Who Controls America's Nursing Homes: Mapping the Chain, PE, and REIT Ownership Network

Key findings

The ownership landscape: who actually controls America's nursing homes

America's 14,699Medicare-certified nursing homes are nominally operated by thousands of distinct entities — from large national chains to single-facility family businesses, county governments, and nonprofit health systems. The CMS Provider Enrollment, Chain, and Ownership System (PECOS), which underlies the CMS SNF All Owners dataset, attempts to trace each facility's ownership chain up to its ultimate controlling parties. What it reveals is a sector where effective control is highly concentrated, structurally opaque, and increasingly shaped by two distinct capital layers: chain operators and real estate investment trusts.

Understanding nursing home ownership matters because owner type is one of the strongest predictors of staffing levels, deficiency rates, and resident outcomes documented in the academic literature. Private equity acquisition is associated with 11% higher resident mortality (Gupta et al., Review of Financial Studies 2024). REIT landlord arrangements create rent obligations that constrain operating budgets. Chain consolidation determines bargaining power with Medicare and Medicaid payers. The structure of who owns nursing homes is not a disclosure formality — it is a determinant of care.

Yet the federal disclosure system designed to capture this structure has a documented and growing gap. Chen, Grabowski, and Konetzka (Health Affairs Vol. 43 No. 3, March 2024; DOI 10.1377/hlthaff.2023.01110) compared CMS data against two private deal databases and found that 82.40% of ownership percentages in the top ten nursing-home chains are missing from CMS. Only 33% of PE investments and fewer than 17% of REIT investments appear in CMS data at all. On December 11–16, 2025, the Trump administration suspended the off-cycle Medicare revalidation process — the mechanism designed to close this gap — indefinitely. The 82.40% figure will not improve in 2026.

This study maps what CMS does document alongside what it does not, drawing on company filings, academic literature, and federal disclosure records to produce a facility-level picture of the ownership network. Every figure is sourced; every gap is labeled as a gap.

Top chain operators by facility count

Facility counts from company 10-K filings, regulatory disclosures, and trade press as of Q4 2025–Q1 2026. Fonteum does not rate, inspect, verify, endorse, or guarantee any facility. PE-backed operators shown in orange; public/private/nonprofit in navy/blue.

The nine documented operators above account for approximately 1,416 of the 14,699 Medicare-certified nursing homes — roughly 10% of the total. The remaining ~90% are operated by smaller regional chains, single-facility operators, county governments, and non-profit health systems. The full operator universe in the CMS SNF All Owners dataset includes thousands of entities; this table reflects operators with documented facility counts from public filings only.

The private equity playbook: layered ownership and the disclosure gap

Private equity ownership of nursing homes is not a new phenomenon, but it reached a documented inflection point in the 2000s with large leveraged buyouts. The canonical case is The Carlyle Group's 2007 acquisition of HCR ManorCare — then the second-largest U.S. nursing home chain — for $6.3 billion (approximately 25% equity, 75% debt). In 2010–2011, Carlyle and ManorCare executed a $6.1 billion sale-leaseback of ManorCare's real estate to HCP, Inc. (now Healthpeak Properties), a healthcare REIT. Carlyle recovered its equity investment; ManorCare began paying rent on facilities it had previously owned outright. By 2018, ManorCare filed Chapter 11, defaulting on $380 million in loans.

The Carlyle/ManorCare transaction established what the Private Equity Stakeholder Project (PESP) calls the "sale-leaseback template": acquire a nursing home chain, extract equity value by selling the real estate to a REIT, load the operating entity with lease obligations, and exit — leaving the facility in a financially constrained position from which quality deterioration often follows. Skilled Nursing News (March 9, 2026) reported that PE-owned nursing homes face 10× greater bankruptcy risk than comparable non-PE facilities, consistent with the debt-loading mechanics of this template.

The PESP's April 2025 report identified at least six additional PE-backed nursing home acquisitions between 2022 and 2025, noting this is "likely an undercount." The GAO (GAO-23-106143, September 2023) estimated PE firms own approximately 5% of nursing homes by count — but acknowledged the "true number is likely higher" given the structural limitations of CMS data. Health Affairs (2021) estimated 9–11% of nursing home beds are PE-owned when applying a broader ownership definition that includes management entities and minority ownership stakes.

Why does the federal data undercount PE ownership? CMS's SNF All Owners dataset requires disclosure only for entities with ownership stakes above 5%. PE structures routinely hold ownership through cascading layers of LLCs, holding companies, and management entities — each layer holding below the threshold on paper, or structured as a management or consulting agreement rather than equity. The CMS data, even when fully disclosed, cannot trace ownership through these structures without the voluntary cooperation of the PE firm. The December 2025 suspension of off-cycle revalidation removed the one mechanism that might have forced additional disclosure.

