{ "study": { "slug": "nursing-home-ownership-concentration-2026", "title": "Who owns America's nursing homes: a concentration story, 2026", "standfirst": "Of the 14,425 U.S. skilled nursing facilities in CMS's PECOS ownership file, only 28.1% are independent — owned by individuals or a single-facility entity. The other 71.9% disclose a multi-facility organization among their owners, and 52.3% belong to a group of 10 or more facilities.", "desk": "financial-distress", "article_type": "Original Research", "published": "2026-06-16", "issue": 80, "doi": "10.5072/fonteum/nursing-home-ownership-concentration-2026", "url": "https://fonteum.com/research/nursing-home-ownership-concentration-2026", "methodology_version": "cms-snf-all-owners/v1" }, "data_as_of": "2026-05-25", "datasets": [ { "slug": "cms-pecos", "name": "CMS PECOS", "publisher": "CMS — Provider Enrollment, Chain & Ownership System", "upstream_url": null } ], "key_findings": [ { "number": "71.9%", "finding": "of the 14,425 skilled nursing facilities in CMS's PECOS All Owners file disclose at least one organization that also owns another facility — a multi-facility group. Only 28.1% are independent: 15.5% owned solely by individuals and 12.6% by an organization tied to no other facility", "dataset": "cms-pecos" }, { "number": "52.3%", "finding": "of all nursing homes — 7,547 facilities — belong to a group of 10 or more facilities. 1,807 (12.5%) sit in groups of 50 to 99 and 1,092 (7.6%) in groups of 100 or more. The single-facility independent is now the exception, not the rule", "dataset": "cms-pecos" }, { "number": "63.1%", "finding": "of the 46,832 facility–owner relationships on file are held by the largest 10% of organizational owners — 1,265 of 12,646 distinct owner organizations. The single most-disclosed organization appears as an owner of 249 facilities", "dataset": "cms-pecos" }, { "number": "3.8", "finding": "organizations are disclosed as owners of the average nursing home (median 2, maximum 99) — direct owners, indirect parents, holding companies, and operators stacked across the layers a single CMS-855A filing can carry", "dataset": "cms-pecos" }, { "number": "280,207", "finding": "owner rows across 14,425 SNF enrollments make up the published file, snapshot dated 2026-05-25. Every figure is a count over disclosed ownership and operational-control relationships — a structural measure only. No individual person is named, and no quality, conduct, or risk inference attaches to any organization", "dataset": "cms-pecos" } ], "faqs": [ { "q": "How concentrated is nursing-home ownership in the United States?", "a": "Heavily. Of the 14,425 skilled nursing facilities in CMS's PECOS All Owners file, 71.9% disclose at least one organization that also owns other facilities, and 52.3% belong to a group of 10 or more. The largest 10% of organizational owners account for 63.1% of all 46,832 facility–owner relationships on file." }, { "q": "What counts as a nursing-home chain in this data?", "a": "This study calls a facility chain-affiliated when at least one of its disclosed organizational owners — deduped by CMS owner PAC ID — also appears as an owner of one or more other facilities. It is a structural count of shared ownership, not a brand or a legal definition of a corporate group." }, { "q": "Who are the largest nursing-home owners?", "a": "By the number of facilities where they appear as a disclosed owner or operator, the largest organizations include PACS Group and PACS Holdings, The Ensign Group, Life Care Centers of America, and several Genesis HealthCare entities — each named on roughly 180 to 250 facilities. These are