Key Findings
- •76.2% of nursing homes are chain-owned (11,223 facilities), while 23.8% are independent (3,528 facilities)
- •Independent facilities earn 5 stars 29% more often (23.9% vs 18.5%)
- •Chain quality varies dramatically—from 36% 5-star (Ensign Group) to 0% 5-star (Cambridge Healthcare)
- •Chain facilities have 26% higher abuse violation rates (9.6% vs 7.6%)
- •Independent facilities have 5% more RN staffing and 9% lower turnover rates
The Consolidation of American Nursing Homes
Three out of four nursing homes in America are owned by corporate chains. This wasn't always the case. Over the past two decades, private equity firms and large healthcare corporations have systematically purchased independent facilities, consolidating what was once a largely local industry into a corporate-dominated market.
Does this matter for quality? The short answer: yes. Our analysis of all 14,751 Medicare-certified nursing homes reveals that independent facilities consistently outperform chain-owned facilities across nearly every quality metric—but not all chains are created equal.
Some chains, like The Ensign Group, deliver exceptional care with 36% of their facilities earning 5 stars. Others, like Cambridge Healthcare Services, have zero 5-star facilities and abuse violations at nearly one-third of their locations. The chain name on the door matters more than most families realize.
The Numbers: Chain-Owned vs Independent Performance
Quality Ratings
| Metric | Independent | Chain-Owned | Difference |
|---|---|---|---|
| Total Facilities | 3,528 | 11,223 | — |
| Average Overall Rating | 3.17 stars | 3.04 stars | +4% better |
| 5-Star Facilities | 23.9% | 18.5% | +29% more |
| 1-Star Facilities | 15.1% | 15.0% | Similar |
That 0.13-star difference might seem small, but here's what it means: if you're choosing between an independent facility and a chain facility with the same posted rating, the independent one is statistically more likely to have stronger underlying performance. Independent facilities are 29% more likely to earn the coveted 5-star rating.
Staffing Levels
| Staffing Metric | Independent | Chain-Owned | Difference |
|---|---|---|---|
| RN Hours per Resident/Day | 0.67 | 0.64 | +5% more |
| Total Nursing Hours/Day | 3.99 | 3.70 | +8% more |
| Nurse Turnover Rate | 43.6% | 47.7% | 9% lower |
| Average Facility Size | 101 beds | 106 beds | 5% larger |
Why Staffing Matters More Than Ratings
Staffing levels are the single best predictor of care quality. Independent facilities maintain higher RN staffing levels (0.67 vs 0.64 hours/day) and experience lower nurse turnover. Lower turnover means continuity of care—nurses who know your parent's needs, preferences, and medical history.
Safety and Compliance
| Safety Metric | Independent | Chain-Owned | Difference |
|---|---|---|---|
| Abuse Violations | 7.6% | 9.6% | 26% higher |
| Special Focus Facilities | 5.0% | 2.4% | 52% lower |
Chain facilities have a 26% higher rate of abuse violations (9.6% vs 7.6%). This is concerning. However, chains have fewer facilities under CMS's Special Focus Facility program—likely because chains have resources to address problems before they escalate to that level of scrutiny.
The abuse violation difference tells a more troubling story: corporate pressure to minimize staffing costs can create environments where neglect becomes more likely.
The Top 20 Nursing Home Chains: Performance Breakdown
Not all chains are created equal. Some deliver care rivaling the best independent facilities. Others consistently underperform across their entire portfolio. Here are the 20 largest nursing home chains, ranked by number of facilities.
Key Insight: Quality Varies Wildly
The best chain (Ensign Group) has a 36.2% 5-star rate. The worst chains have 0% 5-star facilities. Chain name matters more than you might think. Don't judge all chains by the same standard—research the specific operator.
Best Chain Performers
1. The Ensign Group
Best OverallOperating 69 facilities across 2 states, Ensign Group achieves the highest 5-star rate of any major chain—nearly double the chain average. Only 4.3% of their facilities are 1-star rated.
2. Crowne Health Care
Top PerformerSmaller regional chain with zero 1-star facilities. RN staffing at 0.62 hours/day and turnover at just 33.3% (well below the chain average of 47.7%).
3. Covenant Care
Another smaller regional operator with strong performance. Zero 1-star facilities and 30% 5-star rate puts them in the top tier.