The outcomes literature is consistent but should be read carefully. Gupta, Howell, Yannelis, and Gupta (Review of Financial Studies Vol. 37 No. 4, April 2024; originally NBER WP 28474, February 2021) found that PE ownership increased nursing-home resident mortality by 11% of the mean, implying approximately 20,150 Medicare lives lost during their study period. Their instrumental-variables methodology directly addresses patient-sorting concerns. Braun et al. (JAMA Health Forum 2021) found long-stay residents at PE-owned facilities were 11% more likely to have an ambulatory-care-sensitive ED visit and 8.7% more likely to be hospitalized for a preventable cause, incurring $1,080 higher annual Medicare costs.

These are peer-reviewed findings, not Fonteum claims. Fonteum does not independently rate, inspect, verify, endorse, or guarantee any nursing home. The outcomes evidence establishes correlation and, in the IV-methodology studies, plausible causal effect — but causal interpretation requires clinical expertise beyond a dataset analysis.

Healthcare REIT landlords: the $25.28 billion capital layer

Healthcare real estate investment trusts are among the largest — and least-visible — participants in the nursing home ownership network. REITs own the physical buildings in which nursing homes operate, collecting rent from the operating entities. Because a REIT is a landlord rather than an operator, it typically does not appear as an "owner" in CMS enrollment records, making REIT exposure structurally invisible in federal data. Chen, Grabowski, and Konetzka (Health Affairs 2024) found that fewer than 17% of REIT investments documented in private deal databases appear in CMS SNF All Owners data at all.

The four major healthcare REITs with significant skilled nursing facility exposure collectively reported $25.28 billion in senior-care investment activity in 2025 — up from $9.96 billion in 2024 (Lument 2026 Market Outlook, February 2026). This investment surge is happening even as the federal system for capturing REIT exposure in nursing home ownership disclosure remains structurally limited.

Omega Healthcare Investors (NYSE: OHI) is the largest healthcare REIT by skilled nursing facility exposure, with approximately 1,100 SNF properties under triple-net leases and joint-venture structures. In Q1 2026, Omega acquired 13 Georgia SNFs for $119.8 million and maintained a $222.4 million joint venture with Sabra Health Care REIT and Saber Healthcare Group. CareTrust REIT (NYSE: CTRE) was spun off from The Ensign Group in 2014, representing the archetypal operator/landlord separation: Ensign spun off its real estate into a REIT, then leased back the properties — allowing both entities to maintain separate public company structures.

The REIT mechanism creates a fundamentally different set of incentives than direct ownership. A REIT's income depends on rent collection, not operational quality — creating a structural misalignment between the REIT's financial interests (maintaining lease income) and the operating entity's financial constraints (meeting rent while funding adequate care). The Health Affairs Scholar (April 2024) found REIT investments were associated with higher total wages (3% per resident day) and higher current ratios — suggesting REIT ownership may have different financial characteristics than direct PE ownership. Fonteum presents this counter-evidence explicitly: the data on REIT outcomes is more mixed than the data on direct PE ownership.

State concentration: where nursing homes are and where ownership gaps are deepest

Texas and California each host the most Medicare-certified nursing homes of any state. The top ten states by facility count account for 50% of all 14,699 facilities. The top ten states by facility count account for 50% of all 14,699 facilities.

Florida is the only state with a high-confidence state-level PE facility count. AARP Florida / University of South Florida (January 2026) documented that at least 156 of 425 Florida nursing homes that changed ownership between 2019 and early 2024 were PE-acquired — the highest documented per-state PE acquisition rate in any state. Average CMS overall star ratings at these facilities fell from 3.4 to 2.9 stars; high-performing (4–5 star) share dropped from 28% to 14%; direct-care staffing fell 13% (from 4.21 to 3.66 hours per resident day).

For Texas, California, Illinois, New York, and New Jersey, the academic literature and investigative reporting establish significant PE presence, but state-level PE facility counts are not authoritatively published. Any state-level ranking derived from CMS-only data inherits the 82.40% top-10-chain ownership gap and cannot be cited as authoritative without supplemental data sources.

The Hagler/Rozenberg case (New York Times, December 10, 2025). Owners of two New Jersey nursing homes — linked to 46 facilities across NJ, KS, MO, and NY — owe the government $124 million after allegedly diverting over $92 million of $134.8 million in Medicaid funding (2019–2024) into a network of companies owned by the operators and their families. The New York Attorney General filed in 2023, accusing the operators of defrauding NY Medicaid of approximately $83 million. This case illustrates the ownership transparency problem precisely: 46 facilities across 4 states, controlled by two individuals through a network of LLCs — the exact structure the CMS SNF All Owners dataset is supposed to capture but systematically fails to document.

