MONTICELLOAM LLC’s Senior Managing Director Karina Davydov teams up with Kristen Ahrens, Elizabeth Pagliarini, and Elizabeth Butler to discuss credit dynamics in the seniors housing and skilled nursing real estate market.
Explore the perspectives of the women as they share insights on the credit environment, the importance of market and capital partner familiarity, and how to position for strategic growth in 2026.
Moderator
Sr. Managing Director, MONTICELLOAM,LLC
Karina Davydov is a Senior Managing Director on MONTICELLOAM’s Seniors Housing and Healthcare bridge lending team, where she plays a pivotal role in driving the firm’s success. She is actively involved in every stage of the origination process, including sourcing, structuring, closing, and relationship management, ensuring seamless execution and long-term client partnerships. Beyond transactions, Karina is a key force behind the company’s growth initiatives, leveraging her industry expertise and strategic vision to expand MONTICELLOAM’s reach in the seniors housing and healthcare sectors.
In addition to her duties at MONTICELLOAM, Karina serves as head of Business Development for Trustwell Senior Living. Where she helps lead the team’s expansion efforts including asset acquisitions and third-party management contracts.
Senior Managing Director, BLUEPRINT
Kristen Ahrens brings over 25 years of real estate experience to Blueprint, where she is Senior Managing Director of Debt Capital Markets. She leads debt and equity placement for seniors housing sponsors and manages key lender and investor relationships.
Before joining Blueprint, Kristen co-founded Doyenne Healthcare Capital, a Chicago private equity firm focused on healthcare real estate. She also held senior roles at Capitol seniors housing and Capital One Healthcare Finance, where she originated more than $2.5 billion annually. Earlier positions include roles at GE Healthcare Financial Services, Heller Financial, and Ocwen Financial. She began her career at Ernst & Young and later served as onsite controller for Standish Care.
Kristen holds an MBA and a Bachelor of Science in Accounting with Honors from the University of Florida.
National President of Healthcare banking, Valley Bank
Elizabeth Butler is the National President of Healthcare Banking at Valley and brings over 25 years of experience in healthcare lending. She built and scaled Valley’s healthcare banking vertical to $3.5B, leading strategy, business development, and relationship management across the healthcare continuum. Liz is known for her expertise in financial analysis, risk mitigation, and developing innovative credit solutions for skilled nursing, assisted living, memory care, acute care, ambulatory services, and more. She began her career at JP Morgan and Midland Bank before joining Valley, where she advanced through multiple leadership roles. Liz holds a BS in Business Administration from Centenary College, frequently speaks on industry panels, and is an active member of HFMA, ACHE, and AHCA/NCAL.
CEO and Board Member, Summit Healthcare REIT
Elizabeth “Liz” Pagliarini is the Chief Executive Officer and Board Member of Summit Healthcare REIT, Inc. Summit, a public non-traded REIT, invests in seniors housing and care real estate across the United States. Liz broke the glass ceiling early in her career as CEO and chairwoman of an investment brokerage subsidiary of a public company and later co-founded a boutique investment bank and registered broker-dealer. She also serves on the Board of Directors of First Foundation Inc. (NYSE: FFWM) and is the chairperson of the Risk Committee. Liz earned her Bachelor of Science in Business Administration with a concentration in Finance from Valparaiso University, is a Certified Fraud Examiner, and holds a certification in Systemic Cyber Risk Governance. Her work has earned recognition including the Orange County Business Journal’s CFO of the Year Lifetime Achievement Award, “20 Women to Watch,” and several honors for her philanthropic contributions.
Kristen Ahrens (KA): Deal flow has picked up since 2023/2024, especially for financeable transactions moving through the pipe in 2025. Credit has loosened for the right sponsors and operators, but deals outside the fairway still require structure or enhancements. Experience continues to matter most, and the activity uptick is clear.
Karina Davydov (KD): Let’s linger on that thought a moment. The MONTICELLOAM team reviewed nearly $25B in healthcare transactions in 2025, with closings exceeding $2B. This represents a twofold increase in inquiries year over year. When you take a broader view of that volume, a disciplined credit approach is key. With improving census and more stable operations, alignment between operators and capital is strengthening. Well-prepared groups with data and realistic expectations are certainly getting more traction in this market.
