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3G Healthcare Real Estate is a sell-side advisory firm working only in skilled nursing facility real estate. This report is the Alabama ownership and operating picture as we track it, drawn from CMS Provider Information, federal ownership filings, county property records, published Medicaid rate files, and our own resolution work. Every figure below describes the market in aggregate; nothing here is specific to any single owner or property.
224 facilities | 26,504 licensed beds | 83% avg occupancy | 42% showing distress |
Medicaid Rate Context Alabama does not publish facility-level Medicaid daily rates in a form we have been able to obtain, so there is no per-building rate picture in the public record for this market. That absence is itself the point: without published rates most owners have no reliable way to benchmark their own building, and we maintain the comparison independently.
CMS Ownership Analytics · 224 AL SNFs | Ownership | Facilities | Avg ★ | Staffing ★ | Nurse turnover | 1★ / 5★ | CMS fines |
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| For-Profit | 189 | 2.96 | 3.56 | 48% | 36 / 34 | $2.8M | | Non-Profit | 27 | 2.93 | 3.78 | 39% | 6 / 4 | $422K | | Government | 8 | 4.25 | 4.50 | 39% | 1 / 5 | $0 |
Alabama skilled nursing is 84 percent for-profit by facility count: 189 of 224 buildings, averaging 2.96 stars overall and 3.56 on staffing. The balance is 27 non-profit, 8 government. Government buildings rate highest at 4.25 stars and non-profit lowest at 2.93. Ownership type as CMS records it describes the license holder. The real estate behind it is frequently a different party, and that is the layer we resolve.
Quality, Staffing & Distress Signals 38% rated one or two stars | 6 special focus / candidate |
Alabama averages 3.00 stars overall across 224 facilities and 26,504 licensed beds. Average occupancy runs 83 percent, which is the number that decides whether a building services its debt. Quality splits at the bottom: 86 facilities (38 percent) rate one or two stars overall, 43 of them one star. Special Focus status or candidacy covers 6 of them. CMS fines on the current record total $3.2M across 40 facilities. Total nurse turnover averages 46.9 percent. Counting any facility that carries at least one of a one- or two-star overall rating, Special Focus status or candidacy, CMS fines on the current record, or a distressed-title flag from county records, 95 of 224 buildings show a distress signal, 42 percent of the total.
Where the Beds Are | County | Facilities | Licensed beds |
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| Jefferson | 34 | 3,963 | | Mobile | 17 | 1,975 | | Madison | 12 | 1,267 | | Montgomery | 8 | 1,081 | | Baldwin | 7 | 772 | | Tuscaloosa | 6 | 903 | | Etowah | 6 | 848 | | Calhoun | 5 | 667 |
Market Structure 54% run by the eight largest groups | 46% run by everyone else |
The eight largest operating groups run 122 of Alabama's 224 skilled nursing facilities, 54 percent of the state and 54 percent of its licensed beds. The remaining 102 buildings are spread across a long tail of smaller operators and independents. Operating scale is not the same as real-estate ownership, and in most markets the two are separate. The property behind these portfolios is held across a far larger and more fragmented set of owners, many of them holding a single building outright. That is the layer we resolve, and it is why a market that looks consolidated from the operating side is usually anything but from the ownership side.
Hospital Discharge Demand 29,286 SNF-relevant discharges (minimum) | 66 reporting hospitals |
Alabama's 66 reporting hospitals discharged at least 29,286 traditional-Medicare inpatients in the diagnosis groups that most often need skilled care afterward, in federal fiscal 2024. Sepsis leads at 8,551 discharges. Every one of these patients needed a next setting, and the facilities positioned closest to the highest-volume hospitals see that demand first. | Condition | Discharges (at least) |
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| Sepsis | 8,551 | | Heart failure | 4,329 | | Urinary tract infection | 3,107 | | Pneumonia | 3,013 | | Respiratory infection | 2,365 | | Stroke | 2,188 | | Kidney failure | 2,013 | | Hip & femur surgery | 1,442 | | COPD | 1,209 | | Hip & knee replacement | 1,069 |
| Hospital | SNF-relevant discharges | 30-day HF readmissions |
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| HUNTSVILLE HOSPITAL · HUNTSVILLE | 3,031 | 20.8% | | DCH REGIONAL MEDICAL CENTER · TUSCALOOSA | 1,657 | 22.5% | | GRANDVIEW MEDICAL CENTER · BIRMINGHAM | 1,455 | 21.0% | | UNIVERSITY OF ALABAMA HOSPITAL · BIRMINGHAM | 1,453 | 21.0% | | SOUTHEAST HEALTH MEDICAL CENTER · DOTHAN | 1,315 | 19.9% | | NORTH ALABAMA MEDICAL CENTER · FLORENCE | 1,160 | 23.1% | | MOBILE INFIRMARY MEDICAL CENTER · MOBILE | 1,076 | 20.3% | | CULLMAN REGIONAL MEDICAL CENTER · CULLMAN | 953 | 24.4% | | THE EAST ALABAMA HEALTHCARE AUTHORITY · OPELIKA | 872 | 19.5% | | ST VINCENT'S BIRMINGHAM · BIRMINGHAM | 841 | 22.8% |
Traditional Medicare discharges, federal fiscal 2024, in the diagnosis groups that most often discharge to skilled care. CMS withholds any line under 11 discharges, so every figure is a minimum. Readmission rates: CMS Care Compare, three-year window; n/a means CMS reports too few cases.