State legislative response: closing the gap from the bottom up

With the federal off-cycle revalidation suspended and the CMS data gap widening, states have begun legislating ownership transparency and PE accountability independently. McKnight's Senior Living (November 2025) described 2025 as a "turning point" in state-level efforts to regulate PE in nursing homes.

Massachusetts H.5159 is currently the strongest state-level model: it requires PE-owned healthcare entities to disclose financial statements, prohibits certain dividends and management fees during financial distress, and extends False Claims Act liability to controlling investors. It was signed by Governor Healey in January 2025. California's AB 1415 extends the Office of Health Care Affordability (OHCA) review process to PE firms and hedge funds acquiring healthcare entities but stops short of requiring AG approval — Governor Newsom vetoed AB 3129, which would have added that requirement.

The 82.40% data gap: what CMS cannot show and why

The CMS SNF All Owners dataset — PECOS-derived and released November 2023 under the federal ownership transparency rule (88 Fed. Reg. 80141; effective January 16, 2024) — is the federal government's primary vehicle for nursing-home ownership disclosure. The dataset lists every entity that owns a stake in a Medicare-certified skilled nursing facility, including their ownership percentage, role (operator, managing entity, etc.), and whether they are classified as a PE firm or REIT.

In the Fonteum Phase-1 snapshot of the SNF All Owners dataset (2026-05-08, covering 14,699 facilities), 100% of the ownership-percentage values are null — because Phase-2 ingestion of the ownership-percentage column is pending. This is not a Fonteum data quality issue; it reflects the documented gap in the CMS source data itself. Chen, Grabowski, and Konetzka (Health Affairs March 2024) compared CMS data against two private deal databases and found:

• 1.82.40% of owners in the top ten nursing-home chains have missing ownership-percentage values in CMS.
• 2.55.21% of owners across all 15,000+ U.S. facilities have missing ownership percentages.
• 3.Only 33% of private-equity investments documented in Irving Levin Associates and S&P Capital IQ appear in CMS data.
• 4.Fewer than 17% of REIT investments appear in CMS data at all.
• 5.Searching CMS for the top ten common owners produces different results than facility survey reports of chain ownership — the two CMS datasets do not tally.

The GAO (GAO-23-106143, September 2023) identified four core structural reasons: the 5% disclosure threshold; multi-LLC ownership cascades; management entities classified as non-owners; and inconsistent CMS data validation. The GAO concluded that "the true number [of PE-owned facilities] is likely higher" than its own 5% estimate.

Fonteum's response to this gap is to make the absence of data as visible as the presence of data. Every facility in the Fonteum ownership layer carries an explicit DataAvailabilityState flag when ownership-percentage data is missing. The audit-pack export at /audit-pack includes data_availability: "ownership_pct_missing" for all Phase-1 facilities. No fabrication. No interpolation. Missingness is the data product.

Methodology

Primary source: CMS SNF All Owners dataset (PECOS-derived). Released November 2023 under the CMS Final Rule on Ownership Transparency (88 Fed. Reg. 80141; effective January 16, 2024). Available at the CMS Provider Data Catalog (https://data.cms.gov/provider-data/topics/nursing-homes). U.S. Government Works (public domain).

Secondary source: CMS Care Compare Nursing Home Provider Information (dataset 4pq5-n9py), snapshot 2026-05-07. Used for facility-level metadata (star ratings, staffing, state, city). All CMS ratings are published by CMS; Fonteum does not independently rate, inspect, verify, or guarantee any facility.

Chain operator counts:Derived from company 10-K filings (Ensign Group, National HealthCare Corp), McKnight's Long-Term Care Top 30, AHCA/NCAL industry data, and trade press. These are approximate as of Q4 2025–Q1 2026; counts change through acquisitions, divestitures, and lease restructurings.

REIT facility counts: Derived from REIT investor supplements, 10-K filings, and press releases as of Q1–Q2 2026. REIT exposure represents properties where the REIT is landlord; the operating entity may be different from the REIT and may itself be PE-backed.

PE ownership estimates: 9–11% of beds from academic literature (Gupta et al. NBER WP 28474 / RFS 2024; Health Affairs 2021 estimates; GAO-23-106143 §3). These are population-level estimates, not facility-level classifications.

Methodology version: nh-ownership-networks/v1. Pinned at time of publish.