Elizabeth Pagliarini (EP): We saw steady deal flow as well, mostly value-add in seniors housing. Some stabilized skilled deals came across, but pricing often felt high. A few price-per-bed metrics did not match fundamentals, so we stayed disciplined on valuation.
Elizabeth Butler (EB): Additionally, larger, seasoned portfolios are being repackaged for sales and refinances, partly due to COVID-era agency delays. Construction financing requests are increasing in seniors housing, which shows confidence returning. As rates decline, borrowers are turning to agency financing to reduce recourse. Cash-flowing assets remain financeable, but turnaround projects face tighter standards, and regional pricing still varies widely.
KA: The Graying of America is finally here. With minimal new construction, existing assets are positioned to perform well from an occupancy standpoint. Skilled nursing will remain essential in the care spectrum, balancing private-pay risk. Models will continue to evolve with technology, improving both resident and staff experience.
EP: Right, and heading into 2026 we see both tailwinds and headwinds. Borrowing costs, wages, and regulation remain challenges, but demand growth is picking up with very little new supply. With technology and AI advancing, we expect seniors housing and skilled nursing to outperform in the coming years.
EB: With 2026 approaching, strong demographics are driving sustained growth in the sector. Demand is expected to peak near 2028, giving the market a multi-year runway. Lenders are looking beyond occupancy and placing more weight on care quality and operational strength. Operators who can scale, stay compliant, and adapt to reimbursement changes will be best positioned. Care models are shifting toward higher acuity and integrated services like behavioral health and homecare, which will influence underwriting and valuation.
KD: And that is where preparation matters. The strongest results come from teams who understand their markets, manage care quality well, and can show operational efficiency. For groups who execute, the next few years should offer meaningful opportunity in seniors housing.
EB: I’d say the biggest thing is staying close with your lender. Whether you’re growing or working through challenges, that relationship matters and your lender should feel like a strategic partner, not just a capital source.
It’s also important to stay disciplined on valuation, especially price-per- bed. We’re advising operators to plan for reimbursement swings and structure deals with enough cushion to ride out volatility. There’s plenty of capital out there, but it’s not the time to over-lever sustainable leverage wins long-term.
KA: Absolutely. And looking ahead, we think 2026 deal volume will be even stronger. Class A Core and Core plus assets are going to draw heavy competition, and even value-add deals should see more bidders than they have recently. Financing terms, though, will still depend on credit enhancements and a buyer’s track record.
We do expect SOFR to come down, but timing and extent are still unclear. If a maturity is approaching, waiting solely for rate certainty isn’t always the right move. For now, short-term floating or fixed options with prepay flexibility could give borrowers room to benefit if rates compress.
KD: Makes sense. The groups that stay relationship-focused, manage leverage responsibly, and keep flexibility in their capital stack will be best positioned when the market accelerates.
EB: From a financing perspective, we are very optimistic about the senior care market. Occupancy is rising across assisted living, independent living, and skilled nursing, showing stronger demand and stability. Memory care is a big opportunity, and technology is helping offset costs, enable real-time monitoring, and support personalized care that benefits both residents and operations.
KD: Definitely. The focus on tech and innovation is becoming central to operations, not just an add-on. Communities that integrate these tools effectively will have a real advantage.
KA: I agree. Integrated fall prevention and detection technology linked to platforms that track care usage, staff response, and EHR data is going to change how we provide and bill for care. These tools will become table stakes as families evaluate communities.
EP: AI is advancing faster than ever. It will not replace humans in healthcare, but it will transform care management. From higher-acuity residents to optimizing reimbursement and staffing, the benefits are significant, and some innovations have not even been imagined yet.
KD: Right, and communities that adopt these technologies thoughtfully will improve outcomes, reduce costs, and enhance resident experience. In seniors housing, technology is no longer optional. It is essential.
Fundamentals are strengthening, but selectivity matters.
Demand for seniors housing and skilled nursing is rising with demographics and easing credit, yet labor and reimbursement pressures persist. Success will favor disciplined underwriting and strong operator partnerships.
Technology is no longer optional.
Tools like remote monitoring, data analytics, and AI are improving quality of care. Operators who invest in innovation will have a competitive advantage
This is a window for strategic growth.
Aligning capital with demographic trends, staying flexible on financing, and prioritizing care quality will define the evolution of healthcare real estate.