Medicare Readmission Penalty 78% of graded facilities are cut this year | 0.7% average cut across the graded set |
171 of Alabama's 218 graded skilled nursing facilities (78%) are taking a live Medicare payment cut this federal fiscal year under CMS's SNF Value-Based Purchasing program, which blends readmissions, infections, staffing and turnover into one multiplier and applies it to every Medicare day a building bills. The graded set averages a 0.7% cut across the whole state. A federal number like that says little read alone, which is why we check it against the fuller financial and operational record we hold on every building before it reaches a report: the buildings already under pressure elsewhere are the ones a payment cut actually threatens. CMS SNF Value-Based Purchasing, FY2026 determination, published February 2026. The multiplier blends readmissions, infections, staffing and turnover and applies to every Medicare day a facility bills; below 1.0 is a live payment cut, not a one-time fine.
Medicare Advantage Penetration 61.5% of the state's Medicare population is in MA plans |
Medicare Advantage now covers 61.5% of Alabama's Medicare population, as of April 2026. That is up 4.5 points in three years. Lowndes County runs highest in the state at 74.4%. An MA member typically draws fewer skilled-nursing days per admission than traditional Medicare, so the counties at the top of that list are the ones structurally losing SNF days first, whatever the raw discharge count says. | County | Medicare Advantage share |
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| Lowndes County | 74.4% | | Chilton County | 73.0% | | Greene County | 73.0% | | Perry County | 73.0% | | Wilcox County | 72.3% | | Dallas County | 72.3% | | Bullock County | 72.1% | | Mobile County | 70.9% |
CMS Medicare Monthly Enrollment, county grain, April 2026. An MA member typically draws fewer skilled-nursing days per admission than traditional Medicare, so a rising share is a structural headwind on SNF demand, not a one-quarter blip.
Market Observations Beds concentrate where the population does: Jefferson County with 34 facilities and 3,963 beds, Mobile County with 17 facilities and 1,975 beds, Madison County with 12 facilities and 1,267 beds.
Legislative & Regulatory Watch In effect Federal: Staffing Mandate (Aug 2026) Operator implication: Staffing floors bind hardest on buildings already below the state average on hours per resident, which is where distressed sales start. Federal: Reimbursement (Aug 2026) Operator implication: Payment policy changes reach every building in the state, and the effect on a thin-margin operator arrives within a quarter. Federal: Reimbursement (Jul 2026) Two recent reports find that Medicare Advantage organizations deny prior authorization requests for long-term care hospital, inpatient rehabilitation hospital, and skilled nursing facility stays at higher rates than requests overall. When these decisions are appealed, they are frequently overturned, particularly for skilled nursing facility stays. This may cause delays for Medicare beneficiaries who are particularly Operator implication: Payment policy changes reach every building in the state, and the effect on a thin-margin operator arrives within a quarter. Federal: Reimbursement (Sep 2026) Operator implication: Payment policy changes reach every building in the state, and the effect on a thin-margin operator arrives within a quarter. This one moves in the operator's favour. Active / watch Alabama: State Budget (Jan 2026) Nursing facilities, privilege assessments and surcharge on each nursing home bed, sunset removed Last action: Pending House Ways and Means General Fund (2026-01-14) Operator implication: Budget language sets the reimbursement envelope for the following rate year, so it is the earliest reliable signal of where rates are heading. Rescinded Federal: Staffing Mandate (Jul 2026) Amid changes to federal oversight of nursing homes during the Trump administration -- including rescinding the nursing home staffing rule issued by the Biden administration, prioritizing inspections that are triggered by complaints over routine inspections, and suspending the deadline to report detailed ownership information -- this issue brief provides an overview of the nursing home inspection process and the types If a county-level Alabama breakdown, or the ownership and capital-structure detail behind any facility in it, would be useful, a short confidential conversation is the fastest way to get it. There is no cost and no obligation, and the buyer you select covers our fee.
Christian Patrick
President
Exclusively SNF Sell-Side Advisors
Sources - CMS Provider Information / Care Compare: facility counts, licensed beds, occupancy, Five-Star ratings, staffing, nurse turnover, fines and Special Focus status, processed 2026-07-01.
- CMS Payroll-Based Journal: nurse staffing hours and turnover.
- Federal ownership filings: PECOS Form 855A indirect-owner tree and HCRIS cost-report related parties.
- County property and mortgage records via the 3G real-estate-ownership resolution layer.
- 3G Healthcare Real Estate proprietary warehouse, resolved as of the date shown above.
- Alabama does not publish facility-level Medicaid rates in an obtainable form; no per-facility rate data is presented for this state.
- State and federal legislative and regulatory tracking via the 3G intelligence scan, with the source for each item linked in that section.
- CMS Medicare inpatient claims (fiscal 2024): hospital discharge volumes by diagnosis group, traditional Medicare only; CMS withholds lines under 11 discharges, so volumes are minimums. Readmission rates from CMS Care Compare's three-year measure window.
- CMS SNF Value-Based Purchasing facility-level file, FY2026 determination (published February 2026): readmission, infection, staffing and turnover measures rolled into one Medicare payment multiplier per facility.
- CMS Medicare Monthly Enrollment: Medicare Advantage penetration by county, April 2026.
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