Chains to Approach With Caution
Cambridge Healthcare Services
Major ConcernsZero 5-star facilities, 31.8% 1-star rate, and abuse violations at nearly one-third of locations. This pattern of poor performance across their entire portfolio is a serious red flag.
Genesis Healthcare
Below AverageDespite having RN staffing at 0.74 hours/day (above average), Genesis has 38.9% of facilities rated 1-star. Turnover at 49.3% and abuse violations at 27.8% suggest systemic quality issues.
Haven Health
Abuse violations at 30% of facilities is unacceptable. Only 10% achieve 5 stars, with 15% rated 1-star.
Complete Top 20 Chain Rankings
| Rank | Chain Name | Facilities | Avg Rating | 5-Star % | Abuse % |
|---|---|---|---|---|---|
| 1 | The Ensign Group | 69 | 3.86 | 36.2% | 7.2% |
| 2 | PACS Group | 56 | 3.24 | 19.6% | 16.1% |
| 3 | NHS Management | 36 | 2.53 | 5.6% | 2.8% |
| 4 | Central Arkansas Nursing Centers | 36 | 3.20 | 19.4% | 2.8% |
| 5 | Southern Administrative Services | 34 | 3.00 | 14.7% | 5.9% |
| 6 | Anthony & Bryan Adams | 33 | 3.48 | 24.2% | 3.0% |
| 7 | The Springs Arkansas | 24 | 3.08 | 16.7% | 0.0% |
| 8 | Cambridge Healthcare Services | 22 | 2.19 | 0.0% | 31.8% |
| 9 | Haven Health | 20 | 2.75 | 10.0% | 30.0% |
| 10 | Diversicare Healthcare | 18 | 2.94 | 11.1% | 0.0% |
| 11 | Genesis Healthcare | 18 | 2.17 | 11.1% | 27.8% |
| 12 | Crowne Health Care | 17 | 3.88 | 35.3% | 5.9% |
| 13 | The Blossoms Nursing and Rehab | 15 | 2.60 | 13.3% | 6.7% |
| 14 | Brius Management | 13 | 2.69 | 7.7% | 7.7% |
| 15 | Venza Care Management | 11 | 2.73 | 18.2% | 0.0% |
| 16 | Longwood Management Corporation | 11 | 2.36 | 9.1% | 9.1% |
| 17 | Life Care Centers of America | 10 | 2.70 | 10.0% | 30.0% |
| 18 | Thomas Chambers & David Johnson | 10 | 2.90 | 10.0% | 20.0% |
| 19 | Links Healthcare Group | 10 | 3.20 | 20.0% | 0.0% |
| 20 | Covenant Care | 10 | 3.60 | 30.0% | 10.0% |
Why The Difference? What Drives Chain Performance
The Scale Advantage (Potential)
In theory, large chains should outperform independent facilities. They have advantages independents can't match:
- Standardized training programs: Corporate universities, consistent protocols
- Centralized quality control: Data analytics, performance monitoring
- Bulk purchasing power: Better pricing on supplies, medications
- Technology investments: Electronic health records, predictive analytics
- Career advancement: Nurses can transfer between facilities, move up to corporate roles
The best chains—Ensign Group, Crowne Health Care—leverage these advantages effectively. But many don't.
The Profit Motive Problem (Reality for Many)
Here's where it breaks down. Many chains, especially those owned by private equity firms, face pressure to maximize margins. That means:
- Staffing treated as a variable expense: Cut hours when occupancy drops
- Corporate overhead costs: Layers of management between residents and decision-makers
- Standardization without flexibility: Rigid policies that don't adapt to local needs
- Focus on financial metrics over quality: Quarterly earnings calls trump quality improvement
The Private Equity Effect
Several of the worst-performing chains have recent private equity ownership. The business model—acquire facilities, cut costs, maximize cash flow, sell in 5-7 years—fundamentally conflicts with long-term quality care. Genesis Healthcare, Cambridge Healthcare, and NHS Management all show signs of this pattern.
Local Management Matters
The best chains give significant autonomy to facility administrators. The worst micromanage from corporate headquarters.
Our data reveals a pattern: regional chains outperform national chains. The Ensign Group (2 states), Crowne Health Care (1 state), and Covenant Care (1 state) all achieve exceptional results. Meanwhile, national operators like Genesis and Cambridge struggle.
