DEI Info Cover Page Document - shares	3 Months Ended
DEI Info Cover Page Document - shares	Mar. 31, 2019	May 03, 2019
Entity Information [Abstract]
Entity Registrant Name	ENSIGN GROUP, INC
Entity Central Index Key	0001125376
Current Fiscal Year End Date	--12-31
Entity Filer Category	Large Accelerated Filer
Document Type	10-Q
Current Reporting Status	Yes
Document Period End Date	Mar. 31, 2019
Document Fiscal Year Focus	2019
Document Fiscal Period Focus	Q1
Amendment Flag	false
Entity Emerging Growth Company	false
Entity Small Business	false
Entity Common Stock, Shares Outstanding		53,011,547

Consolidated Balance Sheets - USD ($) $ in Thousands	Mar. 31, 2019	Dec. 31, 2018
Current assets:
Cash and cash equivalents	$ 37,824	$ 31,083
Accounts receivable—less allowance for doubtful accounts of $3,380 and $2,886 at March 31, 2019 and December 31, 2018, respectively	291,701	276,099
Investments—current	4,037	8,682
Prepaid income taxes	148	6,219
Prepaid expenses and other current assets	24,019	24,130
Assets held for sale - current	0	1,859
Total current assets	357,729	348,072
Property and equipment, net	627,400	618,874
Right-of-use assets (Note 17)	1,045,638	0
Insurance subsidiary deposits and investments	42,937	36,168
Escrow deposits	300	7,271
Deferred tax assets	8,603	11,650
Restricted and other assets	16,441	20,844
Intangible assets, net	4,131	31,000
Goodwill	87,062	80,477
Other indefinite-lived intangibles	28,118	27,602
Total assets	2,218,359	1,181,958
Current liabilities:
Accounts payable	44,595	44,236
Accrued wages and related liabilities	103,170	119,656
Lease liabilities—current (Note 17)	58,220	0
Accrued self-insurance liabilities—current	25,375	25,446
Other accrued liabilities	69,954	69,784
Current maturities of long-term debt	10,129	10,105
Total current liabilities	311,443	269,227
Long-term debt—less current maturities	240,660	233,135
Long-term lease liabilities—less current portion (Note 17)	963,172	0
Accrued self-insurance liabilities—less current portion	56,419	54,605
Other long-term liabilities	1,662	11,234
Deferred gain related to sale-leaseback (Note 17)	0	11,417
Total liabilities	1,573,356	579,618
Commitments and contingencies (Notes 15, 17 and 18)
Equity:
Common stock; $0.001 par value; 75,000 shares authorized; 55,465 and 52,955 shares issued and outstanding at March 31, 2019, respectively, and 55,089 and 52,584 shares issued and outstanding at December 31, 2018, respectively	55	55
Additional paid-in capital	292,612	284,384
Retained earnings	378,443	344,901
Common stock in treasury, at cost, 1,932 shares at March 31, 2019 and December 31, 2018, respectively	(38,405)	(38,405)
Total Ensign Group, Inc. stockholders' equity	632,705	590,935
Non-controlling interest	12,298	11,405
Total equity	645,003	602,340
Total liabilities and equity	$ 2,218,359	$ 1,181,958

Consolidated Balance Sheets Balance Sheet (Paranthetical) - USD ($) shares in Thousands, $ in Thousands	Mar. 31, 2019	Dec. 31, 2018
Current assets:
Allowance for doubtful accounts	$ 3,380	$ 2,886
Equity:
Common stock, par value	$ 0.001	$ 0.001
Common stock, shares authorized	75,000	75,000
Common stock, shares issued	55,465	55,089
Common stock, shares outstanding	52,955	52,584
Common stock in treasury, at cost	1,932	1,932

Consolidated Statements of Income - USD ($) shares in Thousands, $ in Thousands	3 Months Ended
	Mar. 31, 2019	Mar. 31, 2018
Revenue	$ 549,214	$ 492,134
Expense
Cost of services	430,002	390,243
Return of unclaimed class action settlement (Note 18)	0	(1,664)
Rent—cost of services (Note 17)	35,786	33,850
General and administrative expense	33,024	25,104
Depreciation and amortization	12,598	11,622
Total expenses	511,410	459,155
Income from operations	37,804	32,979
Other income (expense):
Interest expense	(3,672)	(3,613)
Interest income	575	448
Other expense, net	(3,097)	(3,165)
Income before provision for income taxes	34,707	29,814
Provision for income taxes	7,100	6,521
Net income	27,607	23,293
Less: net income attributable to noncontrolling interests	235	161
Net income attributable to The Ensign Group, Inc.	$ 27,372	$ 23,132
Basic:
Basic net income per common share attributable to The Ensign Group, Inc.	$ 0.52	$ 0.45
Diluted:
Diluted net income per common share attributable to The Ensign Group, Inc.	$ 0.49	$ 0.43
Weighted average common shares outstanding:
Basic	53,081	51,585
Diluted	55,698	53,518

