How Nursing Home Ownership Is Disclosed to CMS: PECOS, Cost Reports, the New Transparency Rule, and What Still Falls Through the Gaps
Who owns a nursing home is a question with a more complicated answer than it appears. Federal law requires operators to disclose ownership to CMS through multiple channels — provider enrollment, cost reports, and formal change-of-ownership filings — but the disclosure framework has significant gaps, particularly for private equity fund structures and management company arrangements. The 2024 CMS ownership transparency rule addresses some of these gaps but leaves others open. This walkthrough maps each disclosure pathway, what it captures, and what it misses.
The process, step by step
Disclose all 5%-or-greater owners in PECOS at enrollment
When a nursing home enrolls in Medicare, the authorized official must disclose all individuals and entities with a 5% or greater direct ownership interest through the CMS Provider Enrollment, Chain and Ownership System (PECOS). The disclosure includes ownership type (individual, corporation, LLC, non-profit, government), percentage share, and Social Security number or EIN for each owner. This information is collected on Form CMS-855A.
Source ↗Disclose managing organizations and operational control in PECOS
In addition to direct owners, PECOS requires disclosure of any managing organization — an entity that operates the facility on behalf of the owners but may not hold a direct ownership interest. Management companies, operating companies, and leasehold operators must be disclosed. This layer is important because in private equity structures the management company (not the PE fund) often holds the Medicare provider agreement.
Source ↗File CMS-2540 annual cost report disclosing related-party transactions
Each year, within 5 months of fiscal year end, the facility files Form CMS-2540 (the Skilled Nursing Facility Cost Report). Worksheet A-8 requires detailed disclosure of all related-party transactions — rent paid to a related landlord, management fees paid to a related management company, pharmaceutical or therapy services purchased from affiliated entities. These disclosures are the primary mechanism for identifying the financial relationship between an SNF and its ownership structure.
Source ↗File a Change of Ownership (CHOW) notification before any transfer of operational control
When a nursing home changes ownership, the new owner must file a CHOW notification with CMS before — not after — the transfer occurs. A CHOW is defined broadly to include transfers of operational control, not just asset sales: lease assignments, management agreement transfers, and stock sales that result in a change of majority ownership all typically trigger CHOW requirements. CMS has 90 days to act on a CHOW request.
Source ↗Comply with the 2024 expanded disclosure requirements
CMS's 2024 nursing home ownership transparency rule (effective 2024) expanded PECOS disclosure requirements to capture additional layers of the ownership structure — including private equity investors, real estate investment trusts (REITs), and holding companies above the direct facility owner. The rule also requires disclosure of all members of the governing body and all individuals with 5% or more of any class of equity ownership in any entity in the ownership chain up to 100%.
Source ↗Update PECOS disclosures within 90 days of any material change
After initial enrollment, operators are required to report any material change to their PECOS record within 90 days. Material changes include changes to ownership percentage, new owners exceeding the 5% threshold, changes to the managing organization, and changes to the authorized official. CHOW filings (Step 4) are handled separately from routine PECOS updates.
Source ↗
PECOS: the enrollment-time ownership record
PECOS (Provider Enrollment, Chain and Ownership System) is CMS's primary repository for Medicare provider enrollment data. For nursing homes, the relevant enrollment form is CMS-855A. PECOS captures direct ownership — individuals and entities holding 5% or more of the facility. The public-facing SNF All Owners dataset, published on data.cms.gov, derives from PECOS and covers all SNF-CCN pairs with their disclosed owner, ownership type, and percentage.
PECOS ownership data is a point-in-time disclosure tied to enrollment and subsequent CHOW filings. It does not update continuously as ownership interests are traded in private equity fund secondary markets. A fund that acquired a portfolio of nursing homes in 2019 and sold limited partner interests in 2022 would typically not trigger a new PECOS disclosure — the fund entity in PECOS may be the same even as the underlying LP structure changed.
Fonteum's ownership networks study used the SNF All Owners dataset linked to PECOS corporate chain data and CMS-2540 cost reports to map 856 multi-facility chains, 38 confirmed private equity-affiliated portfolios, and 22 REIT sale-leaseback arrangements. The PECOS data forms the foundation, but the full ownership picture required joining multiple datasets.
Cost reports: the related-party transaction layer
The annual SNF cost report (CMS-2540) requires facilities to complete Worksheet A-8, which identifies all related-party transactions. A related party is any entity under common ownership or control as the nursing home — defined as 5% or more common ownership. Worksheet A-8 requires itemizing rent paid to a related landlord (a common structure when private equity separates the real estate from the operating company), management fees paid to a related management company, and services purchased from affiliated therapy or pharmaceutical companies.
Cost reports are filed annually and processed by CMS's HCRIS (Healthcare Cost Report Information System). The data becomes publicly available approximately 6–12 months after the end of the fiscal year. Fonteum's HCRIS integration covers 6,019 SNF CCNs and provides the financial substrate for ownership transparency analysis that PECOS alone cannot provide.
The related-party disclosures in cost reports are particularly important for identifying the split between real-estate and operating company arrangements — a structural feature of many private equity-backed nursing home portfolios where the PE fund retains the real estate (through a REIT or real property holding company) while spinning off the operating company to a separate entity. The operating company shows up in PECOS; the real estate entity shows up in the cost report.
