Nursing Home Change of Ownership: Every Medicare CHOW Since 2016, by Year and State (2026)

This month in brief

• Stitched across 19 CMS releases, 6,587 Medicare nursing home CHOWs took effect from January 2016 to May 2026.
• Yearly CHOWs rose from 336 (2016) to 950 (2023) and eased to 772 in 2024; 2025 (511 so far) is preliminary.
• The current CMS file keeps only each facility's latest sale, so it shows 30.0% fewer 2016 to 2021 CHOWs than the full release history.
• 37.1% of active Medicare SNFs are run by an owner that arrived through a CHOW since 2016; in Texas the share is 59.4%.
• Texas leads in volume (889); per 100 SNFs, Wyoming, Texas and Montana lead and Maine and North Dakota trail.
• 56.7% of CHOWs came in same-day groups under a shared 5%+ owner, so the number of deals is far below the number of facility filings.
• At least 15.8% of facilities that sold since 2016 have sold again; the median gap was 3.8 years.

Nursing home change of ownership by year: 950 facilities changed hands in 2023, the peak

Medicare-certified nursing homes changed owners 6,540 times from 2016 through 2025, about 669.9 a year from 2016 to 2024. Activity nearly tripled from 2016 to 2023 and eased in 2024.

The stitched CMS series counts 336 CHOWs effective in 2016, 782 in 2019, 763 in 2021 and 950 in 2023, a rise of 182.7% from 2016 to 2023 (CMS SNF CHOW file, extract 2026-09-29 and earlier releases listed in the data.cms.gov catalog).

2024 shows 772 CHOWs, 18.7% below 2023. That figure is near final but not closed: 218 of the 2024 CHOWs first appeared in releases extracted in 2026.

Relative to today's 14,404 Medicare-enrolled skilled nursing facilities, 2023's CHOWs equal 6.6% of the stock and 2024's equal 5.4% (CMS SNF Enrollments, extract 2026-09-29). ASPE, using the April 2022 file, put the average at about 3.5% a year for 2016 to 2021, with a 2019 high of 779 of 15,535 SNFs (ASPE research brief, June 2022).

2025 stands at 511 so far and 2026 at 47, with the latest effective date in the file on 2026-05-08. Both are preliminary. If 2025 fills in at the pace seen for 2022 to 2024, it would end between 560 and 712 CHOWs, a projection rather than a count.

CHOW (change of ownership): Under 42 CFR 489.18, a change of ownership is the removal, addition or substitution of a partner (unless the partners agree otherwise as state law permits), the transfer of title and property of a sole proprietorship, the merger or consolidation of a provider corporation into a new corporation, or the lease of all or part of the facility. A transfer of corporate stock is not a CHOW.

The current CMS file drops a sale once the same home sells again

Every buyer enrollment in the latest CHOW file is the facility's active enrollment, so each facility shows only its most recent CHOW. Earlier sales vanish from later releases. Read on its own, the current file undercounts 2016 to 2021 by 30.0%.

All 5,340 buyer enrollment IDs in the latest release match an active record in the SNF Enrollments file, while only 2 seller enrollment IDs do. The file lists 5,338 distinct facilities in 5,340 rows.

This is by design. CMS's data guidance (version 1.3, July 2026) says the files cover changes of ownership for currently approved SNF enrollments and contain no historical enrollment information. The effect on counts is not published, so we measured it.

We downloaded all 19 releases posted since 2022 (83,127 rows in total) and kept each distinct sale once. The result is 6,587 CHOWs, of which 1,247 no longer appear in the current file: 941 because the same facility sold again later, 196 because the facility is no longer an enrolled SNF, and 110 for reasons the files do not show.

For 2016 to 2021, the current file shows 2,442 CHOWs, the first release of 2022-03-31 showed 3,255, and the stitched series shows 3,489. The first-release total matches ASPE's published count of 3,254 within 1 (ASPE, June 2022).