organizations, not individuals, and the figure is a count of disclosures, not a judgment about any of them." }, { "q": "Does this study say anything about care quality?", "a": "No. It is a structural ownership measure built only from who is disclosed as owning or operating each facility. It draws no inference about staffing, inspection results, penalties, or the quality of care, and naming an organization here is not a statement about its conduct. Quality and enforcement are separate datasets covered in other Fonteum studies." }, { "q": "Why are PACS Group and PACS Holdings listed separately?", "a": "Because CMS discloses them under separate owner PAC IDs, and this study deduplicates by PAC ID rather than guessing which entities share a parent. Related entities within one corporate family — operating companies, property companies, and holding companies — therefore appear as distinct rows. That means true family-level concentration is at least as high as the per-organization figures shown, not lower." }, { "q": "How many nursing homes are truly independent?", "a": "About 28.1% — 4,056 of 14,425 facilities. Of those, 2,232 (15.5%) disclose no organizational owner at all and are owned and run by individuals or families, while 1,824 (12.6%) disclose a single organization that is tied to no other facility. The remaining 71.9% are part of a multi-facility group." }, { "q": "What ownership roles does the study count?", "a": "Direct and indirect ownership interests of 5% or greater, other direct and indirect ownership interests, general and limited partnership interests, and operational or managerial control. It deliberately excludes Additional Disclosable Parties such as accounting firms and banks, mortgage and security-interest holders, corporate officers and directors, managing employees, and trustees — parties CMS discloses but that do not own or operate the facility." }, { "q": "Can I reproduce these figures?", "a": "Yes. Every number is a direct count over the public snf_all_owners and snf_enrollments tables — CMS's PECOS SNF All Owners file, snapshot dated 2026-05-25 — with no modeling. The exact SQL for the chain split, the group-size distribution, the top-decile concentration, and the layering depth is published in the reproducibility block below." } ], "citation": { "apa": "Fonteum Research. (2026, June 16). Who owns America's nursing homes: a concentration story, 2026. Fonteum Research, Issue 80. https://doi.org/10.5072/fonteum/nursing-home-ownership-concentration-2026", "url": "https://fonteum.com/research/nursing-home-ownership-concentration-2026" }, "reproducible_sql": "-- Who owns America's nursing homes — and how concentrated that ownership is.\n-- Fully reproducible query.\n--\n-- Question: across the skilled nursing facilities (SNFs) in CMS's PECOS \"SNF\n-- All Owners\" disclosure file, how many are tied to a multi-facility\n-- ORGANIZATION (a chain/group) versus owned by a single-facility entity or by\n-- individuals, and how concentrated is the organizational ownership? The lead\n-- figure: of 14,425 SNF enrollments, only 4,056 (28.1%) are independent — owned\n-- by individuals or by an organization that appears on no other facility — while\n-- 10,369 (71.9%) disclose at least one organization that also owns other\n-- facilities, and 7,547 (52.3%) belong to a group of 10 or more facilities.\n--\n-- This is a STRUCTURAL ownership measure only. It counts disclosed ownership\n-- and operational-control relationships. It is NOT a quality, fraud, conduct,\n-- or risk signal of any kind, and no individual person is named.