For-Profit vs. Nonprofit
What the Data Shows
Peer-reviewed research and federal data consistently show for-profit nursing homes provide fewer RN hours and receive more quality citations than nonprofits — though individual facility quality varies widely.
at for-profit vs. nonprofit facilities
vs. nonprofit (no recent ownership change)
at PE-owned facilities vs. other for-profits
Chart 1
RN Hours per Resident Day by Ownership Type
Registered nurse staffing hours, measured per resident per day, from CMS Payroll-Based Journal (PBJ) data analyzed by HHS ASPE (May 2024). Higher hours indicate more direct nursing coverage.
Source: HHS ASPE, "Nurse Staffing Estimates in US Nursing Homes" (May 2024). Data from CMS Payroll-Based Journal (PBJ).
Chart 2
Five-Star Quality Rating by Ownership Type
CMS Five-Star ratings (1–5) reflect inspection results, staffing levels, and quality measures. Analysis by HHS ASPE (2024) across ownership structures from 2013–2022.
Source: HHS ASPE, "Trends in Ownership Structures of U.S. Nursing Homes (2013–2022)." Ratings from CMS Five-Star Quality Rating System.
Chart 3
PE & REIT Ownership: Impact vs. Other For-Profits
Relative change in RN staffing hours and deficiency citation scores compared to non-PE for-profit facilities, from a peer-reviewed JAMA Health Forum study (2022) covering 2013–2019 CMS data.
Source: JAMA Health Forum (2022), "Private Equity Investment in US Nursing Homes." Relative changes from multivariable regression models controlling for facility, market, and time characteristics.
Important: Individual Facilities Vary Widely
These statistics describe population-level averages across thousands of facilities. Many for-profit nursing homes provide excellent care, and some nonprofits underperform. Ownership structure is one factor — not a guarantee of quality in either direction.
When evaluating a specific facility, always check the RN hours per resident day, CMS Five-Star rating, recent inspection results, and staffing stability — all available on each facility's page on this site.
Methodology Note
This data draws on federal CMS Payroll-Based Journal (PBJ) staffing reports, the CMS Five-Star Quality Rating system, and peer-reviewed analyses of nursing home ownership structures. All source studies are linked in the citations below. The HHS ASPE reports (2024) use facility-level CMS data covering the full U.S. nursing home industry from 2013–2022. The JAMA Health Forum study uses multivariable regression models controlling for facility characteristics, market conditions, and time trends to isolate the effect of ownership type.
Individual facility performance varies — use the RN hours and CMS Stars displayed on each facility's page to evaluate the specific facility you're considering.
Citations
- 1.
HHS ASPE. "Nurse Staffing Estimates in US Nursing Homes." May 2024.
HHS ASPE PDF - 2.
HHS ASPE. "Trends in Ownership Structures of U.S. Nursing Homes (2013–2022)." 2024.
HHS ASPE PDF - 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.
Comondore VR et al. "Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis." BMJ. 2009;339:b2732.
PMC / BMJ - 5.
Center for Medicare Advocacy. "Non-Profit vs. For-Profit Nursing Homes: Is There a Difference in Care?"
Medicare Advocacy
The Capital Stack
The REIT layer: who owns the real estate
Many for-profit nursing home operators don't own their buildings. The buildings are owned by publicly traded Real Estate Investment Trusts (REITs), which lease them back to the operator for a monthly payment. This sale-leaseback arrangement turns a fixed asset into a recurring operating expense — and creates a separate, often more profitable, public company sitting above the nursing home in the capital stack.
Because REITs are SEC-registered, every dollar is disclosed in quarterly 10-Q and annual 10-K filings. The REIT layer is the most transparent part of the entire nursing home ownership structure. We can name companies, name shareholders, and cite SEC filings line by line.
These financial restructuring costs — paid to the REIT and to lenders — come out of the same revenue pool that funds nurse staffing. The sale-leaseback model is legal and common; the question is whether the resulting cost structure is compatible with adequate care.
Where the dollars flow
¹ Lease payments rise approximately 75% and interest payments approximately 325% in the years following private equity acquisition, per Gupta et al. (2024). REIT ownership separates the real estate asset from the operating business — the REIT collects rent regardless of care quality outcomes. REIT ownership ≠ operational responsibility. The REIT owns the building; the operator runs the home. Both matter, for different reasons.
Pure-play and SNF-heavy REITs
Omega Healthcare Investors
CareTrust REIT
Sabra Health Care REIT
Diversified REITs with meaningful SNF exposure
LTC Properties
National Health Investors
Large diversified REITs — minimal or exiting SNF exposure
These are among the largest healthcare REITs by market cap but have reduced or exited direct SNF holdings. Included here for completeness and because they frequently appear in industry reporting.
The “Big Three” asset managers
Vanguard, BlackRock, and State Street appear as the top-3 institutional holders of virtually every publicly traded healthcare REIT. This is not coincidence — it reflects the mechanics of passive index investing.
Typically #1 holder, ~10–12% of shares
Typically #2, ~8–10% of shares
Typically #3, ~4–6% of shares
These are passive index funds — they hold these stocks because they're in the Russell 1000, S&P 500, or total-market index, not because fund managers made an active bet on nursing home real estate. But the concentration is real: three asset managers collectively hold 20–30% of the outstanding shares of every major public nursing home REIT, giving them meaningful proxy votes at every annual shareholder meeting. Ownership ≠ endorsement, but it does mean these firms can influence governance if they choose to engage.
Verify current percentages from SEC 13F filings via EDGAR full-text search or WhaleWisdom 13F tracker. Percentages above are typical ranges, not live data.
REIT data sources
Data verified April 2026 from SEC EDGAR primary filings and company investor relations pages. Market caps sourced from StockAnalysis.com and CompaniesMarketCap. Institutional holder percentages above are typical ranges from 13F aggregators; verify current figures directly from SEC filings before citing. Quarterly refresh recommended.
Important distinction: REIT ownership means the REIT holds title to the real estate and collects lease payments. The REIT does not hire nursing staff, set care policies, or hold the facility's Medicare/Medicaid certification. Operational responsibility — and regulatory accountability — sits with the licensed operator. Both layers matter for understanding nursing home economics, but for different reasons.