Recent years fill in slowly: 71.8% of 2024 sales were public nine months later

A CHOW typically reaches the public file 275 days after its effective date. That delay is why 2025 looks low and why any count of the latest year needs a preliminary label.

For CHOWs effective from April 2022 to September 2024, the median gap between the effective date and the first release that listed the sale was 275 days; the middle half fell between 199 and 397 days (n = 2,156). Only 19.3% appeared within six months, and 31.7% took more than a year.

By the release about nine months after year end, 87.8% of 2022 CHOWs and 91.3% of 2023 CHOWs were public, but only 71.8% of 2024 CHOWs (554 of the 772 known today).

The gap measures CMS processing plus quarterly publishing, not how long a sale takes to negotiate or close. Under 42 CFR 424.550(b), both the current and the prospective owner must file enrollment applications before the CHOW is completed.

Texas leads in volume and ranks second per facility, behind Wyoming

Across the 50 states and DC, CHOWs since 2016 equal 45.8 per 100 of today's Medicare SNFs. 18 states are above 50 per 100 and 4 are below 20.

Texas recorded 889 CHOWs against 1,160 enrolled SNFs, or 76.6 per 100, and 59.4% of Texas SNFs are run by an owner that arrived through a CHOW since 2016. California follows with 470, then Ohio (400), Illinois (384) and Pennsylvania (362).

Per facility, Wyoming ranks first (84.8 per 100, 28 CHOWs on 33 SNFs), followed by Texas (76.6), Montana (73.3), Maryland (65.3), Oregon (63.0) and Virginia (62.4). Small states move a lot on a few sales. Maine (7.6), North Dakota (8.3), New York (16.5) and Hawaii (18.6) turn over slowest.

In Texas, 177 of the 889 CHOWs (19.9%) were at nursing homes that Care Compare now lists under the ownership type Government – Hospital district; Texas has 229 such homes (Care Compare Provider Information, October 2026). The data does not say why these transfers happened.

More than half of CHOWs arrive in same-day groups under a shared owner

3,030 of the 5,340 CHOWs in the current file (56.7%) share an effective date and a 5%+ owner with at least one other CHOW. The 5,340 facility records collapse into 3,081 groups.

CMS lists one row per facility, so a single portfolio deal shows up as many rows. Linking buyer enrollments through owners with 5% or greater direct or indirect interest in the CHOW Owner Information file gives 771 multi-facility groups. 675 CHOWs (12.6%) came in groups of ten or more, and the largest single-day group covered 36 facilities.

Timing is concentrated too: 71.6% of CHOWs in the current file took effect on the first day of a month, and 352 took effect on January 1.

The grouping is a proxy built for this report. It can join two separate purchases by the same owner on the same day, and it treats the 585 buyer enrollments with no 5%+ owner listed as single-facility sales.

About one in seven homes that sold since 2016 has sold again

890 of the 5,644 facilities with any CHOW in the stitched files (15.8%) changed owners at least twice. Because pre-2022 resales are invisible, this is a floor.

837 facilities show two CHOWs and 53 show three. Where a facility sold more than once, the median time between sales was 3.8 years, and 18.5% of resales came within two years of the previous CHOW (n = 943).

A cleaner cohort: of the 813 facilities with a CHOW in 2022, a period fully covered by the public releases, 76 (9.3%) had changed owners again by May 2026.

For-profit operators run 91.6% of the homes that changed owners

5,409 of the 14,686 nursing homes in Care Compare (36.8%) have a CHOW on record since 2016. The current operator of 91.6% of them is for-profit, against 74.1% of all nursing homes.

Among for-profit nursing homes, 45.5% have a CHOW since 2016, compared with 20.1% of government homes and 9.2% of nonprofit homes. ASPE found the same ordering for 2016 to 2021, with yearly CHOW rates of 4.3% for for-profit, 1.6% for nonprofit and 1.1% for government SNFs (ASPE research brief, June 2024).

