PROJECT SUMMARY/ABSTRACT Alzheimer's disease and related dementias (ADRD) affect 5.5 million people in the US and account for $305 billion in health care spending annually. Nearly half of all Medicare decedents have an ADRD diagnosis prior to death. Nursing homes play an important role in end-of-life (EOL) care for individuals with ADRD. Among the 1.4 million nursing home residents in the US, 68% have some degree of ADRD, with the prevalence expected to increase. More than two-thirds of all ADRD-related deaths occur in nursing homes. Nursing home ownership has been associated with the quality of EOL care for residents with ADRD. Among US nursing homes, 12% have investment from real estate investment trusts (REITs). It is not known whether REIT investments in nursing homes are associated with the quality of EOL care. The prevalence and increasing rates of these corporate investments have raised concerns among policymakers and oversight agencies including the Government Accountability Office, MedPAC, the House Ways and Means Committee, the Senate Finance Committee, and The White House. The Centers for Medicare and Medicaid Services have proposed a new rule that would require public reporting of REIT investments in nursing homes. REITs are for-profit public or private corporations that invest in income- producing properties. They are “pass-through entities” which qualify for tax exemptions if they satisfy requirements related to sources of income and assets, including disbursing 90% of their taxable income to shareholders as dividends. These corporations purchase a nursing home's property and lease it back to the nursing home operator. Under this arrangement, the operator pays all of the expenses of the property, including real estate taxes, building insurance, and maintenance. These expenses are in addition to the cost of rent and utilities that are paid to the REIT by the operator. REITs are not directly involved in nursing home operations, though they may provide guidance to help the operator achieve profitability goals. Selling a nursing home's property to a REIT provides the operator with an infusion of capital that can conceivably be used for facility improvements and/or to provide more resources for resident care. However, annual rent escalations that are typically included in the leases may make rent unaffordable for nursing home operators over time and potentially lead to reductions in staffing, supplies, or equipment that negatively impact the quality of EOL care. Preliminary analyses indicate that registered nurse staffing levels in nursing homes are often reduced following REIT investment. For this project, a nationally representative database of nursing home residents with ADRD will be constructed from Medicare claims and Minimum Data Set assessments and merged with a novel database of REIT investments in nursing homes for the period 2012-2022. This will be the first study of the relationships between REIT investments in nursing homes a...