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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.
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TX
Texas Skilled Nursing: Market Intelligence Report
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 Texas 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.
1,177
facilities
133,493
licensed beds
66%
avg occupancy
73%
showing distress
What the Cost Reports Say · FY2024 to FY2026
34% of the bed days went unsold.
Every full-year Medicare cost report Texas's skilled nursing facilities filed in FY2024 to FY2026, read as one set of bands: 1,146 reports across 207 counties. This is the table an owner puts their own filing against.
1,146
cost reports read across 207 counties
65.9%
median occupancy
62.5%
of the days reported by payer were Medicaid
4.2%
median net margin, 34.2% filed a loss
Six of every ten patient days Texas's skilled nursing facilities billed in FY2024 to FY2026 were Medicaid days: 62.5% of the 30,714,249 patient days on the 1,132 reports that break days out by payer. The median building ran 65.9% occupancy, with the middle half between 52.2% and 78.4%, on 1,143 reports that carry it. Patient revenue ran $268 a patient day at the median against $279 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 4.2% at the median. 380 of the 1,111 reports that carry a bottom line filed a loss, which is 34.2% 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.
52.2%
65.9%
78.4%
1,143
84.2%
Medicare share of days
Traditional Medicare days as a share of all patient days, off Worksheet S-3 Part I.
4.0%
6.6%
10.1%
1,146
7.7%
Medicaid share of days
Medicaid days as a share of all patient days, off Worksheet S-3 Part I.
55.1%
66.8%
76.2%
1,132
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.
17.8%
26.3%
35.3%
1,132
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.
$240
$268
$325
1,144
$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.
$248
$279
$325
1,143
$372
Net income per patient day
Net income off Worksheet G-3, divided by patient days.
-$9
$12
$32
1,122
$14
Margin and liquidity
Net margin
Net income off Worksheet G-3 over net patient revenue off the same worksheet.
-3.2%
4.2%
11.1%
1,111
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 30,714,249 days on the 1,132 reports that break days out by payer
Median facility
Medicaid
62.5%
66.8%
Traditional Medicare
8.2%
6.6%
Everyone else, including managed care
29.3%
26.3%
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. Managed care is broken out separately on 444 of the state’s reports; on those 12,585,517 days Medicare Advantage is 6.4% and managed Medicaid 56.5%, and both sit inside the row above.
Urban against rural, at the median
Urban (843)
Rural (303)
Occupancy
68.8%
57.5%
Medicaid share of days
67.8%
66.7%
Patient revenue per patient day
$281
$248
Operating expense per patient day
$289
$256
Net margin
4.3%
3.9%
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.
The beds are the constraint
22% of Texas buildings closed the year at 80% occupancy or better, on the 1,143 reports that carry occupancy, and 34% of the 1,111 that carry a bottom line still filed a loss.
A $77 gap per patient day
Operating cost runs $248 a patient day at the 25th percentile against $325 at the 75th, on 1,143 Texas reports. At the median building's own year of 26,808 patient days, that gap is $2.1 million a year between a lean cost structure and a heavy one.
Margin without liquidity
The median Texas filing closed on a current ratio of 1.32, on the 1,015 reports that carry both sides of the balance sheet, and 37% of them closed under 1.00, which means owing more inside a year than they hold to pay it with. Only 34% 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 2024-05-31 to 2026-06-30, one full-year report per facility: 1,146 reports covering 30,971,678 patient days, of which 30,714,249 sit on the 1,132 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
Texas 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 · 1,177 TX SNFs
Ownership
Facilities
Avg ★
Staffing ★
Nurse turnover
1★ / 5★
CMS fines
For-Profit
825
2.51
1.74
58%
249 / 75
$39.7M
Government
247
2.75
1.91
54%
63 / 32
$9.6M
Non-Profit
105
3.65
2.88
42%
10 / 34
$2.6M
Texas skilled nursing is 70 percent for-profit by facility count: 825 of 1,177 buildings, averaging 2.51 stars overall and 1.74 on staffing. The balance is 247 government, 105 non-profit. Non-Profit buildings rate highest at 3.65 stars and for-profit lowest at 2.51. The 247 government-owned buildings are a structural feature worth reading carefully: in most states these are county or hospital-district arrangements in which a public body holds the license while the real estate sits with a private party. 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
48%
rated one or two stars
36
special focus / candidate
Texas averages 2.66 stars overall across 1,177 facilities and 133,493 licensed beds. Average occupancy runs 66 percent, which is the number that decides whether a building services its debt. Quality splits at the bottom: 566 facilities (48 percent) rate one or two stars overall, 322 of them one star. Special Focus status or candidacy covers 36 of them. CMS fines on the current record total $51.9M across 805 facilities. Total nurse turnover averages 55.3 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, 861 of 1,177 buildings show a distress signal, 73 percent of the total.