On enrollment forms, 23.7% of buyer enrollments with an organizational owner list an owner created solely to acquire the facility, against 16.9% of seller enrollments. 30.8% of buyers list a holding company, against 12.4% of sellers. Only 1.0% of buyers tick the investment firm box. These are self-reported flags.

Facilities that changed owners are slightly larger: a median of 107 certified beds, against 97 for homes with no CHOW on record.

What happens to the Medicare provider agreement when a nursing home is sold

Federal rules assign the existing Medicare provider agreement to the new owner automatically, with its open obligations. Since January 16, 2024, SNF buyers must also disclose a wider circle of owners and managers at the CHOW.

42 CFR 489.18(c) assigns the existing provider agreement to the new owner automatically. Under 489.18(d), the assigned agreement carries any existing plan of correction and the duty to meet health and safety standards and ownership disclosure rules. A provider contemplating a CHOW must notify CMS (489.18(b)). CMS's CHOW data guidance adds that the transfer includes any outstanding Medicare debt of the old owner, and that a buyer who declines the assignment is treated as a new applicant.

42 CFR 424.550 bars a provider from selling its Medicare billing number or billing privileges. Both owners must file enrollment applications before the CHOW completes, and CMS may deactivate billing if the new owner has not filed within 30 days. The rule under which the provider agreement does not pass to a buyer within 36 months of initial enrollment or the last majority-ownership change applies to home health agencies and hospices, not to SNFs.

The final rule at 88 FR 80141, published 2023-11-17 and effective 2024-01-16, added 42 CFR 424.516(g): at initial enrollment, which includes a CHOW, and at revalidation, an SNF must disclose its governing body, officers, directors, managing employees and every additional disclosable party with its organizational structure. The rule also defined private equity company and real estate investment trust in 42 CFR 424.502.

For sellers weighing a sale of any business, the site's overview of the six stages of a sale covers the steps that precede a closing; this report covers only what CMS records.

Momentum and share analysis

Download the calculations (CSV)

Findings to track

1. CMS published 6,587 distinct Medicare SNF change-of-ownership filings effective 2016-01-01 to 2026-05-08 across 19 quarterly releases (US, stitched by SMBB).^[1][9]
2. US nursing home CHOWs peaked at 950 in 2023, up 182.7% from 336 in 2016.^[1][9]
3. US nursing home CHOWs fell to 772 in 2024, 18.7% below 2023, with late 2024 filings still arriving in 2026.^[1][9]
4. The current CMS CHOW file (extract 2026-09-29) shows 2,442 CHOWs for 2016 to 2021, 30.0% fewer than the 3,489 found across all releases.^[1][10][9]
5. 37.1% of the 14,395 active Medicare SNFs in the 50 states and DC (September 2026) are run by an owner that took over through a CHOW since 2016.^[1][5]
6. Texas had 889 nursing home CHOWs from 2016 to May 2026, the most of any state, equal to 76.6 per 100 of its 1,160 SNFs.^[1][5]
7. Maine (7.6) and North Dakota (8.3) had the fewest CHOWs per 100 SNFs from 2016 to May 2026.^[1][5]
8. 56.7% of CHOWs in the 2026-09-29 file came in same-day groups sharing a 5%+ owner; 12.6% came in groups of ten or more facilities.^[1][3]
9. 15.8% of US facilities with a CHOW since 2016 changed owners at least twice by May 2026 (a lower bound).^[1][9]
10. A CHOW effective between April 2022 and September 2024 took a median 275 days to appear in a public CMS release.^[1][9]
11. 5,338 of 5,340 CHOWs in the current file are typed Change of Ownership; 2 are Acquisition/Merger and none are Consolidation.^[1][2]
12. For-profit operators run 91.6% of US nursing homes with a CHOW since 2016, against 74.1% of all nursing homes (Care Compare, October 2026).^[7][1]
13. 71.6% of CHOWs in the current file took effect on the first day of a month.^[1]

Frequently asked questions

Related guides, services and research

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• Liquor License Transfer Rules by State: Can a Bar or Restaurant License Be Sold? (2026)
• Mini WARN Act by State: 16 Layoff Notice Laws Compared With Federal WARN (2026)
• Non Compete Sale of Business Rules: 51-Jurisdiction Statute Registry (2026)
• Pharmacy Change of Ownership Rules by State: Permits, Notice Periods and Share-Sale Triggers (2026)
• All business sale research

Reproduce this analysis

Every figure comes from the files below. The scripts that pulled and computed them are kept with the report and can be re-run.

