the properties by NHI. The lease termination was part of an agreement to resolve outstanding litigation with NHI. In conjunction with the agreement, a wholly-owned subsidiary and the lessee on the master lease agreed to release $6,883,000 of cash to the landlord, which represents the net cash flow generated from the properties since we assumed the leasehold interest. Additionally, in connection with the lease termination, during the nine months ended September 30, 2022, we recognized $58,621,000 in other income on our Consolidated Statements of Comprehensive Income from the derecognition of the right of use asset and related lease liability.
During the three months ended September 30, 2023, we paid $69,606,000 to acquire the 45% redeemable noncontrolling ownership interest in two consolidated joint ventures with the Canadian Pension Plan Investment Board, which owned interests in ten medical office buildings. In conjunction with the transaction $118,256,000 was removed from redeemable noncontrolling interests with the difference recorded to capital in excess of par value on our Consolidated Balance Sheets. The transaction is excluded from the table above.
In October 2023, we purchased 12 Seniors Housing Operating properties in Canada for a total purchase price of $678 million through a 95% owned and consolidated partnership with Cogir Management Corporation owning the remaining 5%. In conjunction with this transaction, we assumed $59 million of secured debt.
Construction Activity 
The following is a summary of the construction projects that were placed into service and began generating revenues during the periods presented (in thousands):
 Nine Months Ended
 September 30, 2023September 30, 2022
Development projects:
Seniors Housing Operating
$280,333 $182,421 
Triple-net
141,142 — 
Outpatient Medical
30,071 — 
Total development projects
451,546 182,421 
Expansion projects
62,292 — 
Total construction in progress conversions$513,838 $182,421