Change of Ownership (CHOW): the transaction disclosure mechanism
A Change of Ownership is a formal filing that triggers CMS review of a nursing home's provider agreement when operational control changes hands. CMS defines CHOW broadly: it includes not only asset sales but also lease assignments, stock transfers that result in a new majority shareholder, and management agreement changes that effectively transfer control of facility operations. The operative regulatory standard is whether there is a transfer of 'operational control.'
CMS has 90 days to respond to a CHOW request. The new owner must execute a new provider agreement; the prior owner's agreement terminates on the CHOW effective date. During the 90-day window, surveyors may conduct a change-of-ownership survey to ensure the facility continues to meet conditions of participation under new management.
In practice, private equity acquisitions structured through stock purchases — where the acquired entity is the direct SNF owner — can be structured to avoid triggering a CHOW if the legal entity holding the provider agreement does not change. This is a known gap in the CHOW framework that the 2024 transparency rule partially addresses by requiring disclosure of stock transfers above certain thresholds.
The 2024 ownership transparency rule
CMS finalized its nursing home ownership transparency rule in the 2024 SNF Prospective Payment System final rule. The key expansions are: (1) facilities must disclose all individuals and entities with 5% or more of any class of equity in any entity in the ownership chain, not just the direct facility owner; (2) private equity companies (as defined in the rule) that hold a direct or indirect ownership interest must be disclosed, along with the private equity funds through which they hold the interest; (3) real estate investment trusts (REITs) that own the facility's real property must be disclosed; and (4) all members of the governing body must be disclosed.
The rule also requires disclosure of the organizational structure — a visual or text representation of the ownership chain from the facility up through any parent entities to the ultimate controlling owner. This organizational chart requirement is new and is intended to surface structures that existing PECOS disclosure did not capture.
Compliance with the expanded disclosure requirements began in late 2024 for new enrollments and CHOWs, with existing providers required to update their PECOS records on a rolling basis. As of the current Fonteum dataset, the expanded disclosures are partially reflected in the SNF All Owners file but the full organizational-chart data is not yet reliably accessible through the standard public data feeds.
What's still not captured
Despite the 2024 expansion, the ownership disclosure framework has documented gaps. Private equity fund structures above the direct-ownership entity are now nominally required to be disclosed, but enforcement has been limited and the public data feeds have not yet fully incorporated the new disclosures. CMS has indicated that more granular fund-level data will be added to the SNF All Owners download in future releases.
Management company arrangements that fall short of 'operational control' as defined in the CHOW regulations may not trigger disclosure even when the management company effectively controls clinical and financial decisions. This is particularly common with management agreements that expire and are renewed as rolling month-to-month arrangements — technically not a CHOW but operationally indistinguishable from one.
International ownership and obscured beneficial ownership through multi-layer offshore holding structures remain a challenge. CMS disclosure requirements apply to US entities and individuals but do not have equivalent reach into foreign holding structures. Several academic studies have documented nursing home chains with beneficial ownership in jurisdictions that do not require public disclosure of beneficial owners.
Frequently asked questions
- What is the SNF All Owners dataset?
- The SNF All Owners dataset is a CMS public data file published on data.cms.gov that contains all ownership interests disclosed through PECOS for Medicare-certified skilled nursing facilities. It identifies each owner by name, organization type, ownership percentage, and association type (individual, corporate, non-profit, etc.). The file is updated periodically as PECOS records change and is the primary public source for nursing home ownership research.
- Does CMS require private equity funds to disclose their nursing home investments?
- Yes, as of the 2024 transparency rule. The rule requires disclosure of private equity companies with direct or indirect ownership interests, including the private equity funds through which they hold those interests. Before the 2024 rule, private equity fund structures above the direct facility owner were not captured in PECOS. Compliance with the new requirement is being phased in and the public data feeds do not yet fully reflect the expanded disclosures.
- How is a REIT involved in nursing home ownership?
- Real estate investment trusts often acquire nursing home real estate in sale-leaseback transactions: the nursing home operator sells the facility building to the REIT for a lump sum, then leases it back and continues to operate under a long-term lease. The REIT is the landlord; the operator is the tenant. This arrangement separates ownership of the physical plant from operational control. The 2024 transparency rule requires REIT landlords to be disclosed on PECOS records for the facilities they own.
- How long does a CHOW take and what happens to residents during the process?
- CMS has 90 days to approve or deny a CHOW request. During this period, the existing provider agreement remains in effect and the facility continues to bill Medicare under its current CCN. Residents are not transferred and the facility continues to operate normally. A CHOW survey may occur during the 90-day window. Upon approval, the new provider agreement takes effect and the CCN transfers to the new entity.
Reviewed by Jennifer Montecillo, MD, medical reviewer. Non-practicing medical reviewer. Last reviewed: June 2026. Data last updated: 2026-06-03.
This explainer draws from federal primary sources. Every figure is traceable to a specific CMS dataset with provenance documentation. Data sources → Corrections log → Methodology library →
Federal data is in the public domain under U.S. Government Works. Fonteum analysis and synthesis are copyright Fonteum, Inc.