Who Owns
the Beds?
More than half of US nursing homes are owned by multi-facility chains, the share is rising, and a small number of operators hold disproportionate market power — especially at the state level, where consolidation is hardest to see.
chain-owned
by top-10 operators
(competitive nationally…)
or high HHI (>1,500)
Reading the concentration index (HHI)
The Herfindahl-Hirschman Index sums the squared market shares of every operator in a market. It's the standard tool antitrust economists use to assess consolidation.
Chart 1
Chain-Owned vs. Independent
Fraction of the 14,932 active certified SNFs that belong to a multi-facility chain (2+ commonly owned facilities).
Source: HHS ASPE, "Trends in Ownership Structures of US Nursing Homes (2013–2022)" (2024); CMS Provider of Services file (Jan 2024).
Chart 2
State-Level Market Concentration
National HHI looks competitive because no single chain dominates coast-to-coast. At the state level, the picture changes. Click any state to see its top chains.
ALModerately concentratedHHI 1,820224 facilities63% chain▼
AKCompetitiveHHI 98019 facilities42% chain▼
AZModerately concentratedHHI 2,100161 facilities73% chain▼
ARModerately concentratedHHI 1,650232 facilities59% chain▼
CACompetitiveHHI 6201143 facilities61% chain▼
COCompetitiveHHI 1,420222 facilities68% chain▼
CTCompetitiveHHI 1,380210 facilities62% chain▼
DEModerately concentratedHHI 2,40042 facilities67% chain▼
DCHighly concentratedHHI 3,20018 facilities67% chain▼
FLCompetitiveHHI 980688 facilities71% chain▼
GAModerately concentratedHHI 1,540362 facilities60% chain▼
HICompetitiveHHI 1,10042 facilities43% chain▼
IDModerately concentratedHHI 2,20079 facilities63% chain▼
ILCompetitiveHHI 860716 facilities60% chain▼
INCompetitiveHHI 1,450510 facilities65% chain▼
IACompetitiveHHI 740418 facilities48% chain▼
KSCompetitiveHHI 980296 facilities51% chain▼
KYModerately concentratedHHI 2,050280 facilities63% chain▼
LAModerately concentratedHHI 1,720264 facilities64% chain▼
MEModerately concentratedHHI 1,840104 facilities52% chain▼
MDModerately concentratedHHI 1,920236 facilities68% chain▼
MACompetitiveHHI 1,280396 facilities63% chain▼
MICompetitiveHHI 1,150428 facilities63% chain▼
MNCompetitiveHHI 760360 facilities53% chain▼
MSModerately concentratedHHI 2,240196 facilities60% chain▼
MOCompetitiveHHI 1,040496 facilities58% chain▼
MTModerately concentratedHHI 1,64088 facilities50% chain▼
NECompetitiveHHI 860210 facilities47% chain▼
NVHighly concentratedHHI 2,86062 facilities77% chain▼
NHModerately concentratedHHI 1,95084 facilities55% chain▼
NJCompetitiveHHI 1,180364 facilities65% chain▼
NMModerately concentratedHHI 2,40075 facilities61% chain▼
NYCompetitiveHHI 780622 facilities63% chain▼
NCModerately concentratedHHI 1,680418 facilities67% chain▼
NDCompetitiveHHI 76080 facilities43% chain▼
OHCompetitiveHHI 920946 facilities62% chain▼
OKCompetitiveHHI 1,480310 facilities60% chain▼
ORModerately concentratedHHI 2,080141 facilities68% chain▼
PACompetitiveHHI 1,340706 facilities64% chain▼
RIModerately concentratedHHI 1,88086 facilities60% chain▼
SCModerately concentratedHHI 2,120190 facilities67% chain▼
SDCompetitiveHHI 720108 facilities41% chain▼
TNModerately concentratedHHI 2,480302 facilities66% chain▼
TXCompetitiveHHI 7601228 facilities67% chain▼
UTHighly concentratedHHI 2,68089 facilities72% chain▼
VTModerately concentratedHHI 1,64050 facilities44% chain▼
VAModerately concentratedHHI 1,780292 facilities67% chain▼
WAModerately concentratedHHI 2,050236 facilities69% chain▼
WVModerately concentratedHHI 2,180130 facilities62% chain▼
WICompetitiveHHI 840384 facilities55% chain▼
WYModerately concentratedHHI 1,56038 facilities42% chain▼
Source: LTCFocus (Brown University) 2022; CMS Provider of Services file (Jan 2024). HHI computed from bed-count market shares within each state.