Where the Beds Are
County
Facilities
Licensed beds
Harris
97
11,621
Dallas
82
10,718
Tarrant
72
9,076
Bexar
62
7,679
Travis
28
3,203
Hidalgo
22
2,772
Collin
22
2,640
El Paso
22
2,585
Market Structure
46%
run by the eight largest groups
54%
run by everyone else
The eight largest operating groups run 545 of Texas's 1,177 skilled nursing facilities, 46 percent of the state and 48 percent of its licensed beds. The remaining 632 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
138,625
SNF-relevant discharges (minimum)
236
reporting hospitals
Texas's 236 reporting hospitals discharged at least 138,625 traditional-Medicare inpatients in the diagnosis groups that most often need skilled care afterward, in federal fiscal 2024. Sepsis leads at 49,963 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
49,963
Heart failure
20,354
Pneumonia
12,149
Urinary tract infection
11,901
Kidney failure
11,025
Respiratory infection
10,211
Stroke
10,063
Hip & femur surgery
6,578
Hip & knee replacement
3,741
COPD
2,640
Hospital
SNF-relevant discharges
30-day HF readmissions
METHODIST HOSPITAL · SAN ANTONIO
5,194
21.1%
MEMORIAL HERMANN HOSPITAL SYSTEM · HOUSTON
3,693
21.4%
HOUSTON METHODIST HOSPITAL · HOUSTON
2,751
18.9%
BAPTIST MEDICAL CENTER · SAN ANTONIO
2,578
19.8%
CHRISTUS MOTHER FRANCES HOSPITAL · TYLER
2,447
20.7%
TEXAS HEALTH HARRIS METHODIST FORT WORTH · FORT WORTH
2,419
20.3%
TEXOMA MEDICAL CENTER · DENISON
2,055
22.6%
BSA HOSPITAL · AMARILLO
2,025
19.7%
UNITED REGIONAL HEALTH CARE SYSTEM · WICHITA FALLS
1,980
23.9%
HENDRICK MEDICAL CENTER · ABILENE
1,977
19.9%
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
91%
of graded facilities are cut this year
1.3%
average cut across the graded set
1,006 of Texas's 1,100 graded skilled nursing facilities (92%) 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.
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
54.9%
of the state's Medicare population is in Medicare Advantage plans
Medicare Advantage now covers 54.9% of Texas's Medicare population, as of April 2026. That is up 3.0 points in three years. Starr County runs highest in the state at 84.2%. 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.
County
Medicare Advantage share
Starr County
84.2%
Willacy County
78.9%
Hidalgo County
77.2%
Maverick County
75.9%
Zapata County
75.2%
El Paso County
74.4%
Zavala County
74.4%
Cameron County
74.3%
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: Harris County with 97 facilities and 11,621 beds, Dallas County with 82 facilities and 10,718 beds, Tarrant County with 72 facilities and 9,076 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.
Per QSO-26-03-NH, CMS updated the State Operations Manual to tighten onsite survey timelines and revisit protocols, expand per-instance/per-day civil money penalties (reflected in the CMP Analytic Tool from March 31, 2026), refine Immediate Jeopardy definitions, and publish some penalties on Care Compare starting June 24, 2026. The enforcement intensification raises regulatory and financial exposure for Texas SNF ope
Operator implication: Survey and enforcement changes move the risk of citation and fines, which lenders and buyers price directly.
If a county-level Texas 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.
Texas 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: 1,146 filings from 1,146 Texas 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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