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. Author manuscript; available in PMC: 2026 Sep 15.
Published in final edited form as: Pain Manag Nurs. 2026 Feb 19;27(4):e550–e557. doi: 10.1016/j.pmn.2026.01.004

Nursing Home Profit Status and Pain Among Residents Living With Dementia

Sorah Levy *,1, Barbara Resnick *, Elizabeth Galik *, Kelly Doran *, Tara McMullen †, Sarah Holmes *
PMCID: PMC13574152  NIHMSID: NIHMS2196300  PMID: 41720641

Abstract

Background:

Nursing home (NH) residents living with dementia experience pain that is often sub-optimally managed. There is a known relationship between NH organizational factors, such as profit status, and quality of care. However, little attention has been paid to understanding the relationship between NH ownership profit status and pain among residents living with dementia.

Aim:

To examine the relationship between NH ownership profit status and pain among residents living with dementia.

Design:

This cross-sectional secondary data analysis of the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) study included 553 NH residents living with dementia residing in 55 NHs in the United States.

Methods:

Descriptive statistics were used to summarize the sample, and generalized linear mixed models were used to examine the relationship between NH ownership profit status and pain, controlling for resident comorbidities, cognition, and NH quality rating.

Results:

NH communities were mostly owned by for-profit entities (61.8%, n = 34), and less than one quarter of residents had pain (23.3%, n = 125). NH ownership profit status was not significantly associated with pain (OR = −0.88, 95% CI = −1.86 to 0.10; p = .08).

Conclusions:

Given the complexity of assessing and treating pain in this population, there is a need for increased attention to improving pain management. Future studies should examine other NH organizational factors, such as for-profit entity subtype and its relationship with pain among residents living with dementia.

Keywords: Nursing homes, Ownership, Pain management, Dementia

Over 1.2 million individuals reside in nursing home (NH) communities across the United States (Henry J. Kaiser Family Foundation, 2023). It is estimated that greater than two-thirds of NH residents are living with dementia or some level of cognitive impairment that is severe enough to interfere with their activities of daily living (Hoben et al., 2024). Within this population, as many as 85% of residents experience pain (Helvik, Bergh, Šaltytė Benth, et al., 2023a). Residents living with dementia are at increased risk of their pain being underassessed and undertreated by NH staff due to their cognitive impairment and challenges related to their diminished ability to verbally report pain (Cole, Blackburn, et al., 2023; Helvik, Bergh, Šaltytė Benth, et al., 2023a; Wagatsuma et al., 2021). Suboptimal pain management among NH residents living with dementia is associated with resistive and aggressive behaviors (Ahn et al., 2015), more rapid progression of cognitive impairment (Achterberg et al., 2020; Agit et al., 2018; Bell et al., 2022), decline in physical function (Kolanowski et al., 2015; Resnick et al., 2022), and poor quality of life (Helvik, Bergh, Šaltytė Benth, et al., 2023a).

Background

Effective pain assessment and management for NH residents living with dementia requires dedicated resources to implement evidence-based guidelines, support ongoing staff training, and facilitate timely care planning (Baumgartner-Violand et al., 2024; Kodagoda Gamage et al., 2023; Minaya-Freire et al., 2020; Stahl et al., 2023). NH communities often lack staff trained in dementia care and pain management, largely due to resource limitations within the care setting (Lichtner et al., 2016; Minaya-Freire et al., 2020). NH ownership profit status may influence how resources are distributed for care delivery and operational priorities (Barsanti et al., 2021; Madrigal et al., 2023; Millar et al., 2024), potentially affecting pain management outcomes for residents.

The Centers for Medicare and Medicaid Services (CMS) State Operations Manual: Guidance to Surveyors for Long-Term Care Facilities, Appendix PP Section §483.25(k) provides guidance on pain management in NHs under regulation F697. The guidelines focus on the NH community’s responsibility to develop and implement a resident-centered pain management plan. This care plan must address pain prevention, assessment, and treatment interventions with ongoing evaluation of the effectiveness of each resident’s individualized pain management plan (State Operations Manual Appendix PP—Guidance to Surveyors for Long Term Care Facilities, 2024, Section §483.25(k)). Despite regulatory guidance and clinical practice guidelines (Association for Post-Acute and Long-Term Care Medicine [PALTmed], 2021), NH residents living with dementia continue to experience pain that is often not adequately assessed, diagnosed, or appropriately treated (Centmayer et al., 2024; Hunnicutt et al., 2017; Resnick et al., 2025).