Consolidated Statement of Stockholders' Equity Statement - USD ($) shares in Thousands, $ in Thousands	Total	Common Stock [Member]	Additional Paid-in Capital [Member]	Retained Earnings [Member]	Treasury Stock [Member]	Noncontrolling Interest [Member]
Balance - January 1, at Dec. 31, 2017	$ 500,059	$ 53	$ 266,058	$ 264,691	$ (38,405)	$ 7,662
Balance - January 1 (in shares) at Dec. 31, 2017		51,360
Balance - January 1 (in treasury shares) at Dec. 31, 2017					1,932
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		404			0
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	2,920	$ 1	2,919		$ 0
Dividends declared	(2,346)			(2,346)
Employee stock award compensation	1,971		1,971
Noncontrolling interest attributable to subsidiary equity plan (Note 16)	338			(79)		417
Distribution to noncontrolling interest holder	(292)					(292)
Net income attributable to noncontrolling interest	161					161
Net Income (Loss) Attributable to the Ensign Group, Inc.	23,132
Balance - March 31, at Mar. 31, 2018	525,943	$ 54	270,948	285,398	$ (38,405)	7,948
Balance - March 31 (in shares) at Mar. 31, 2018		51,764
Balance - March 31 (in treasury shares) at Mar. 31, 2018					1,932
Balance - January 1, at Dec. 31, 2018	$ 602,340	$ 55	284,384	344,901	$ (38,405)	11,405
Balance - January 1 (in shares) at Dec. 31, 2018	52,584	52,584
Balance - January 1 (in treasury shares) at Dec. 31, 2018					1,932
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		371			0
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	$ 5,616	$ 0	5,616		$ 0
Dividends declared	(2,543)			(2,543)
Employee stock award compensation	2,612		2,612
Noncontrolling interest attributable to subsidiary equity plan (Note 16)	341			(317)		658
Net income attributable to noncontrolling interest	235					235
Net Income (Loss) Attributable to the Ensign Group, Inc.	27,372
Balance - March 31, at Mar. 31, 2019	$ 645,003	$ 55	$ 292,612	378,443	$ (38,405)	$ 12,298
Balance - March 31 (in shares) at Mar. 31, 2019	52,955	52,955
Balance - March 31 (in treasury shares) at Mar. 31, 2019					1,932
Cumulative effect of new accounting change, net of tax	$ 9,030			$ 9,030

Consolidated Statements of Cash Flows - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2019	Mar. 31, 2018
Cash flows from operating activities:
Net income	$ 27,607	$ 23,293
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation and amortization	12,598	11,622
Impairment of long-lived assets	0	155
Amortization of deferred financing fees	293	299
Amortization of deferred gain on sale-leaseback (Note 17)	0	(164)
Amortization of right-of-use assets (Note 17)	(254)	0
Deferred income taxes	0	14
Provision for doubtful accounts	615	570
Share-based compensation	2,953	2,309
Cash received from insurance proceeds related to replacement properties and business interruptions	0	167
Gain on insurance claims and disposal of assets	(4)	(667)
Change in operating assets and liabilities
Accounts receivable	(16,341)	6,453
Prepaid income taxes	6,072	6,654
Prepaid expenses and other assets	4,995	2,162
Insurance subsidiary deposits	0	80
Accounts payable	558	(6,815)
Accrued wages and related liabilities	(13,204)	(6,490)
Income taxes payable	990	0
Other accrued liabilities	(3,345)	(647)
Accrued self-insurance liabilities	1,352	1,061
Other long-term liability	(43)	339
Net cash provided by operating activities	24,842	40,395
Cash flows from investing activities:
Purchase of property and equipment	(13,645)	(11,082)
Cash payments for business acquisitions (Note 8)	(8,004)	0
Cash payments for asset acquisitions (Note 8)	(5,763)	(4,447)
Escrow deposits	(300)	(10,025)
Escrow deposits used to fund acquisitions	7,271	228
Cash proceeds from the sale of assets and insurance proceeds	2,521	64
Change in other assets	(7,473)	(201)
Net cash used in investing activities	(25,393)	(25,463)
Cash flows from financing activities:
Proceeds from revolving credit facility and other debt (Note 15)	265,000	195,000
Payments on revolving credit facility and other debt (Note 15)	(257,517)	(217,421)
Issuance of common stock upon exercise of options	2,334	2,920
Dividends paid	(2,525)	(2,328)
Non-controlling interest distribution	0	(292)
Payments of deferred financing costs	0	(91)
Net cash provided by/(used in) financing activities	7,292	(22,212)
Net increase/(decrease) in cash and cash equivalents	6,741	(7,280)
Cash and cash equivalents beginning of period	31,083	42,337
Cash and cash equivalents end of period	37,824	35,057
Cash paid during the period for:
Interest	2,916	3,809
Lease liabilities	36,183	0
Non-cash financing and investing activity:
Accrued capital expenditures	3,300	3,300
Accrued dividends declared	2,543	2,346
Note receivable from sale of ancillary business	0	139
Note payable due to seller from business acquisition	924	0
Right-of-Use Asset Obtained in Exchange for Operating Lease Liability	$ 6,348	$ 0