\n--\n-- Sources:\n-- public.snf_all_owners — CMS PECOS \"Skilled Nursing Facility All Owners\"\n-- file. One row per owner per SNF enrollment. 280,207 rows; snapshot\n-- 2026-05-25. associate_id_owner is the canonical owner identifier (PAC ID)\n-- — chains are deduped by PAC ID, NOT by name.\n-- public.snf_enrollments — companion PECOS \"SNF Enrollments\" file. One row per\n-- SNF enrollment (14,425). enrollment_id is the join key to snf_all_owners.\n-- Both: CMS PECOS SNF All Owners, https://data.cms.gov/provider-characteristics/\n-- hospitals-and-other-facilities/skilled-nursing-facility-all-owners\n-- Public, read-only. License: US-Government-Works (17 U.S.C. Sec. 105).\n-- Authorizing statute: ACA Section 6101; 42 CFR Sec. 424.516; CMS-855A.\n--\n-- Owner roles used as ORGANIZATIONAL OWNERSHIP / OPERATIONAL CONTROL throughout:\n-- 34 = 5% OR GREATER DIRECT OWNERSHIP INTEREST\n-- 35 = 5% OR GREATER INDIRECT OWNERSHIP INTEREST\n-- 85 = DIRECT OWNERSHIP INTEREST\n-- 86 = INDIRECT OWNERSHIP INTEREST\n-- 43 = OPERATIONAL/MANAGERIAL CONTROL\n-- 38 = GENERAL PARTNERSHIP INTEREST\n-- 39 = LIMITED PARTNERSHIP INTEREST\n-- DELIBERATELY EXCLUDED: role 72 (ADP — Additional Disclosable Party, e.g.\n-- accounting firms, banks, consultants), 36/37 (mortgage/security interest =\n-- lenders), 40/41 (corporate officer/director), 42/25/63 (managing employees,\n-- governing body), 71 (trustee). Those parties are disclosed but are not\n-- owners or operators of the facility.\n\n-- ============================================================================\n-- (1) Universe reconciliation — the two PECOS files at a glance.\n-- ============================================================================\nSELECT\n (SELECT count(*) FROM public.snf_enrollments) AS snf_enrollments,\n (SELECT count(*) FROM public.snf_all_owners) AS owner_rows,\n (SELECT count(DISTINCT associate_id_owner) FROM public.snf_all_owners\n WHERE type_owner = 'O') AS distinct_org_pac_ids,\n (SELECT count(DISTINCT associate_id_owner) FROM public.snf_all_owners\n WHERE type_owner = 'I') AS distinct_individual_pac_ids,\n (SELECT max(snapshot_date) FROM public.snf_all_owners) AS snapshot;\n-- snf_enrollments 14,425 · owner_rows 280,207 · distinct_org_pac_ids 26,453\n-- distinct_individual_pac_ids 58,866 · snapshot 2026-05-25\n\n-- ============================================================================\n-- (2) HEADLINE: chain vs independent. For each SNF, find the largest \"reach\"\n-- (number of facilities owned) of any of its organizational owners, then\n-- classify the facility. Independents = facilities with no organizational\n-- owner (individually/family owned) or whose only org owner appears on that\n-- one facility. Chain-affiliated = an org owner that also owns >=1 other SNF.\n-- ============================================================================\nWITH org_owner AS (\n SELECT DISTINCT associate_id_owner, enrollment_id\n FROM public.snf_all_owners\n WHERE type_owner = 'O'\n AND role_code_owner IN ('34','35','85','86','43','38','39')\n),\nreach AS ( -- how many facilities each organizational owner touches\n SELECT associate_id_owner, count(DISTINCT enrollment_id) AS r\n FROM org_owner GROUP BY associate_id_owner\n),\nfac AS ( -- per facility: the largest reach among its organizational owners\n SELECT oo.enrollment_id, max(rr.r) AS mr\n FROM org_owner oo JOIN reach rr USING (associate_id_owner)\n GROUP BY oo.enrollment_id\n),\nallf AS ( -- every enrollment, NULL mr = no organizational owner disclosed\n SELECT e.enrollment_id, f.mr\n FROM public.snf_enrollments e LEFT JOIN fac f USING (enrollment_id)\n)\nSELECT\n count(*) AS total_snfs,\n count(*) FILTER (WHERE mr >= 2) AS