The NH Industry

NH communities in the United States have evolved from primarily charity-operated institutions to mostly profit-driven entities (Institute of Medicine [US] Committee on Implications of For-Profit Enterprise in HealthCare, 1986). Currently, these communities deliver a wide range of resource-intensive services, including skilled nursing and medical care, 24-hour supervision, hospice and end-of-life care, rehabilitation services, and assistance with activities of daily living (Health in Aging Foundation, 2023). The high cost of delivering such services, coupled with regulatory changes related to reimbursement policy, has contributed to the predominance of for-profit NH ownership (Institute of Medicine [US] Committee on Implications of For-Profit Enterprise in Health Care, 1986). It is estimated that 73% of US NH communities are owned by for-profit entities, including corporate chains, individuals owners, partnerships, and private equity investment firms; 22% are nonprofit; and 5% are government-owned (Medicare Payment Advisory Commission, 2025).

The National NH Initiative was launched in 2020 by the United States Department of Justice to investigate NH owners and operators potentially engaging in practices prioritizing financial gain over resident care (U.S. Department of Justice, 2020). In 2022, a report by the National Academies of Sciences, Engineering, and Medicine’s Committee on the Quality of Care in NHs emphasized the association between NH ownership profit status and care quality. Specifically, for-profit NH communities were more likely than nonprofit NHs to have lower staffing levels, lower quality ratings, more deficiencies, and increased likelihood of being designated as a special focus facility, which is a NH identified by CMS to have serious and persistent quality issues (Centers for Medicare and Medicaid Services, 2025; Committee on the Quality of Care in Nursing Homes, Board on Health Care Services, Health and Medicine Division, & National Academies of Sciences, Engineering, and Medicine, 2022). Although both for-profit and nonprofit NHs face significant financial challenges (Marselas, 2025), the emphasis on minimizing expenditures in for-profit communities (Orewa et al., 2025) may lead to reduced investment in resources such as nurse staffing, training, and the systems and processes required to meet the complex care needs of residents living with dementia. Although prior work has established a significant association between NH ownership profit status and quality of care (Committee on the Quality of Care in Nursing Homes, Board on Health Care Services, Health and Medicine Division, & National Academies of Sciences, Engineering, and Medicine, 2022), the relationship between NH ownership profit status and pain outcomes among residents living with dementia has not been fully explored.

Literature Review

Factors Associated With Pain Among NH Residents Living With Dementia

Individual-level factors

Known factors related to pain among NH residents living with dementia include individual characteristics such as age, gender, race, cognition, comorbidities, and functional ability (Bae et al., 2020; Brandauer et al., 2020; Cole, Blackburn, et al., 2023; Cole, Carpenter, et al., 2023; Helvik, Bergh, Šaltytė Benth, et al., 2023a). Being female and older is associated with higher prevalence of pain (Centmayer et al., 2024). Additionally, NH residents who identify as being from underrepresented racial and ethnic groups are more likely to experience untreated or undertreated pain compared to non-Hispanic White residents (Hunnicutt et al., 2017; Morrison et al., 2021). Pain among NH residents has been positively associated with comorbidities (Cole et al., 2022; Wu et al., 2023) such that residents with more comorbidities report higher levels of pain. Comorbidities related to musculoskeletal disorders, such as osteoarthritis, are the most frequently cited clinical category associated with chronic pain (Myrenget et al., 2023).

The relationship between pain and physical function among residents living with dementia is complex (Kolanowski et al., 2015; Resnick et al., 2022). Previous studies demonstrate that higher pain is associated with poorer physical function (Kalinowski et al., 2019). Among residents living with dementia, staff may overlook pain and its symptoms as a contributing factor to a resident’s functional decline and instead attribute the decline to cognitive impairment (Resnick et al., 2022). This challenge is compounded by the fact that many residents living with dementia experience communication difficulties and may not be able to verbally report having pain (Myrenget et al., 2023; Sabater-Gárriz et al., 2024).