Description of Business	3 Months Ended
Description of Business	Mar. 31, 2019
DESCRIPTION OF BUSINESS [Abstract]
Organization, Consolidation and Presentation of Financial Statements Disclosure [Text Block]	DESCRIPTION OF BUSINESS The Company - The Ensign Group, Inc. (collectively, Ensign or the Company), is a holding company with no direct operating assets, employees or revenue. The Company, through its operating subsidiaries, is a provider of health care services across the post-acute care continuum. As of March 31, 2019, the Company operated 245 facilities, 56 home health, hospice and home care agencies and other ancillary operations located in Arizona, California, Colorado, Idaho, Iowa, Kansas, Nebraska, Nevada, Oklahoma, Oregon, South Carolina, Texas, Utah, Washington, Wisconsin and Wyoming. The Company's operating subsidiaries, each of which strives to be the operation of choice in the community it serves, provide a broad spectrum of skilled nursing, senior living, home health, hospice, home care and other ancillary services. The Company's operating subsidiaries have a collective capacity of approximately 19,800 operational skilled nursing beds and 5,600 senior living units. As of March 31, 2019, the Company owned 72 of its 245 affiliated facilities and leased an additional 173 facilities through long-term lease arrangements and had options to purchase 12 of those 173 facilities. As of December 31, 2018, the Company owned 72 of its 244 affiliated facilities and leased an additional 172 facilities through long-term lease arrangements and had options to purchase 12 of those 172 facilities. Certain of the Company’s wholly-owned independent subsidiaries, collectively referred to as the Service Center, provide certain accounting, payroll, human resources, information technology, legal, risk management and other centralized services to the other operating subsidiaries through contractual relationships with such subsidiaries. The Company also has a wholly-owned captive insurance subsidiary (the Captive) that provides some claims-made coverage to the Company’s operating subsidiaries for general and professional liability, as well as coverage for certain workers’ compensation insurance liabilities. Each of the Company's affiliated operations are operated by separate, wholly-owned, independent subsidiaries that have their own management, employees and assets. References herein to the consolidated “Company” and “its” assets and activities in this Report is not meant to imply, nor should it be construed as meaning, that The Ensign Group, Inc. has direct operating assets, employees or revenue, or that any of the subsidiaries, are operated by The Ensign Group, Inc. Proposed Spin-Off Transaction — On May 6, 2019, the Company announced a proposed plan to separate its transitional and skilled nursing services, and its home health and hospice operations and substantially all of its senior living and other ancillary operations into two separate, publicly traded companies. See Note 2, Proposed Spin-Off of Subsidiaries. Other Information — The accompanying condensed consolidated financial statements as of March 31, 2019 and for the three months ended March 31, 2019 and 2018 (collectively, the Interim Financial Statements) are unaudited. Certain information and note disclosures normally included in annual consolidated financial statements have been condensed or omitted, as permitted under applicable rules and regulations. Readers of the Interim Financial Statements should refer to the Company’s audited consolidated financial statements and notes thereto for the year ended December 31, 2018 which are included in the Company’s annual report on Form 10-K, File No. 001-33757 (the Annual Report) filed with the Securities and Exchange Commission (SEC). Management believes that the Interim Financial Statements reflect all adjustments which are of a normal and recurring nature necessary to present fairly the Company’s financial position and results of operations in all material respects. The results of operations presented in the Interim Financial Statements are not necessarily representative of operations for the entire year.

