Mergers and acquisitions in the skilled nursing sector reached an estimated 420 transactions in 2025, approaching the pre-pandemic high of 450 deals recorded in 2019. The rebound reflects improved sector fundamentals, pent-up seller interest, and abundant capital seeking deployment in healthcare real estate.
Deal Flow Analysis
Transaction volume accelerated throughout the year, with Q4 accounting for approximately 130 deals—the strongest quarterly performance since 2018. Brokers attribute the late-year surge to sellers racing to close transactions before potential tax law changes in 2026 and buyers deploying capital accumulated during a cautious 2024.
Deal size varied widely, from single-facility transactions valued under $5 million to portfolio deals exceeding $500 million. The median transaction involved 2-3 facilities with a combined value of approximately $25 million. Large portfolio transactions (10+ facilities) represented just 8% of deal count but 45% of total transaction value.
Buyer Composition
Regional operators accounted for the majority of acquisitions, with established chains expanding their geographic footprints through tuck-in acquisitions. The Ensign Group led activity with 45 operations acquired, continuing its decade-long roll-up strategy. Other active strategic buyers included Marquis Health Consulting Services, Consonus Healthcare, and SavaSeniorCare.
Private equity remained active despite increased scrutiny, with PE-backed platforms completing an estimated 85 transactions. New PE entrants have adopted more operator-friendly partnership structures, often retaining existing management and providing growth capital rather than pursuing the leveraged buyout model that drew criticism in earlier years.
Healthcare REITs represented the third major buyer category, with CareTrust, Omega Healthcare, and Welltower all completing significant acquisitions. REIT transactions typically involve sale-leaseback structures that provide liquidity to operators while expanding the REITs’ triple-net lease portfolios.
Valuation Trends
Pricing has stabilized after pandemic-era volatility, with per-bed valuations ranging from $40,000 for distressed assets to $180,000 for premium properties in high-reimbursement markets. The national median of approximately $85,000 per bed represents a modest increase from 2024 levels.
Quality metrics increasingly drive valuation premiums. Facilities with 4- or 5-star CMS ratings command 15-25% premiums over lower-rated peers. Diverse payer mixes with strong Medicare and managed care penetration also attract premium pricing, reflecting buyer preference for revenue stability and upside potential.
2026 Outlook
Market participants expect continued robust activity in 2026, with several factors supporting deal flow. An estimated 800-1,000 facilities remain in financial distress, creating a pipeline of potential sellers. Baby boomer owners reaching retirement age are increasingly motivated to exit. And stabilizing operations reduce buyer risk perception, supporting continued capital deployment.
Potential headwinds include regulatory uncertainty around ownership transparency requirements, rising interest rates that increase acquisition financing costs, and potential Medicaid rate pressure as states address budget deficits.