Why? Regional operators understand local labor markets, build relationships with local hospitals, and adapt to community needs. National chains apply one-size-fits-all policies.
Red Flags: How to Spot Problematic Chains
Before choosing any chain facility, research the parent company's entire portfolio. These warning signs indicate systemic problems:
Portfolio Red Flags
- •No 5-star facilities across entire chain
- •Abuse violation rate >20% of facilities
- •Average rating below 2.5 stars
- •Multiple special focus facilities
Corporate Structure Red Flags
- •Recent private equity acquisition
- •Rapid expansion (doubled facilities in <3 years)
- •High executive turnover
- •Bankruptcy or financial distress
Chains With Major Concerns
Based on our data, approach these chains with extreme caution:
- •Cambridge Healthcare Services: 0% 5-star, 31.8% abuse violations, 31.8% 1-star
- •Haven Health: 30% abuse violations, 15% 1-star
- •Life Care Centers of America: 30% abuse violations, 0% 1-star but concerning safety record
- •Genesis Healthcare: 38.9% 1-star, 27.8% abuse violations
How to Use This Information When Choosing
DO
- •Check if facility is chain-owned (visible on CMS.gov and our facility pages)
- •Research the parent chain's overall performance using the table above
- •Look at ALL facilities in the chain, not just the one you're considering
- •Ask about local autonomy: "Does corporate dictate staffing levels, or does the administrator decide?"
- •Check recent inspection reports for all chain facilities in your state
DON'T
- •Assume all chains are bad (Ensign Group, Crowne Health Care excel)
- •Assume all independent facilities are good (some have serious problems)
- •Focus only on one facility without checking the chain's track record
- •Ignore patterns across the chain's portfolio
- •Trust marketing materials without verifying data on CMS.gov
The Bottom Line
Chain ownership isn't inherently good or bad—but it's a critical factor to investigate. Use our facility search to filter by chain ownership and compare multiple facilities from the same chain side-by-side. Patterns emerge quickly.
The Exception: When Chains Can Be Better
Despite the overall independent advantage, there are specific scenarios where chain facilities might be the better choice:
Specialized Rehabilitation
Large chains often have dedicated rehab programs with specialized equipment and therapists. If your parent needs short-term rehab after surgery or illness, a chain facility with a strong rehab focus might offer better outcomes.
Look for chains with dedicated rehab wings and high Medicare Part A census.
Technology & Records
Chains typically have better electronic health records, family portals, and communication systems. If you live far away, being able to check on your parent through a chain's family app can provide peace of mind.
Ask about family portals, electronic records access, and telehealth capabilities.
Transfers Between Facilities
If your parent might need to relocate (closer to family, different climate), some chains make transfers within their network easier. Medical records, care plans, and preferences transfer seamlessly.
Relevant if you anticipate needing to move your parent in the future.
Capital Improvements
Well-capitalized chains can afford major renovations, new HVAC systems, modern safety features. Independent facilities sometimes struggle with capital-intensive improvements.
Check facility age and recent renovation history.
These advantages matter—but they don't outweigh poor staffing or safety violations. A chain facility with great technology but 50% nurse turnover and abuse violations is still the wrong choice.
Compare Chain and Independent Facilities
Explore both types of nursing homes in your area:
Methodology
This analysis examined all 14,751 Medicare-certified nursing homes in the CMS Nursing Home Compare database as of January 2025.
- Data source: CMS Nursing Home Compare, updated quarterly
- Chain identification: Based on CMS-reported organization name field
- Independent facilities: Defined as facilities with no chain affiliation or single-facility operators
- Metrics analyzed: Overall star ratings, staffing levels, quality measures, abuse violations, special focus facility status
- Minimum threshold: Chains included in rankings have 10+ facilities to ensure statistical validity
Some chains may have missing staffing or turnover data (reported as 0.00 in our tables). This typically indicates the chain operates in states where these metrics aren't publicly reported or facilities are exempt from reporting requirements.
Related Guides
Continue learning with these related articles:
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Nonprofit vs For-Profit Analysis →
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Understanding Star Ratings →
Learn what CMS star ratings really mean and how to use them effectively in your search.
Why Staffing Matters Most →
RN hours and turnover rates predict quality better than ratings. Here's what to look for.
Search by Chain Ownership →
Filter facilities by specific chains and compare performance across their portfolio.
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