CareTrust REIT — a real estate investment trust that owns more than 500 senior housing and nursing home buildings — reported net income last year of $320 million from $476 million in rents and other revenue. That's a 67% profit margin, according to securities filings reviewed by KFF Health News. For reference, HCA Healthcare, one of the nation's largest for-profit hospital chains, reported a 10% profit margin over the same period.
The investigation, published by NPR and KFF Health News today, documents how real estate investment trusts have become a dominant ownership structure in long-term care — and how that structure creates financial incentives that work directly against adequate nurse staffing.
How the REIT Model Works in Long-Term Care
A REIT does not operate nursing homes directly. It buys the building and leases it back to an operating company, which then bears responsibility for care, staffing, and regulatory compliance. The REIT collects rent regardless of census, staffing levels, or inspection outcomes. As long as the operator pays, the REIT profits.
This separation of ownership and operations creates a specific financial dynamic: the operator is squeezed between fixed rent obligations to the REIT and variable costs it can control — primarily staffing. Research cited in the NPR investigation found that after REIT acquisition, nursing homes frequently replaced registered nurses with less-skilled CNAs and aides. A separate analysis found that health inspection results worsened after REIT investment.
One study did find REIT investment was associated with higher spending on nursing wages — showing the research is genuinely mixed. But the pattern of replacing RNs with less-skilled staff while maintaining total labor spend is consistent with operators trying to hold payroll flat while reducing the most expensive labor tier: RNs.
The Staffing Numbers on the Ground
KFF Health News analyzed federal data and found that on average, CareTrust nursing homes provided a half hour less nursing care per resident per day than the national average of four hours. One facility — City Creek — earned one star from Medicare as recently as November 2023 and was cited for failing to meet California's minimum staffing law on five of 24 randomly selected days.
CareTrust's counsel told KFF Health News that the REIT worked to "identify quality operators as tenants" and that the homes it rents have more nurses and aides than state minimums require. The company said operators "retain sole responsibility for operations."
That legal separation is exactly the problem, argued plaintiff attorney Lesley Ann Clement, whose client suffered harm in a CareTrust-linked facility: "There's plenty of money. They're just not spending it on patient care."
What This Means for LTC Nurses
For nurses working in LTC and SNF settings, the REIT investigation maps to something they experience shift by shift: facilities chronically understaffed not because there's no money, but because the ownership structure extracts cash above the level that enables safe staffing. The financial pressure flows down to whatever the operator can control — and that's usually nurse-to-patient ratios.
The CMS nursing home staffing mandate — the federal minimum staffing rule finalized in 2024 — was specifically designed to set a floor on this dynamic. That rule was rolled back earlier in 2026, removing the federal floor that would have constrained REIT operators from cutting staffing below safe levels.
Without a federal floor, enforcement falls to states. Facilities in states with their own minimum staffing laws — California, New York, New Jersey, and a handful of others — have more protection. Facilities in states without minimum staffing requirements are operating under the REIT's economic logic with no regulatory check.
I spent years in LTC environments as both a bedside nurse and a unit manager. The staffing pressure is constant, and the gap between what administrators say about resources and what actually appears on the schedule is real. The REIT model puts a name and a number on that gap — 67% profit margins while your floor runs one RN to 40 residents. The rollback of the federal staffing mandate earlier this year removed the one federal lever that would have forced these operators to staff to a minimum. If you're an LTC nurse considering contract or travel work, the facility's ownership structure and CMS star rating are worth checking before you sign. Medicare's Care Compare shows staffing levels for every certified facility in the country. The data is there. Use it.