NH organizational-level factors

Organizational factors within NH communities (e.g., size, staffing, quality rating, profit status) can influence the effectiveness of pain management among residents living with dementia. Recent research demonstrated a significant association between large NH size and increased pain among residents (Bae et al., 2020), indicating that the size of the community may be important for understanding pain outcomes among its residents. Additionally, organizational practices, such as staffing levels and staff qualification, can affect NH staff’s ability to optimally support the management of pain in their residents (Pringle et al., 2021). In this, poor pain management can predict deficient survey performance (Mashouri et al., 2020). Further, NH communities with higher CMS quality ratings often have better NH staffing levels, training, and retention (Millar et al., 2024), all of which may contribute to better pain management processes and practices. Conversely, NH communities with lower quality ratings may lack sufficient resources to adequately assess and manage pain, particularly for residents living with dementia (Broms et al., 2024; Rodríguez-Martínez et al., 2023).

NH organizational-level factors, such as profit status, may influence care delivery decisions that can impact effective management of pain among residents living with dementia, particularly in an organization’s resource allocation choices (Orewa et al., 2025). Prior work demonstrates the influence of ownership profit status on staffing and resources (Kruse et al., 2021; Orewa et al., 2025). Transition from nonprofit to for-profit ownership has been associated with significant decreases in registered nurse and certified nursing assistant care delivery hours (Ryskina et al., 2024), potentially limiting staffing resources allocated for pain management.

Providing high-quality dementia care often requires resources beyond basic staffing ratios, including the additional costs of care coordination and specialized dementia services (Mukamel et al., 2024; Sheets et al., 2025; Williams et al., 2017). Consequently, the financial burden of caring for residents living with dementia and the impact this has on a NH community may contribute to findings that for-profit NH communities have 42% lower odds of having a special care unit for Alzheimer’s disease and related dementias (Orth & Cagle, 2022). Considering that NH residents living with dementia often experience pain that requires more complex and resource-intensive care (Achterberg et al., 2020; Sheets et al., 2025), and that pain management is not directly incentivized under the Patient Driven Payment Model, (Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, 2024, Chapter 6), pain management may receive less emphasis in for-profit NH communities where financial margins are closely monitored (Geng et al., 2025; He & Konetzka, 2015).

Given the increased focus on the profit status of NH communities and the impact that this can have on clinical outcomes for residents living with dementia, the purpose of this study was to examine the association between NH ownership profit status and pain in this population. It was hypothesized that controlling for residents’ age, gender, race, cognition, comorbidities, and function, as well as NH size, quality rating, and staffing, residents living with dementia in for-profit NH communities would have greater odds of pain than residents in nonprofit NH communities.

Methods

Study Design and Sample Procedure

This study was a cross-sectional descriptive secondary analysis of baseline data from the Testing the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) study (Resnick et al., 2018, 2021). The study sample included 553 NH residents from 55 NHs in Maryland and Pennsylvania. Data were collected between 2017 and 2020. Residents were eligible to participate in the EIT-4-BPSD study if they were 55 years of age or older, living in the NH, English speaking, were cognitively impaired based on a score of 12 or less on the Brief Interview for Mental Status (BIMS), and had at least one behavioral or psychological symptom associated with dementia (e.g., agitation, aggression, depressive symptoms) documented in their clinical record in the past month. Residents admitted to the NH community for short-stay or hospice were excluded from the study. NHs communities were included in the EIT-4-BPSD study if they had greater than 100 beds or greater than 50 beds when they had a dedicated dementia unit, had access to email, and identified a champion to work with the research team.

All participants were administered the Evaluation to Sign Consent, a five-item questionnaire evaluating the individual’s understanding and ability to consent to participation in the research (Resnick et al., 2007). If the participant agreed to participate and passed this evaluation, consent was obtained. If the participant did not pass the evaluation, assent was nevertheless obtained, and subsequently, the legally authorized representative was approached to complete the informed consent process. This study was reviewed and approved by the University of Maryland School of Medicine Institutional Review Board and the Pennsylvania State University Institutional Review Board. This research follows the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for reporting cross-sectional studies (von Elm et al., 2007).