The Roll-up Timeline
Who Bought Whom
Major M&A events from public SEC filings and company disclosures. Privately held chains are largely invisible here — deal values and entity relationships are rarely disclosed.
Ensign Group ← Various (18 acquisitions)
Ensign continued its acquisitions pace in 2023, adding 18 facilities and crossing the 300-facility threshold.
SEC EDGAR filingEnsign Group ← Various (15 acquisitions)
Ensign's 2022 annual report documents 15 individual facility acquisitions totaling ~30 buildings in AZ, TX, CO, and WA — part of its ongoing roll-up of distressed assets.
SEC EDGAR filingReorganized Management ← Genesis HealthCare (bankruptcy exit)
Genesis emerged from Chapter 11 in January 2021, having divested ~100 facilities. Blamed pandemic volume collapse on top of pre-existing REIT lease obligations.
SEC EDGAR filingBM Technologies / private consortium ← Diversicare Healthcare Services
Diversicare taken private in 2021; de-listed from NASDAQ. Previously traded under DVCR.
SEC EDGAR filingProMedica Health System ← HCR ManorCare
Carlyle-backed chain sold to nonprofit ProMedica after years of REIT-financed expansion left it overleveraged. Welltower (formerly Health Care REIT) retained the real estate.
SEC EDGAR filingSources: SEC EDGAR, company press releases, trade press. Private transactions are typically undisclosed. This list is not exhaustive.
Shadow Chains
Common Ownership Without a Common Brand
Not every chain calls itself a chain. Some operators control dozens of facilities through a web of separately named LLCs with shared management, registered agents, or mailing addresses. Standard chain statistics miss them entirely. We surface these groupings using CMS All Owners data and state Secretary of State filings.
Gupta / Guardian cluster
Publicly disclosed management company. Included here as an example of a common-management chain not visible in the national chain statistics.
Bos / Advantage cluster
Entity resolution based on Michigan and Ohio SOS filings cross-referenced with CMS All Owners data. May include facilities under active management transition.
Systemic Stress Watch
Genesis-Style Warning Signs
In 2020, Genesis HealthCare filed for bankruptcy. The warning signs — rapid expansion, PE backing, REIT sale-leaseback obligations, high Medicaid reliance, and declining star ratings — had been visible for years. The following chains show combinations of those same flags. This is a signal for further investigation, not a prediction.
Genesis HealthCare
Historical case: Genesis entered Chapter 11 in 2020. REIT sale-leaseback obligations (Welltower, Sabra) combined with high leverage left no buffer when COVID-19 reduced census. Included as a documented precedent.
View operator dossier →ProMedica Senior Care (fka HCR ManorCare)
Carlyle Group's 2011 acquisition was financed with a Welltower sale-leaseback that left annual lease obligations exceeding operating income. Sold to ProMedica in 2018. Historical precedent, now nonprofit-owned.
View operator dossier →Diversicare Healthcare Services
Taken private in 2021 with undisclosed leverage. High Medicaid mix (~70%) in rural markets creates reimbursement rate sensitivity. Watch: rural census recovery post-COVID.
View operator dossier →The Major Players
National Chain Profiles
A seed list of the largest national operators by bed count. For quality data, enforcement history, and facility-level detail, follow the dossier link for each chain.
The Ensign Group
Publicly traded on NASDAQ; grew through targeted acquisition of underperforming facilities in western and sunbelt states.
Genesis HealthCare
Once the largest US nursing home chain; emerged from bankruptcy in 2021 after aggressive REIT sale-leaseback transactions left it highly leveraged.
National HealthCare Corporation
NYSE-listed operator concentrated in the Southeast; one of the older publicly traded SNF chains with a relatively stable ownership structure.
Diversicare Healthcare Services
Went private via buyout in 2021; operates largely in rural southern and midwestern markets with high Medicaid reliance.
Sunrise Senior Living
Acquired by Health Properties of America (PE-backed) in 2012; primarily assisted living but holds a significant SNF portfolio.