Data quality and exclusions

• Stacked 83,127 rows from 19 releases; collapsed to 6,595 distinct CCN/buyer/seller triples and then to 6,587 CHOWs after merging 8 triples that shared a CCN and effective date (re-entered buyer enrollments or a revised seller enrollment).
• 15 triples had their effective date revised between releases; the date from the latest release was kept, and 0 pairs of remaining CHOWs at the same facility fall within 90 days of each other.
• Two current-file rows share a buyer enrollment ID with different sellers and dates; both were kept as separate CHOWs.
• The CHOW CSV files contain a non-UTF-8 byte; all files were read as Latin-1, with 0 rows lost.
• Facility state: 6,390 CHOWs placed by Care Compare, 10 by SNF Enrollments and 187 by the CCN state prefix; buyer enrollment state was not used because it differs from the facility's state in 33 matched rows.
• 8 rows whose seller enrolled as a provider type other than SNF were kept, because the buyer and the CCN are SNFs.
• Same-day grouping: 585 buyer enrollments with no owner of role 34 or 35 were treated as single-facility CHOWs.
• 9 SNF enrollments in US territories were excluded from state denominators (14,404 to 14,395).

Methodology

Selection: we used only federal primary data for counts: every CMS Skilled Nursing Facility Change of Ownership release listed in the data.cms.gov catalog (19 files, 2022-03-31 to the release extracted 2026-09-29), the CHOW Owner Information file and SNF Enrollments file of 2026-09-29, and the Care Compare Provider Information file of October 2026. Rules come from eCFR and the Federal Register. ASPE briefs and press coverage are used for comparison only.

Inclusion: a CHOW is one row in a CMS release, keyed by facility CCN, buyer enrollment ID and seller enrollment ID, with the effective date from the latest release that lists it. Rows with the same CCN and effective date are merged. Counts are by effective date, never by enrollment date. Both CHOW types present in the files (CH and AM) are kept.

Conflicts: when CMS revised an effective date between releases, the latest value wins. Our first-release count for 2016 to 2021 matches ASPE's published 3,254 within one, which we treat as confirmation that the stitching starts from the same base.

Derived metrics: every formula, input row and result is in derived_metrics.csv and was computed by scripts/05_build_events.py and scripts/06_metrics.py from the files saved in raw/. State rates use 2026 enrollment counts as the denominator for the whole period.

Limitations are listed below under what this data does not show. Owners who want help finding a broker can use the separate broker match form; nothing in this report depends on it.

Last updated 2026-10-31. We plan to refresh the tracker after each quarterly CMS release.

This report presents published data with its limitations. It is not legal, financial or investment advice.

Sources, ranked by quality

Tier 1: primary and official sources (20)

