Ownership Type and Functional Decline Among Long-Stay Nursing Home Residents

Introduction: Functional decline is a major adverse outcome among long-stay nursing home residents because it reflects loss of independence and increased care needs. Nursing home ownership type may be associated with resident outcomes due to differences in organizational structure, staffing, resident populations, and care processes. This study examined whether ownership type was associated with functional decline among long-stay nursing home residents.

Methods: This cross-sectional facility-level study used April 2026 CMS Nursing Home Compare data. Ownership type was categorized into for-profit, nonprofit, and government-owned facilities, with for-profit facilities used as the reference group. Functional decline was evaluated using two CMS Minimum Data Set quality measures: ADL decline and worsened walking ability. Two multivariate ordinary least squares regression models were estimated. The regression models adjusted for resident case-mix, total nursing hours, physical therapy hours, total nursing staff turnover, RN turnover, and occupancy.

Results: A total of 11,931 facilities were included in the ADL decline model, and 11,521 facilities were included in the worsened walking ability model. Compared with for-profit facilities, nonprofit ownership was associated with a 3.73 percentage-point higher ADL decline rate, while government ownership was associated with a 2.24 percentage-point higher ADL decline rate (p<0.001 for both). For worsened walking ability, nonprofit ownership was associated with a 3.85 percentage-point higher rate, while government ownership was associated with a 1.28 percentage-point higher rate compared with for-profit facilities (p<0.001 for both).

Conclusions: Ownership type was significantly associated with functional decline among long-stay nursing home residents. Nonprofit and government-owned facilities had higher adjusted rates of ADL decline and worsened walking ability compared to for-profit facilities. These findings should be interpreted cautiously, as they reflect associations rather than causal relationships and may be confounded by unobserved differences across facilities, including resident acuity, referral patterns, payer mix, and facility structure.