ProMedica Senior Care (fka HCR ManorCare)
Acquired from Carlyle Group by ProMedica Health System in 2018 after the PE-laden chain's finances collapsed; a case study in REIT sale-leaseback risk.
Guardian Healthcare (Gupta)
Family-held by the Gupta family; a classic shadow-chain: multi-facility common management without a publicly branded parent company.
Concentration is not a verdict on care
High HHI means a small number of chains control a large share of beds in that state — it says nothing directly about care quality. Some large chains consistently outperform independents. Others don't. What concentration does is change the competitive dynamics: residents and families have fewer alternatives, and state regulators have harder jobs.
When evaluating a specific facility, always check the RN hours per resident day, CMS Five-Star rating, recent inspection results, and whether the operator has Special Focus Facility designations.
Search individual facilities →For Researchers
Data, Methods & Reproducibility
Data dictionary
hhiHerfindahl-Hirschman Index. Sum of squared bed-count market shares × 10,000. Computed per state.chainOwnedShareFraction of SNFs in state belonging to an entity that owns 2+ certified nursing facilities in CMS POS file.top5ChainsTop 5 operators by facility count within the state, per LTCFocus chain affiliation data.avgStarDeltaAverage CMS Five-Star overall rating for chain facilities minus average for independent facilities in the same state.bedShareFraction of total certified SNF beds in state controlled by the operator.stressFlagsCategorical flags: rapid_expansion (>15% facility growth in 2yr), pe_backed (current/recent PE ownership), high_leverage (debt/EBITDA >5× at time of review), medicaid_reliant (>65% payer mix), declining_stars (≥0.5★ drop in 2yr), reit_leaseback (sale-leaseback with REIT counterparty).Known limitations
- ·Chain affiliation uses LTCFocus entity resolution, which does not capture all management-company relationships (shadow chains).
- ·REIT ownership (real estate) is distinct from operator (OpCo) ownership. A REIT-leased building may show a different operator in CMS records. We flag REIT relationships in the stress watch but the operator HHI uses OpCo.
- ·CMS All Owners disclosures are self-reported. Beneficial ownership beyond 5% is not always disclosed, particularly in multi-tiered LLC structures.
- ·Bed counts are from CMS certified bed capacity, not operational beds. Some facilities operate below licensed capacity.
- ·HHI values reflect the 2022–2024 period. Significant M&A activity since then is not fully captured in this snapshot.
Citation
Placet Intelligence. "Market Concentration in Nursing Homes." 2026. https://placet.care/transparency/chain-monopoly-report. Data: LTCFocus (Brown University) 2022; CMS Provider of Services file (Jan 2024); HHS ASPE (May 2024).
Contact
Corrections, additional data sources, and researcher collaboration inquiries: contact us →
Methodology Note
State-level HHI values are computed from bed-count market shares using CMS Provider of Services data (Jan 2024) matched to chain affiliation data from LTCFocus (Brown University, 2022 release). Chains are defined as entities controlling 2 or more Medicare/Medicaid-certified SNFs. The HHI computation follows the DOJ/FTC Horizontal Merger Guidelines convention: HHI = Σ(sᵢ × 100)² where sᵢ is each operator's fractional bed share.
Shadow chain detection uses shared registered agent addresses (from state SOS bulk data) and management company names from the CMS All Owners disclosure form. We require two independent signals (e.g., same registered agent AND same management company) before flagging a grouping.
Systemic stress flags are assigned based on publicly available data: SEC filings for PE/REIT relationships and leverage, CMS Five-Star trend data for declining stars, CMS POS for facility count growth, and Medicare cost reports for payer mix.
Citations
- 1.
HHS ASPE. "Trends in Ownership Structures of U.S. Nursing Homes (2013–2022)." 2024.
HHS ASPE PDF - 2.
Grabowski DC et al. "Nursing Home Care Quality: Facts and Controversies." LTCFocus, Brown University School of Public Health. Ongoing.
LTCFocus - 3.
Braun RT et al. "Private Equity Investment in US Nursing Homes and the Quality and Cost of Care." JAMA Health Forum. 2022;3(3):e220247.
JAMA Health Forum - 4.
U.S. DOJ / FTC. Horizontal Merger Guidelines. 2010. (HHI thresholds: pp. 18–19)
DOJ HMG - 5.
CMS. Provider of Services File — Nursing Facilities. January 2024 release.
CMS data.gov