• [1] Centers for Medicare & Medicaid Services (CMS). Skilled Nursing Facility Change of Ownership, release 2026-09-01 (file SNF_CHOW_2026.09.29.csv). CHOWs effective 2016-01-01 to 2026-05-08; posted 2026-10-19. Accessed 2026-10-31.
• [2] CMS. Skilled Nursing Facility Change of Ownership Data Dictionary. 2026. Accessed 2026-10-31.
• [3] CMS. Skilled Nursing Facility Change of Ownership: Owner Information, release 2026-09-01 (file SNF_CHOW_Owners_2026.09.29.csv). Owners of buyer and seller enrollments, extract 2026-09-29. Accessed 2026-10-31.
• [4] CMS. Skilled Nursing Facility Change of Ownership: Owner Information Data Dictionary. 2026. Accessed 2026-10-31.
• [5] CMS. Skilled Nursing Facility Enrollments, release 2026-10-01 (file SNF_Enrollments_2026.09.29.csv). Active Medicare SNF enrollments, extract 2026-09-29. Accessed 2026-10-31.
• [6] CMS. Skilled Nursing Facility Enrollments Data Dictionary. 2026. Accessed 2026-10-31.
• [7] CMS (Care Compare provider data). Nursing homes including rehab services: Provider Information, October 2026 (NH_ProviderInfo_Oct2026.csv). Released 2026-10-28; next update 2026-12-02. Accessed 2026-10-31.
• [8] CMS. Nursing Home Data Dictionary (Care Compare provider data). 2026. Accessed 2026-10-31.
• [9] CMS. data.cms.gov catalog (data.json): release history of the SNF CHOW and SNF All Owners datasets. 19 CHOW releases, 2022-05-04 to 2026-10-19. Accessed 2026-10-31.
• [10] CMS. Skilled Nursing Facility Change of Ownership, first public release 2022-03-31 (SNF_CHOW_2022Q1.csv). CHOWs effective 2016-01-01 to early 2022. Accessed 2026-10-31.
• [11] Office of the Federal Register / GPO. 42 CFR 489.18 Change of ownership or leasing: Effect on provider agreement (eCFR, current to 2026-10-29). Current text. Accessed 2026-10-31.
• [12] Office of the Federal Register / GPO. 42 CFR 424.550 Prohibitions on the sale or transfer of billing privileges (eCFR). Current text. Accessed 2026-10-31.
• [13] Office of the Federal Register / GPO. 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status (eCFR). Current text. Accessed 2026-10-31.
• [14] Office of the Federal Register / GPO. 42 CFR 424.502 Definitions (eCFR). Current text. Accessed 2026-10-31.
• [15] Federal Register. Disclosures of Ownership and Additional Disclosable Parties Information for Skilled Nursing Facilities and Nursing Facilities (final rule, 88 FR 80141). Published 2023-11-17; effective 2024-01-16. Accessed 2026-10-31.
• [16] CMS Newsroom. HHS Releases New Data and Report on Hospital and Nursing Home Ownership (press release, 2022-04-20). 2022-04-20. Accessed 2026-10-31.
• [17] CMS Newsroom. Biden-Harris Administration Makes More Medicare Nursing Home Ownership Data Publicly Available (press release, 2022-09-26). 2022-09-26. Accessed 2026-10-31.
• [18] HHS ASPE. Changes in Ownership of Skilled Nursing Facilities from 2016 to 2021: Variations by Geographic Location and Quality (research brief, June 2022). 2016 to 2021, CHOW data of 2022-04-02. Accessed 2026-10-31.
• [19] HHS ASPE. Changes in Ownership Among Skilled Nursing Facilities from 2016 to 2021: Variations by Size, Occupancy Rate, Penalty Amount, and Type of Ownership (research brief, June 2024). 2016 to 2021. Accessed 2026-10-31.
• [20] CMS Center for Program Integrity. Provider Enrollment: Skilled Nursing Facility (SNF) Change of Ownership: Data Guidance, Version 1.3. July 2026. Accessed 2026-10-31.

Tier 3: journalism and expert commentary (3)

• [21] Skilled Nursing News. [UPDATED] CMS Sets its Sights on Nursing Home Ownership Turnover in Unveiling New Database. April 2022. Accessed 2026-10-31.
• [22] Crowell & Moring LLP. Changing Hands, Not Washing Them: CMS' First Report on Nursing Home M&A Data. 2022-05-10. Accessed 2026-10-31.
• [23] Arnall Golden Gregory LLP. CMS Releases Skilled Nursing CHOW (and Ownership) Data. 2022-04-27. Accessed 2026-10-31.