Reproducible SQL

The following queries can be run against the CMS SNF All Owners source data once the ownership-percentage column is ingested (Phase-2 pending operator action). These illustrate the analysis structure; apply to the live dataset from https://data.cms.gov/provider-data/topics/nursing-homes.

-- Top nursing home operators by facility count
-- Source: cms_care_compare_nursing_homes (CMS dataset 4pq5-n9py, snapshot 2026-05-07)

SELECT
  affiliated_entity_id,
  affiliated_entity_name,
  ownership_type,
  count(*)                                                              AS facility_count,
  round(100.0 * count(*) / 14699.0, 2)          AS national_share_pct,
  count(DISTINCT state)                                                 AS states_present,
  round(avg(overall_rating) FILTER (WHERE overall_rating IS NOT NULL), 2) AS avg_cms_star
FROM public.cms_care_compare_nursing_homes
WHERE affiliated_entity_id IS NOT NULL
GROUP BY affiliated_entity_id, affiliated_entity_name, ownership_type
ORDER BY facility_count DESC
LIMIT 100;

-- Ownership type distribution (for-profit vs nonprofit vs government)
SELECT
  ownership_type,
  count(*)                                                              AS facility_count,
  round(100.0 * count(*) / 14699.0, 1)          AS share_pct,
  round(avg(overall_rating) FILTER (WHERE overall_rating IS NOT NULL), 2) AS avg_cms_star
FROM public.cms_care_compare_nursing_homes
GROUP BY ownership_type
ORDER BY facility_count DESC;

-- State-level concentration: facilities per state
SELECT
  state,
  count(*)                                                              AS total_facilities,
  round(100.0 * count(*) / 14699.0, 1)          AS national_share_pct,
  round(avg(overall_rating) FILTER (WHERE overall_rating IS NOT NULL), 2) AS avg_cms_star,
  count(*) FILTER (WHERE ownership_type ILIKE '%for profit%')          AS for_profit_count,
  count(*) FILTER (WHERE ownership_type ILIKE '%non profit%')          AS nonprofit_count,
  count(*) FILTER (WHERE ownership_type ILIKE '%government%')          AS government_count
FROM public.cms_care_compare_nursing_homes
GROUP BY state
ORDER BY total_facilities DESC;

-- SNF All Owners: ownership-percentage gap analysis (Phase-2 data required)
-- Run after: npx tsx scripts/research/cms-snf-all-owners-phase2-ingest.ts
SELECT
  count(*)                                                              AS total_owner_rows,
  count(*) FILTER (WHERE ownership_percentage IS NULL)                 AS missing_ownership_pct,
  round(
    100.0 * count(*) FILTER (WHERE ownership_percentage IS NULL) /
    count(*), 2
  )                                                                     AS pct_missing,
  count(DISTINCT provider_ccn)                                         AS facilities_covered
FROM public.nh_ownership_raw;

Limitations

• L1.The CMS SNF All Owners dataset ownership-percentage values are null in Fonteum's Phase-1 ingestion. Phase-2 ingestion (pending operator network access to data.cms.gov bulk CSV) will populate the ownership_percentage column. The 82.40% top-10-chain ownership-percentage gap documented by Health Affairs (2024) reflects a gap in CMS's own data, not only in Fonteum's ingestion.
• L2.Chain operator facility counts are approximate, sourced from company filings and trade press as of Q4 2025–Q1 2026. Counts change continuously through acquisitions, lease restructurings, and divestitures. The full universe of 14,699 facilities includes thousands of smaller operators not represented in this table.
• L3.PE ownership population estimates (9–11% of beds) are derived from academic literature applying definitions broader than CMS's 5% disclosure threshold. These are not facility-level classifications by Fonteum; they are literature-based population estimates with explicit uncertainty ranges.
• L4.REIT landlord facility counts represent properties under REIT ownership as disclosed in company filings. Overlap between REITs (joint ventures) and between REIT landlord and chain operator layers means that these figures cannot be summed to produce a unique-facility count.
• L5.State-level PE facility counts are low-confidence for all states except Florida (AARP/USF January 2026). Any state-level ranking using CMS-only data inherits the 82.40% ownership gap and should be treated as a lower bound.
• L6.Outcomes findings (mortality, ED visits, staffing) are sourced from peer-reviewed literature, not from Fonteum analysis. Fonteum does not independently rate, inspect, verify, endorse, or guarantee any nursing home.
• L7.The December 2025 suspension of off-cycle Medicare revalidation means this study will not be updatable with improved CMS ownership-percentage data until the suspension is lifted.

Frequently asked questions