Measures

Descriptive demographic and clinical information, including residents’ gender, age, and race, was gathered from the participants’ medical record. Additional resident measures were collected by trained research staff to assess physical function based on the Barthel Index (Mahoney & Barthel, 1965; Stone et al., 1994), cognition using the BIMS (Chodosh et al., 2008; Saliba et al., 2012), and comorbidities using the Cumulative Illness Rating Scale (Linn et al., 1968; Parmelee et al., 1995). NH community descriptive information collected included publicly reported quality rating scores and staffing levels based on CMS’ Care Compare data (Centers for Medicare and Medicaid Services, n.d.), as well as NH size measured by the community’s self-reported number of occupied beds.

Independent Variable: NH Ownership Profit Status

NH ownership profit status was collected from publicly reported information on the Care Compare website. Communities were categorized on Care Compare as nonprofit or for-profit based on their classification in the Provider Enrollment, Chain, and Ownership System using the criteria of the Internal Revenue Services (United States Government Accountability Office, 2023).

Dependent Variables: Pain

The Pain Assessment in Advanced Dementia Scale (PAINAD) (Warden et al., 2003) was used to objectively evaluate pain among participants. To address bias, this standardized observational measure was used by trained research staff while the resident was engaged in some type of activity. The PAINAD includes five behaviors commonly observed in individuals with pain: breathing, vocalization, facial expression, body language, and consolability (Warden et al., 2003). Each of these five behaviors are scored from 0 to 2 based on symptoms observed by the assessor over a 5-minute period. Scores are then totaled to create an aggregate pain score that ranges from 0 to 10, which has concurrent validity with the Numeric Pain Scale score (p < .0001) (Mosele et al., 2012), as well as the visual analog scale (Natavio et al., 2020). The PAINAD has established evidence of reliability based on internal consistency with an equivalent alpha coefficient of 0.95 (Resnick et al., 2022), an intra-rater reliability of 0.71–0.89, and inter-rater reliability of 0.79–0.94 (Smith & Harvey, 2022). In this study, the PAINAD scores were positively skewed. Therefore, as was done in prior work (Holmerová et al., 2018; Tan et al., 2016), the variable was recoded to a binary response with a score of zero indicating no observed pain symptoms and a score of one or above indicating the presence of observed pain symptoms.

Data Analysis

Descriptive statistics were used to summarize the sample, including mean, median, mode, frequencies, proportions, and standard deviations. Data missingness was analyzed, and found that 3% of the sample (n = 17) had missing pain scores. Little’s MCAR test demonstrated that missing data were missing completely at random (χ2 (36) = 27.71, p = .837). Covariates were identified to address confounding bias. Exploratory data analysis was conducted using bivariate analyses to examine the associations between pain and the hypothesized covariates, including age, race, gender, cognition, comorbidities, function, nurse staffing, NH quality rating, and NH size. A significance level of 0.05 was used to determine statistical significance. Based on the results of these bivariate analyses, covariates that were significantly associated with pain and had strong theoretical justification based on prior literature were retained in the final multivariable model. Therefore, resident cognition and comorbidities, and NH quality rating were included as covariates in the final model.

Generalized linear mixed models (GLMM) were used to examine the relationship between NH ownership profit status and pain, controlling for residents’ comorbidities, cognition, and NH quality rating. Observations within a group or cluster, such as residents living in an NH, tend to be more alike compared to observations among other groups (Bolker et al., 2009). Consequently, the assumption of independence may be violated (Bolker et al., 2009). The intra-class correlation (ICC) was assessed as the proportion of total variance accounted for by clustering of residents within NH communities. An ICC value ranges from zero to one, with higher values indicative of the need to adjust for a potential clustering effect (Killip et al., 2004). The ICC in the null model was 0.258, indicating that 25.8% of the total variation was attributed to the community variance. Thus, we used GLMM to account for the clustering effect.

The GLMM allows for the use of clustered data and enables group-level characteristics, such as NH ownership profit status, to be included in models with the individual-level pain outcome. The NH community of residence was applied as the random effect, and community ownership profit status, along with covariates (comorbidities, cognition, and quality rating), were entered as fixed effects. The model was statistically significant (F (5,527) = 3.206, p = .007), and the pseudo-R2 indicated that 31.9% of the variance in pain among NH residents living with dementia is explained by the model. Statistical Package for Social Science, Version 29 (IBM Corp., 2023) was used for data analysis.