chain_affiliated,\n round(100.0 * count(*) FILTER (WHERE mr >= 2) / count(*), 1) AS chain_pct,\n count(*) FILTER (WHERE mr >= 10) AS in_group_10plus,\n round(100.0 * count(*) FILTER (WHERE mr >= 10) / count(*), 1) AS group_10plus_pct,\n count(*) FILTER (WHERE mr IS NULL OR mr = 1) AS independent,\n round(100.0 * count(*) FILTER (WHERE mr IS NULL OR mr = 1) / count(*), 1) AS independent_pct\nFROM allf;\n-- total_snfs 14,425 · chain_affiliated 10,369 (71.9%) · in_group_10plus 7,547 (52.3%)\n-- independent 4,056 (28.1%)\n\n-- ============================================================================\n-- (3) HERO: the group-size distribution. Every SNF bucketed by the size of the\n-- largest facility-group any of its organizational owners belongs to.\n-- ============================================================================\nWITH org_owner AS (\n SELECT DISTINCT associate_id_owner, enrollment_id\n FROM public.snf_all_owners\n WHERE type_owner = 'O' AND role_code_owner IN ('34','35','85','86','43','38','39')\n),\nreach AS (SELECT associate_id_owner, count(DISTINCT enrollment_id) r FROM org_owner GROUP BY 1),\nfac AS (SELECT oo.enrollment_id, max(rr.r) mr FROM org_owner oo JOIN reach rr USING (associate_id_owner) GROUP BY 1),\nallf AS (SELECT e.enrollment_id, f.mr FROM public.snf_enrollments e LEFT JOIN fac f USING (enrollment_id))\nSELECT\n CASE WHEN mr IS NULL THEN '0 individually/family owned'\n WHEN mr = 1 THEN '1 single-facility org'\n WHEN mr BETWEEN 2 AND 9 THEN '2-9 facilities'\n WHEN mr BETWEEN 10 AND 49 THEN '10-49 facilities'\n WHEN mr BETWEEN 50 AND 99 THEN '50-99 facilities'\n ELSE '100+ facilities' END AS group_size,\n count(*) AS snfs,\n round(100.0 * count(*) / sum(count(*)) OVER (), 1) AS pct\nFROM allf\nGROUP BY 1 ORDER BY min(coalesce(mr, -1));\n-- 0 individually/family owned 2,232 15.5%\n-- 1 single-facility org 1,824 12.6%\n-- 2-9 facilities 2,822 19.6%\n-- 10-49 facilities 4,648 32.2%\n-- 50-99 facilities 1,807 12.5%\n-- 100+ facilities 1,092 7.6%\n\n-- ============================================================================\n-- (4) The concentration tail. Rank every organizational owner by reach and take\n-- the top decile. The largest 10% of owner organizations account for the\n-- majority of all facility-owner relationships on file.\n-- ============================================================================\nWITH org_owner AS (\n SELECT DISTINCT associate_id_owner, enrollment_id\n FROM public.snf_all_owners\n WHERE type_owner = 'O' AND role_code_owner IN ('34','35','85','86','43','38','39')\n),\nreach AS (SELECT associate_id_owner, count(DISTINCT enrollment_id) r FROM org_owner GROUP BY 1),\nranked AS (SELECT associate_id_owner, r, ntile(10) OVER (ORDER BY r DESC) decile FROM reach)\nSELECT\n count(*) AS owner_orgs,\n sum(r) AS facility_owner_links,\n sum(r) FILTER (WHERE decile = 1) AS top_decile_links,\n round(100.0 * sum(r) FILTER (WHERE decile = 1) / sum(r), 1) AS top_decile_pct,\n min(r) FILTER (WHERE decile = 1) AS top_decile_floor_reach,\n max(r) AS max_reach\nFROM ranked;\n-- owner_orgs 12,646 · facility_owner_links 46,832 · top_decile_links 29,550\n-- top_decile_pct 63.1% · top_decile_floor_reach 7 · max_reach 249\n\n-- ============================================================================\n-- (5) The largest disclosed organizations, deduped by canonical PAC ID. Column\n-- is \"SNF enrollments where the organization appears as an owner/operator.