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Real Property Acquisitions and Development
 12 Months Ended
Dec. 31, 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 directly 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. Our acquisition of properties are at times subject to earn out provisions based on the future operating performance of the acquired properties, which could result in incremental payments in the future. Our policy is to recognize such contingent consideration when the contingency is resolved and the consideration becomes payable. As of December 31, 2023, we do not expect future payments under these provisions to be material and no liabilities for such amounts have been accrued.
The following is a summary of our real property investment activity by segment for the periods presented (in thousands):
Year Ended December 31, 2023
 Seniors Housing OperatingTriple-netOutpatient MedicalTotal
Land and land improvements  $251,507 $127,523 $79,506 $458,536 
Buildings and improvements  2,006,021 969,481 343,252 3,318,754 
Acquired lease intangibles  208,239 — 50,373 258,612 
Construction in progress165,934 — — 165,934 
Right of use assets, net24,212 — 927 25,139 
Total net real estate assets2,655,913 1,097,004 474,058 4,226,975 
Receivables and other assets21,999 — 1,632 23,631 
Total assets acquired(1)
2,677,912 1,097,004 475,690 4,250,606 
Secured debt  
(372,482)— (40,953)(413,435)
Lease liabilities(24,212)— (953)(25,165)
Accrued expenses and other liabilities(26,666)— (11,528)(38,194)
Total liabilities acquired(423,360)— (53,434)(476,794)
Noncontrolling interests(2)
(32,692)— (925)(33,617)
Non-cash acquisition related activity(3)
(181,929)— — (181,929)
 Cash disbursed for acquisitions2,039,931 1,097,004 421,331 3,558,266 
Construction in progress additions646,466 25,646 422,103 1,094,215 
Less: Capitalized interest(39,799)(2,416)(8,484)(50,699)
Accruals(4)
(4,735)(1,358)(22,488)(28,581)
Cash disbursed for construction in progress601,932 21,872 391,131 1,014,935 
Capital improvements to existing properties399,130 33,592 84,960 517,682 
Total cash invested in real property, net of cash acquired  
$3,040,993 $1,152,468 $897,422 $5,090,883 
(1) Excludes $4,708,000 of unrestricted and restricted cash acquired.
(2) Includes amounts attributable to both redeemable noncontrolling interests and noncontrolling interests.
(3) Relates to the acquisition of assets previously financed as loans receivable and the acquisition of assets previously recognized as investments in unconsolidated entities.
(4) Represents non-cash accruals for amounts to be paid in future periods for properties that converted, off-set by amounts paid in the current period.
Year Ended December 31, 2022
 Seniors Housing OperatingTriple-netOutpatient MedicalTotal
Land and land improvements  $206,618 $7,536 $68,379 $282,533 
Buildings and improvements  2,067,051 59,248 253,358 2,379,657 
Acquired lease intangibles  129,429 — 35,316 164,745 
Construction in progress108,141 — — 108,141 
Right of use assets, net169 — 3,852 4,021 
Total net real estate assets2,511,408 66,784 360,905 2,939,097 
Receivables and other assets  14,406 — 501 14,907 
Total assets acquired(1)
2,525,814 66,784 361,406 2,954,004 
Secured debt  (279,788)(39,574)— (319,362)
Lease liabilities— — (3,852)(3,852)
Accrued expenses and other liabilities(112,962)(1,428)(1,414)(115,804)
Total liabilities acquired(392,750)(41,002)(5,266)(439,018)
Noncontrolling interests(2)
(115,112)(4)(1,095)(116,211)
Non-cash acquisition related activity(3)
(64,975)(27,780)— (92,755)
Cash disbursed for acquisitions1,952,977 (2,002)355,045 2,306,020 
Construction in progress additions489,001 83,368 91,662 664,031 
Less: Capitalized interest(24,432)(4,210)(1,849)(30,491)
Accruals (4)
(4,621)— 2,818 (1,803)
Cash disbursed for construction in progress459,948 79,158 92,631 631,737 
Capital improvements to existing properties352,099 48,052 75,865 476,016 
Total cash invested in real property, net of cash acquired$2,765,024 $125,208 $523,541 $3,413,773 
(1) Excludes $6,563,000 of unrestricted and restricted cash acquired.