Results

A summary of the sample characteristics is provided in Table 1. The average age of residents in the sample was 83.9 (SD = 10.45) and 72.0% (n = 398) of participants were female. Most residents were White (75.8%, n = 419), and the participants had an average of 7.1 comorbidities (SD = 2.16), function with a mean Barthel Index score of 36.5 (SD = 30.20), and cognitive impairment with a mean BIMS score of 4.3 (SD = 3.48). Less than one third of residents had observed pain (n = 125, 23.3%). NH communities were mostly for-profit (n = 34, 61%), had an average occupancy of 150 residents (SD =78.05), and a mean quality rating of 3.4 (SD = 1.29).

Table 1.

Summary of Resident and Nursing Home Community Characteristics.

N (%) Mean, SD (Range) Missing Data
Resident characteristics (N = 553)
 Female 398 (72.0) 0
 Age 83.9, 10.45 (56–105) 7
 White 419 (75.8) 0
 Comorbidities 7.1, 2.16 (2–12) 11
 Physical function 36.5, 30.20 (3–100) 17
 Cognition 4.3, 3.48 (0–12) 8
 Pain (PAIN-AD > 0) 125 (23.3) 17
Community characteristics (N = 55)
 For-profit 34 (61.8) 0
 Size 150, 78.05 (45–412) 0
 Quality rating 3.4, 1.29 (1–5) 0
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There were 17 residents missing pain assessments.

As shown in Table 2, results from the GLMM demonstrated that NH ownership profit status was not significantly associated with having observed pain among NH residents living with dementia (OR = −0.88, 95% CI = −1.86 to 0.10; p = .08), controlling for the residents’ cognition, comorbidities, and NH quality rating. Cognition was significantly associated with pain (OR = 0.90, 95% CI = −0.18 to −0.03; p ≤ .01) in that a one unit decrease in BIMS score, indicating lower cognitive ability, was associated with approximately 10% decreased odds of a resident having observed pain. Additionally, higher NH quality rating was significantly associated with decreased odds of observed pain among residents living with dementia (OR = 0.59, 95% CI = −0.80 to 0.06; p = .02).

Table 2.

Results of Generalized Linear Mixed Model Analysis (N = 553).

Beta Standard Error Odds Ratio (95% CI) p
Profit status −0.88 0.50 0.41 (−1.86 to 0.10) .08
Comorbidities −0.01 0.07 0.99 (−0.14 to 0.13) .93
Cognition −0.11 0.04 0.90 (−0.18 to −0.03) <.01
Quality rating −0.43 0.19 0.59 (−0.80 to 0.06) .02
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There were 17 residents missing pain assessments.

Discussion

This study examined the relationship between NH ownership profit status and pain among residents living with dementia. The hypothesis that residents living with dementia in for-profit NH communities would have greater odds of pain than residents in nonprofit NH communities was not supported in this study. The prevalence of pain observed among residents living with dementia in this study was relatively low, with only 23.3% (n = 125) exhibiting observed signs of pain using the PAINAD. This is lower than what has been found in other studies, which have documented pain among 30% to 85% of residents living with dementia (Ersek et al., 2020; Helvik et al., 2023b; Hunnicutt et al., 2017; van Kooten et al., 2017). Future research might consider alternative measures of pain, including both verbal and observational measures, and measuring pain at more than one point in time. Additionally, exploring the frequency and effectiveness of comprehensive pain management plan of care reviews, and both pharmacological and nonpharmacological pain treatment options, are areas that could be explored in future work. The profit status of NH communities may influence the use of nonpharmacologic approaches to pain management, which can be resource-intensive and are often less frequently provided to residents living with dementia (Nakashima et al., 2019; Resnick et al., 2024; Veal et al., 2018).

Although this study did not find a significant association between NH ownership profit status and pain among residents living with dementia, assessing and managing pain in residents living with dementia requires substantial time and specialized care planning and processes (Yao et al., 2025). Prior work has found that providing care for residents living with dementia is associated with higher costs (Sheets et al., 2025), which may influence organizational practices, particularly in for-profit NH communities. Given the established relationships between NH ownership type and quality of care outcomes (Braun et al., 2021), future research should examine organizational factors and their relationship with pain management among residents living with dementia, such as individual versus chain ownership or the involvement of private equity investment in NH communities (Centers for Medicare and Medicaid Services, 2023).