\"\n-- NOTE: related entities within one corporate family are disclosed under\n-- SEPARATE PAC IDs and so list separately — e.g. PACS Group, Inc. and PACS\n-- Holdings, LLC; the several Genesis HealthCare operating entities. This is\n-- a count of disclosed organizations, NOT resolved beneficial owners; true\n-- family-level concentration is therefore AT LEAST what is shown here. No\n-- quality, conduct, or risk inference attaches to any organization listed.\n-- ============================================================================\nWITH org_owner AS (\n SELECT associate_id_owner AS pac, enrollment_id,\n nullif(trim(organization_name_owner), '') AS nm\n FROM public.snf_all_owners\n WHERE type_owner = 'O' AND role_code_owner IN ('34','35','85','86','43','38','39')\n),\nnm AS ( -- representative display name per PAC ID (most frequent non-blank name)\n SELECT pac, nm, row_number() OVER (PARTITION BY pac ORDER BY count(*) DESC) rn\n FROM org_owner WHERE nm IS NOT NULL GROUP BY pac, nm\n)\nSELECT n.nm AS owner_org, o.pac AS pac_id,\n count(DISTINCT o.enrollment_id) AS snf_enrollments\nFROM org_owner o JOIN nm n ON n.pac = o.pac AND n.rn = 1\nGROUP BY n.nm, o.pac\nORDER BY snf_enrollments DESC\nLIMIT 12;\n-- PACS Holdings, LLC 6103289202 249\n-- PACS Group, Inc. 7911360011 248\n-- The Ensign Group Inc 3476460494 233\n-- Life Care Centers Of America 6608783543 194\n-- HCCF Management Group XI LLC 1456511880 187\n-- Gen Operations II LLC 2769671536 186\n-- ZAC Properties XI LLC 7911167341 186\n-- Gen Operations I LLC 1759570526 185\n-- Genesis Healthcare LLC 6305035171 184\n-- Genesis Healthcare Inc 7810077864 183\n-- Providence Group NH, LLC 5294198396 178\n-- Sun Healthcare Group Inc 6507774304 177\n\n-- ============================================================================\n-- (6) Ownership is layered, not flat. How many DISTINCT organizational owners\n-- each facility discloses across direct + indirect + operational layers.\n-- ============================================================================\nWITH oo AS (\n SELECT enrollment_id, count(DISTINCT associate_id_owner) AS n_org_owners\n FROM public.snf_all_owners\n WHERE type_owner = 'O' AND role_code_owner IN ('34','35','85','86','43','38','39')\n GROUP BY enrollment_id\n)\nSELECT\n count(*) AS facilities_with_org_owner,\n round(avg(n_org_owners), 1) AS mean_org_owners,\n percentile_cont(0.5) WITHIN GROUP (ORDER BY n_org_owners) AS median_org_owners,\n max(n_org_owners) AS max_org_owners\nFROM oo;\n-- facilities_with_org_owner 12,193 · mean_org_owners 3.8 · median_org_owners 2\n-- max_org_owners 99\n\n-- ============================================================================\n-- (7) The independent minority, characterized. Of the 2,232 SNFs with NO\n-- organizational owner disclosed, what roles ARE disclosed? They are owned\n-- and run by individuals — confirming these are genuinely independent, not\n-- a data gap.\n-- ============================================================================\nWITH has_org AS (\n SELECT DISTINCT enrollment_id FROM public.snf_all_owners\n WHERE type_owner = 'O' AND role_code_owner IN ('34','35','85','86','43','38','39')\n)\nSELECT o.type_owner, o.role_text_owner,\n count(DISTINCT o.enrollment_id) AS facilities\nFROM public.snf_all_owners o\nWHERE o.enrollment_id NOT IN (SELECT enrollment_id FROM has_org)\nGROUP BY o.type_owner, o.role_text_owner\nORDER BY facilities DESC\nLIMIT 6;\n-- I · OPERATIONAL/MANAGERIAL CONTROL 1,464\n-- I · CORPORATE OFFICER 1,371\n-- I · 5% OR GREATER DIRECT OWNERSHIP INTEREST 1,289\n-- I · CORPORATE DIRECTOR 1,110\n-- I · W-2 MANAGING EMPLOYEE 1,052\n-- I · ADP OF THE SNF 1,018", "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)", "generated_by": "Fonteum — https://fonteum.com", "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included." }