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Every Alabama building in this report has its own page.
This report is the state. The full read is one building: its occupancy month by month, its cost reports, its Medicaid rate files and its surveys. Free with an account.
October 27, 2026 · Exclusively SNF Sell-Side Advisors · Since 2014
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
What the Cost Reports Say · FY2024 to FY2026
Seven days in ten are Medicaid.
Every full-year Medicare cost report Alabama's skilled nursing facilities filed in FY2024 to FY2026, read as one set of bands: 212 reports across 63 counties. This is the table an owner puts their own filing against.
212
cost reports read across 63 counties
87.2%
median occupancy
66.5%
of the days reported by payer were Medicaid
2.2%
median net margin, 29.2% filed a loss
Seven of every ten patient days Alabama's skilled nursing facilities billed in FY2024 to FY2026 were Medicaid days: 66.5% of the 7,469,163 patient days on the 208 reports that break days out by payer. The median building ran 87.2% occupancy, with the middle half between 76.8% and 92.0%, on 206 reports that carry it. Patient revenue ran $311 a patient day at the median against $311 of reported operating expense, the cost report's own operating line rather than every cost a building carries. Net margin on the filings themselves was 2.2% at the median. 62 of the 212 reports that carry a bottom line filed a loss, which is 29.2% of them.
Statistic
25th
Median
75th
Reports
National median
Census and payer mix
Occupancy
Patient days as a share of available bed days, both off Worksheet S-3 Part I.
76.8%
87.2%
92.0%
206
84.2%
Medicare share of days
Traditional Medicare days as a share of all patient days, off Worksheet S-3 Part I.
3.1%
4.9%
8.0%
212
7.7%
Medicaid share of days
Medicaid days as a share of all patient days, off Worksheet S-3 Part I.
57.3%
68.3%
78.1%
208
66.3%
Everyone else as a share of days
Patient days that are neither traditional Medicare nor Medicaid, as a share of all patient days on the same filing. Managed care sits in here.
17.9%
26.6%
35.6%
208
23.4%
Per-resident-day economics
Patient revenue per patient day
Net patient revenue off Worksheet G-3, divided by patient days off Worksheet S-3 Part I. Blended across every payer.
$295
$311
$335
211
$373
Operating expense per patient day
Total operating expense off Worksheet G-3, divided by patient days. Net income also counts income and expense outside patient care, such as investment income, rentals and donations, which is why it is not patient revenue minus this line.
$287
$311
$334
211
$372
Net income per patient day
Net income off Worksheet G-3, divided by patient days.
-$3
$7
$21
212
$14
Margin and liquidity
Net margin
Net income off Worksheet G-3 over net patient revenue off the same worksheet.
-0.9%
2.2%
6.6%
212
3.7%
Current ratio
Current assets over current liabilities on the same filing. Under 1.00 means the building owes more inside a year than it holds to pay it with.
Statewide pool, of the 7,469,163 days on the 208 reports that break days out by payer
Median facility
Medicaid
66.5%
68.3%
Traditional Medicare
6.2%
4.9%
Everyone else, including managed care
27.3%
26.6%
The statewide pool adds to 100 because it divides one set of days three ways. The median facility column does not, and is not meant to: every building’s own mix sums to 100, but the median Medicaid building is not the median Medicare building.
Urban against rural, at the median
Urban (137)
Rural (75)
Occupancy
87.2%
87.1%
Medicaid share of days
66.1%
72.0%
Patient revenue per patient day
$319
$302
Operating expense per patient day
$315
$301
Net margin
3.2%
1.7%
Each side is ranked over its own filings, so the two columns are two medians and not a split of one. A filing CMS left unclassified is in neither column, which is why the two counts need not add to the state total.
Census is not the constraint
69% of Alabama buildings closed the year at 80% occupancy or better, on the 206 reports that carry occupancy, and 29% of the 212 that carry a bottom line still filed a loss.
A $47 gap per patient day
Operating cost runs $287 a patient day at the 25th percentile against $334 at the 75th, on 211 Alabama reports. At the median building's own year of 33,868 patient days, that gap is $1.6 million a year between a lean cost structure and a heavy one.
Margin without liquidity
The median Alabama filing closed on a current ratio of 1.27, on the 171 reports that carry both sides of the balance sheet, and 36% of them closed under 1.00, which means owing more inside a year than they hold to pay it with. Only 29% of the state's filings lost money on patient care, so this is a working-capital reading rather than an earnings one.
Medicare cost reports as filed, fiscal years ending 2024-06-30 to 2026-03-31, one full-year report per facility: 212 reports covering 7,605,398 patient days, of which 7,469,163 sit on the 208 reports that break days out by payer, which is what the payer table below divides by. Every line carries the number of reports behind it, and a line standing on fewer than 20 reports is not ranked. Operating expense is the cost report’s own operating line. Net income also counts income and expense outside patient care, such as investment income, rentals and donations, which is why it is not patient revenue minus that line.
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 published 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
For-Profit
189
2.96
3.57
48%
37 / 35
$2.4M
Non-Profit
27
3.00
3.85
39%
4 / 5
$408K
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 3.57 on staffing. The balance is 27 non-profit, 8 government. Government buildings rate highest at 4.25 stars and for-profit lowest at 2.96. 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
39%
rated one or two stars
6
special focus / candidate
Alabama averages 3.01 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: 87 facilities (39 percent) rate one or two stars overall, 42 of them one star. Special Focus status or candidacy covers 6 of them. CMS fines on the current record total $2.8M across 35 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
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)
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
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 Medicare Advantage 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
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 (Oct 2026)
Operator implication: Staffing floors bind hardest on buildings already below the state average on hours per resident, which is where distressed sales start.
Operator implication: Staffing floors bind hardest on buildings already below the state average on hours per resident, which is where distressed sales start.
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.
CMS Provider Information / Care Compare: facility counts, licensed beds, occupancy, Five-Star ratings, staffing, nurse turnover, fines and Special Focus status, processed 2026-09-01.
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.
Medicare cost reports (CMS HCRIS), FY2024 to FY2026: 212 filings from 212 Alabama skilled nursing facilities, one full-year report each, loaded 2026-10-06. Occupancy, patient days by payer, patient revenue, operating expense and net income as each facility filed them.
3G Healthcare Real Estate is a brokerage firm specializing exclusively in skilled
nursing facility real estate. We do not provide legal, financial, or tax advice.
3G Healthcare Real Estate, 456 N. Meridian St #441332, Indianapolis, IN 46204.
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