Strengths and Limitations

Strengths of this study include the use of valid and reliable measures to assess the predictors and outcome, as well as the large sample size. The lack of heterogeneity in pain, possibly because a single observational measure was used to assess pain, as well as the lack of consideration for other indicators of pain management, such as assessment documentation and appropriate treatment approaches (e.g., pharmacological opioid, nonopioid pharmacological, nonpharmacological), are limitations in this study. The sample was limited in that it only included NH communities from a single geographic region of the United States. Consequently, the findings cannot be generalized to all NHs and residents across the country or internationally. Future research is needed to confirm these findings in other geographic locations with a diverse population of NH residents living with dementia. NH ownership profit status was measured in this study using the dichotomous for-profit and non-profit categories defined by Internal Revenue Service’s reporting regulation and utilized by Provider Enrollment, Chain, and Ownership System. While this measure is widely used (Millar et al., 2025; Ryskina et al., 2018; Travers et al., 2023), this is a limitation as the type of for-profit entity can range from an individual or partnership ownership arrangement to chain, corporation, or private equity investment with possible varying emphasis on profits over resident outcomes (U.S. Department of Justice, 2020).

Implications for Nursing Education, Practice, and Research

Managing pain in NH residents living with dementia is particularly challenging and often consumes resources disproportionately (Mukamel et al., 2024; Sheets et al., 2025; Williams et al., 2017). There is opportunity for policy promoting increased clinical and regulatory focus to encourage the implementation of pain management clinical practice guidelines in NH communities (Brunkert et al., 2021). Additionally, including pain management, such as pain assessment and treatment, in value-based care models may influence NH leadership’s clinical focus (Konetzka et al., 2018; Lee et al., 2020; Liao et al., 2020), resulting in improved resident care. While assessing pain in NH residents living with dementia remains clinically complex and difficult to measure, additional research is needed to further explore other organizational-level factors, as well as the associations between the NH community ownership entity subtype (e.g., individuals, chains, corporations, partnerships, or investment firms) and pain management outcomes among NH residents living with dementia.

Conclusion

This study adds to the growing body of literature examining how NH ownership profit status is associated with pain among residents living with dementia. The findings are notable that no significant association was observed between for-profit NH ownership and pain. Resident cognition and a community’s quality rating did have significant associations with pain. Given the complexity of managing pain in residents living with dementia, there is a need for increased clinical and policy attention to improving resident outcomes. Future research should consider examining more comprehensive models that include a broader range of resident and community-level factors and test their associations with pain in a diverse and representative sample of NH residents living with dementia.

Funding

This work was supported by the National Institutes of Nursing Research, United States (1R01NR015982-01A1, 2016). PI: Barbara Resnick, PhD, CRNP, FAAN, FAANP.

Footnotes

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article. All authors contributed to the conception or design of the study. All authors drafted the manuscript, or critically revised the manuscript, and gave final approval of the version that was submitted for publication. All authors agree to be accountable for all aspects of the work, ensuring integrity and accuracy.

Ethical Statement

This study was reviewed and approved by the University of Maryland, Baltimore, Institutional Review Board (HP-00069354) and the Pennsylvania State University Institutional Review Board (Study00008695).

Consent to Participate

Verbal informed consent was obtained by all participants or by their legally authorized representatives when applicable.

CRediT authorship contribution statement

Sorah Levy: Writing – review & editing, Writing – original draft, Software, Project administration, Methodology, Formal analysis, Conceptualization. Barbara Resnick: Writing – review & editing, Writing – original draft, Software, Resources, Methodology, Data curation, Conceptualization. Elizabeth Galik: Writing – review & editing, Conceptualization. Kelly Doran: Writing – original draft, Conceptualization. Tara McMullen: Writing – review & editing, Conceptualization. Sarah Holmes: Writing – review & editing, Writing – original draft, Validation, Supervision, Software, Methodology, Formal analysis, Conceptualization.

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