North Dakota 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 North Dakota 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.

Five of every ten patient days North Dakota's skilled nursing facilities billed in FY2024 to FY2026 were Medicaid days: 53.9% of the 1,251,868 patient days on the 49 reports that break days out by payer. The median building ran 94.3% occupancy, with the middle half between 86.7% and 97.4%, on 50 reports that carry it. Patient revenue ran $432 a patient day at the median against $440 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 2.6% at the median. 18 of the 51 reports that carry a bottom line filed a loss, which is 35.3% of them.

North Dakota carries a median Medicaid daily rate of $401 across 59 rated facilities, 82 percent of the buildings we track in the state, with the middle half of the market between $368 and $420 a day. The distribution is tight, which usually means a cost-capped methodology holding most buildings in a band. Rates are effective January 2026.

North Dakota skilled nursing is 92 percent non-profit by facility count: 66 of 72 buildings, averaging 3.20 stars overall and 4.25 on staffing. The balance is 4 for-profit, 2 government. Government buildings rate highest at 3.50 stars and for-profit lowest at 2.25. 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.

North Dakota averages 3.15 stars overall across 72 facilities and 4,909 licensed beds. Average occupancy runs 93 percent, which is the number that decides whether a building services its debt. Quality splits at the bottom: 24 facilities (33 percent) rate one or two stars overall, 14 of them one star. Special Focus status or candidacy covers 6 of them. CMS fines on the current record total $2.0M across 45 facilities. Total nurse turnover averages 48.8 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, 47 of 72 buildings show a distress signal, 65 percent of the total.

The four largest operating groups run 23 of North Dakota's 72 skilled nursing facilities, 32 percent of the state and 37 percent of its licensed beds. The remaining 49 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.

North Dakota's 7 reporting hospitals discharged at least 5,835 traditional-Medicare inpatients in the diagnosis groups that most often need skilled care afterward, in federal fiscal 2024. Sepsis leads at 1,938 discharges. Every one of these patients needed a next setting, and the facilities positioned closest to the highest-volume hospitals see that demand first.

27 of North Dakota's 61 graded skilled nursing facilities (44%) 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 0.2% raise 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 35.5% of North Dakota's Medicare population, as of April 2026. That is up 4.7 points in three years. Kidder County runs highest in the state at 55.6%. 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: Cass County with 8 facilities and 856 beds, Burleigh County with 5 facilities and 549 beds, Morton County with 5 facilities and 384 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. North Dakota published Medicaid nursing-facility rate files: 59 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: 51 filings from 51 North Dakota 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.