When you walk through the front door of a nursing home to visit your father or tour it for your mother, you're looking at a building, a staff, a name on the wall. What you can't see is who actually owns what you're looking at — and in an industry where ownership structure is one of the strongest predictors of whether your loved one will receive good care, that invisibility has real consequences.
The honest answer to "who owns this nursing home" is often: more entities than you'd expect, none of whom have their name on the door, and most of whom collect a fee before a single dollar reaches the person providing care.
The simple picture most people have
Most families assume a nursing home is owned by the organization that operates it — a healthcare company, a hospital system, a religious nonprofit, or an individual owner. That simple picture describes roughly 27% of U.S. skilled nursing facilities: the nonprofits and government-operated facilities where ownership and mission are largely aligned.
For the other 73% — the for-profit majority — the reality is considerably more layered.
What for-profit ownership actually looks like
A for-profit nursing home might be owned by a regional operator running a handful of facilities. In those cases, the ownership structure is still relatively straightforward, even if profit motives shape decisions about staffing and investment.
But a significant and growing share of the industry — estimates range from 5% to 13% of all facilities, depending on methodology — is owned, in whole or in part, by private equity firms. And when PE enters the picture, the ownership structure transforms into something most families would find genuinely surprising.
Here's what the typical structure looks like:
A private equity firm acquires a nursing home or chain. Almost immediately, it executes a sale-leaseback: it sells the physical building to a real estate investment trust (REIT), pockets the cash, and leases the building back to the operating company at rates that almost always exceed what the facility would pay on the open market. Annual rent escalators of 2–4% are written into the lease — meaning rent goes up every year whether the facility improves or not.
The operating company is then managed by a management company — often owned by the same PE firm, or a related entity — that charges a management fee of 5–7% of revenue. Not of profit. Of revenue. Regardless of clinical quality, staffing levels, or inspection results.
That same ownership group may also own the staffing agency that supplies the certified nursing assistants. So the fee structure is self-reinforcing: the facility pays a markup on every agency worker it hires, and that markup flows back to a related entity.
By the time Medicare and Medicaid reimbursements arrive and work their way through these layers, the money available for actual care — nurses, aides, food, medication, therapy — is what remains after the rent, the management fee, the staffing markup, and the debt service on the heavily leveraged acquisition.
Researchers at UCLA and Lehigh University who studied this structure found that 63–68% of actual nursing home profits are through these related-party transactions — and that the unreported profit flowing through these structures would be sufficient to fund a 29% increase in registered nurse staffing across every facility in America.
Why PE ownership specifically produces worse outcomes
The research on this question is among the most consistent in health services literature.
A landmark 2024 study published in The Review of Financial Studies analyzed more than 7 million Medicare patients across 18,000+ facilities over 15 years. The findings were stark: private equity ownership was associated with a 10–11% increase in short-term mortality, translating to approximately 20,150 additional deaths over the study period. At the same time, Medicare spending per patient increased 11–19%.
The mechanism is not mysterious. After PE acquisition, the study found certified nursing assistant hours decreased 3%, overall staffing declined, and antipsychotic drug use increased approximately 50% — antipsychotics being a well-documented chemical restraint used in understaffed facilities to manage residents who would otherwise require more direct care. Management fee payments to related entities rose over 300%.
A separate study found PE-owned facilities were 10–17 percentage points less likely to have adequate PPE during COVID-19. When the pandemic hit, the financial engineering that had extracted value from these facilities for years left them structurally unprepared for a crisis requiring exactly the investment they hadn't made.
None of this means every PE-owned facility delivers poor care. But the pattern is consistent enough, and the mechanism clear enough, that ownership structure is one of the first things worth understanding when evaluating a facility.
The challenge: this information is genuinely hard to find
Here's what makes this particularly difficult for families: the ownership data that CMS publishes is incomplete by design.
CMS requires nursing homes to disclose ownership, but the disclosure rules have historically allowed the layers described above to remain invisible. A GAO analysis found that fewer than 100 nursing homes in the entire country self-report PE ownership in CMS data — a figure that represents roughly 1% of the estimated PE-owned facilities actually operating. The reason is structural: the entity that holds the Medicare provider number is typically the operating company, not the PE firm or REIT that controls it. Unless you trace the ownership chain through multiple LLCs, you often cannot tell from CMS data alone who actually owns a facility.
CMS began requiring more detailed ownership disclosure in 2024, but even under improved rules, researchers publishing in Health Affairs found "major gaps and discrepancies" between disclosed ownership and what can be identified through independent financial database analysis.
This opacity is not accidental. A financial structure designed to separate beneficial ownership from legal accountability produces exactly this result.
What to look for — and what NursingHomeIQ surfaces
You shouldn't need a financial forensics background to make a good decision about where a family member receives care. There are signals that are accessible and meaningful:
Chain affiliation is the first indicator. Facilities affiliated with large national chains — especially publicly traded ones — operate under corporate cost targets that frequently conflict with care quality. The 10 largest for-profit chains have been documented to employ fewer RNs and receive significantly more deficiency citations than nonprofit facilities. A facility's chain affiliation is visible in CMS data and surfaced in NursingHomeIQ profiles.
Recent ownership changes are a red flag worth understanding. Research shows that quality metrics — staffing levels, inspection outcomes, star ratings — deteriorate measurably in the two years following an ownership transition, particularly when the acquiring entity is for-profit and the acquired facility was nonprofit. When a facility changes hands, the new owner's financial priorities become the facility's operational priorities.
Related-party transaction flags are harder to surface but meaningful. When a facility's Medicare cost reports show significant payments to related management or real estate entities, it's a signal that a portion of the revenue stream is being extracted rather than reinvested.
Nonprofit and government status remains the most reliable structural predictor of better-than-average care. Nonprofits are 41% likely to meet minimum federal staffing thresholds compared to 11% for for-profit facilities. They receive fewer deficiency citations, employ more registered nurses per resident, and consistently outperform for-profits on virtually every measured clinical outcome. Religious, community, and mission-driven operators represent the strongest concentration of high-quality care in the industry.
The question you can actually ask
When you tour a facility, you're unlikely to get a useful answer if you ask "are you owned by private equity?" The person giving the tour probably doesn't know, or won't say. What you can ask — and what will tell you something — is: "Can you show me your staffing levels, including registered nurse hours per resident per day? And have there been any ownership changes in the last three years?"
RN staffing hours per resident day is the single variable most consistently associated with care quality across decades of research. If a facility's answer is confident and specific, that's a good sign. If it's vague, evasive, or the numbers are low, the ownership structure — however complex — is producing predictable results.
The nursing home industry has spent considerable energy making its financial architecture invisible to the people who most need to understand it. The gap between the name on the door and who actually owns the building, the operating company, the management contract, and the staffing agency is not just a business curiosity. It is the explanation for why 20,000 people die unnecessarily in PE-owned facilities every decade, while the entities that caused those deaths report returns of 20% or more.
Understanding who owns a nursing home doesn't guarantee you'll find a good one. But it's the right place to start.
NursingHomeIQ surfaces ownership type, chain affiliation, and recent ownership change history for every certified nursing facility in the United States. Use our facility profiles to start your search.