An NBER working paper (Tunneling and Hidden Profits in Health Care by Ashvin Gandhi & Andrew Olenski) on the nursing home sector reveals extensive profit tunneling, particularly in real estate and management services. This involves nursing homes purchasing services from related entities at inflated prices, effectively transferring profits and concealing the true financial state of these providers.
Seems like they should require the homes to self service all parts. It must have its own laundry facilities and kitchen and such and must employee directly the majority of its staff (some allowance for handling temporary short staffing with requirements for keeping a fulltime head count). I mean thats what these things are supposed to be.