(2) Includes amounts attributable to both redeemable noncontrolling interests and noncontrolling interests. For the year ended December 31, 2022, 1,227,000 OP Units were issued as a component of funding for certain transactions.
(3) Relates to the acquisition of assets previously financed as loans receivable and the acquisition of assets previously recognized as investments in unconsolidated entities.
(4) Represents non-cash accruals for amounts to be paid in future periods for properties that converted, off-set by amounts paid in the current period.
Year Ended December 31, 2021
 Seniors Housing OperatingTriple-netOutpatient MedicalTotal
Land and land improvements  $449,335 $88,839 $64,843 $603,017 
Buildings and improvements  2,347,609 809,328 313,864 3,470,801 
Acquired lease intangibles  264,589 — 24,751 289,340 
Right of use assets, net77,455 — — 77,455 
Total net real estate assets3,138,988 898,167 403,458 4,440,613 
Receivables and other assets  6,096 411 3,534 10,041 
Total assets acquired(1)
3,145,084 898,578 406,992 4,450,654 
Lease liabilities(138,126)— — (138,126)
Accrued expenses and other liabilities(191,454)(8,703)(266)(200,423)
Total liabilities acquired(329,580)(8,703)(266)(338,549)
Noncontrolling interests(2)
(4,942)(6,449)(16,540)(27,931)
Cash disbursed for acquisitions2,810,562 883,426 390,186 4,084,174 
Construction in progress additions322,050 77,412 42,464 441,926 
Less: Capitalized interest(13,834)(3,078)(2,440)(19,352)
Accruals(3)
35 — (4,646)(4,611)
Cash disbursed for construction in progress308,251 74,334 35,378 417,963 
Capital improvements to existing properties197,829 37,345 47,414 282,588 
Total cash invested in real property, net of cash acquired$3,316,642 $995,105 $472,978 $4,784,725 
(1) Excludes $4,201,000 of unrestricted and restricted cash acquired.
(2) Includes amounts attributable to both redeemable noncontrolling interests and noncontrolling interests.
(3) Represents non-cash accruals for amounts to be paid in future periods for properties that converted, off-set by amounts paid in the current period.
Canadian Pension Plan Investment Board ("CPPIB")
During the year ended December 31, 2023, we paid $69,606,000 to acquire the 45% redeemable noncontrolling ownership interest in two consolidated joint ventures with CPPIB, 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.
Holiday Retirement Acquisition
On July 30, 2021, we acquired a portfolio of 85 seniors housing properties owned by Holiday Retirement for $1,576,600,000, which are included in our Seniors Housing Operating segment and in the table above for the year ended December 31, 2021. Atria Senior Living assumed operations of the portfolio following its acquisition of the Holiday Retirement management company pursuant to an incentive-based management agreement. As part of this transaction, a wholly owned subsidiary assumed the leasehold interest in a 26 property portfolio and subsequently purchased eight of the leased properties and one of the properties was sold by the landlord, National Health Investors ("NHI"), and removed from the master lease. Effective April 1, 2022, our leasehold interest related to the master lease with NHI for the remaining 17 properties 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 conjunction with the lease termination, during the year ended December 31, 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 liability.
Affinity Living Communities ("Affinity") Acquisition
In February 2024, we entered into a definitive agreement to acquire 25 Seniors Housing Operating properties for a total purchase price of $969 million, which will be managed under the Affinity brand. The transaction is expected to be funded through a combination of cash and the assumption of $523 million of secured debt, subject to customary closing conditions and lender consents.
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):
 Year Ended
 December 31, 2023December 31, 2022December 31, 2021
Development projects:
Seniors Housing Operating$463,644 $227,796 $117,386 
Triple-net141,142 — 22,990 
Outpatient Medical190,770 44,777 125,179 
Total development projects795,556 272,573 265,555 
Expansion projects71,250 18,280 5,292 
Total construction in progress conversions$866,806 $290,853 $270,847