Missouri Skilled Nursing - Market Intelligence

3G Healthcare Real Estate is a sell-side advisory firm working only in skilled nursing facility real estate. This report is the Missouri 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.

Seven of every ten patient days Missouri's skilled nursing facilities billed in FY2024 to FY2026 were Medicaid days: 67.3% of the 12,272,540 patient days on the 459 reports that break days out by payer. The median building ran 72.6% occupancy, with the middle half between 59.0% and 85.2%, on 459 reports that carry it. Patient revenue ran $273 a patient day at the median against $272 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 3.4% at the median. 170 of the 458 reports that carry a bottom line filed a loss, which is 37.1% of them.

Missouri carries a median Medicaid daily rate of $246 across 467 rated facilities, 96 percent of the buildings we track in the state, with the middle half of the market between $219 and $274 a day. The distribution is wide, which is where facility class, acuity, and add-on programs are doing the work rather than a single statewide base rate. Non-profit buildings run $16 a day above government ones ($255 against $239 at the median), a gap that reflects the class each sits in rather than the quality of the building. Rates are effective January 2026.

Missouri skilled nursing is 80 percent for-profit by facility count: 388 of 487 buildings, averaging 2.34 stars overall and 1.90 on staffing. The balance is 77 non-profit, 22 government. Non-Profit buildings rate highest at 3.30 stars and for-profit lowest at 2.34. 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.

Missouri averages 2.51 stars overall across 487 facilities and 50,053 licensed beds. Average occupancy runs 71 percent, which is the number that decides whether a building services its debt. Quality splits at the bottom: 254 facilities (52 percent) rate one or two stars overall, 163 of them one star. Special Focus status or candidacy covers 18 of them. CMS fines on the current record total $18.2M across 208 facilities. Total nurse turnover averages 56.0 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, 316 of 487 buildings show a distress signal, 65 percent of the total.

The eight largest operating groups run 187 of Missouri's 487 skilled nursing facilities, 38 percent of the state and 40 percent of its licensed beds. The remaining 300 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.

Missouri's 60 reporting hospitals discharged at least 43,292 traditional-Medicare inpatients in the diagnosis groups that most often need skilled care afterward, in federal fiscal 2024. Sepsis leads at 13,281 discharges. Every one of these patients needed a next setting, and the facilities positioned closest to the highest-volume hospitals see that demand first.

401 of Missouri's 441 graded skilled nursing facilities (91%) 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 1.3% 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.

Medicare Advantage now covers 54.6% of Missouri's Medicare population, as of April 2026. That is up 3.7 points in three years. Douglas County runs highest in the state at 73.2%. 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.

Beds concentrate where the population does: St. Louis County with 69 facilities and 9,380 beds, Jackson County with 39 facilities and 4,605 beds, Greene County with 21 facilities and 2,321 beds.

1. 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.
2. CMS Payroll-Based Journal: nurse staffing hours and turnover.
3. Federal ownership filings: PECOS Form 855A indirect-owner tree and HCRIS cost-report related parties.
4. County property and mortgage records via the 3G real-estate-ownership resolution layer.
5. 3G Healthcare Real Estate proprietary warehouse, resolved as of the date shown above.
6. Missouri published Medicaid nursing-facility rate files: 467 rated facilities, effective January 2026.
7. State and federal legislative and regulatory tracking via the 3G intelligence scan, with the source for each item linked in that section.
8. 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.
9. 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.
10. CMS Medicare Monthly Enrollment: Medicare Advantage penetration by county, April 2026.
11. Medicare cost reports (CMS HCRIS), FY2024 to FY2026: 464 filings from 464 Missouri 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.