Proposed Spin-Off of Subsidiaries

3 Months Ended

Mar. 31, 2019

Proposed Spin-Off [Abstract]

Proposed Spin-Off [Text Block]

PROPOSED SPIN-OFF OF SUBSIDIARIES

On May 6, 2019, the Company announced a proposed plan to separate its transitional and skilled nursing services, and its home health and hospice operations and substantially all of its senior living and other ancillary operations into two separate, publicly traded companies:


•	Ensign, which will include transitional and skilled services, rehabilitative care services, healthcare campuses, post-acute-related new business ventures and real estate investments; and


•	The Pennant Group, Inc. ("Pennant"), which will be a holding company of operating subsidiaries that provide home health, hospice, senior living and mobile diagnostic and clinical laboratory operations.

The Company intends to accomplish the proposed separation through a Spin-Off, in which it expects to distribute shares of Pennant common stock to the Company’s stockholders, on a pro rata basis. The Company anticipates that at the time of the Spin-Off, Pennant, which is currently a wholly-owned subsidiary of the Company, will consists of 60 home health, hospice and home care agencies, 51 senior living communities and other ancillary operations as of May 6, 2019. Ensign affiliates will retain ownership of the real estate at 28 of the 51 senior living operations that are being contributed to Pennant. The Company anticipates that after the Spin-Off, all of these properties will be leased to Pennant on a triple-net basis, under which Pennant affiliates will be responsible for all costs at the properties, including property taxes, insurance and maintenance and repair costs.

In accordance with Accounting Standards Codification (ASC) 505-60, Equity-Spinoffs and Reverse Spinoffs, the accounting for the separation of the Company follows its legal form, with Ensign as the legal and accounting spinnor and Pennant as the legal and accounting spinnee, due to the relative significance of Ensign’s healthcare business, the relative fair values of the respective companies, the retention of all senior management, and other relevant indicators.

In connection with the adoption of the stockholder rights plan, the Company anticipates that the board of directors will declare a dividend of one share of Pennant common stock for every two shares of the Company's common stock held by stockholders as of the record date. Pennant is also anticipating that awards of equity of Pennant subsidiaries granted to certain individuals will be exchanged for Pennant common stock immediately prior to the distribution. The number of shares of Ensign common stock each stockholder owns and the related proportionate interest in Ensign will not change as a result of the proposed Spin-Off. Each Ensign stockholder will receive only whole shares of Pennant common stock in the distribution, as well as cash in lieu of any fractional shares. The proposed Spin-Off is subject to customary conditions, including receipt of a tax opinion from counsel, effectiveness of the registration statement filed with the Securities and Exchange Commission, execution of third-party agreements and final approval by Ensign’s board of directors.

Significant Accounting Policies	3 Months Ended
Significant Accounting Policies	Mar. 31, 2019
Accounting Policies [Abstract]
Basis of Presentation and Significant Accounting Policies [Text Block]	SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Basis of Presentation — The accompanying Interim Financial Statements have been prepared in accordance with accounting principles generally accepted in the United States (GAAP). The Company is the sole member or stockholder of various consolidated limited liability companies and corporations established to operate various acquired skilled nursing and senior living operations, home health, hospice and home care operations, and related ancillary services. All intercompany transactions and balances have been eliminated in consolidation. The condensed consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest. The Company presents noncontrolling interests within the equity section of its condensed consolidated balance sheets. The Company presents the amount of consolidated net income that is attributable to The Ensign Group, Inc. and the noncontrolling interest in its condensed consolidated statements of income. The condensed consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest and the accounts of any variable interest entities (VIEs) where the Company is subject to a majority of the risk of loss from the VIE's activities, or entitled to receive a majority of the entity's residual returns, or both. The Company assesses the requirements related to the consolidation of VIEs, including a qualitative assessment of power and economics that considers which entity has the power to direct the activities that "most significantly impact" the VIE's economic performance and has the obligation to absorb losses of, or the right to receive benefits that could be potentially significant to, the VIE. The Company's relationship with variable interest entities was not material during the three months ended March 31, 2019. The Company completed the sale of one of its senior living operations for a sale price of $1,838 during the three months ended March 31, 2019. The sale transaction does not meet the criteria of discontinued operations as it does not represent a strategic shift that has, or will have, a major effect on the Company's operations and financial results. The Company presented property and equipment assets of the senior living operation sold as held for sale in the consolidated balance sheet as of December 31, 2018. Reclassifications - Certain prior period amounts have been reclassified to conform to the current financial statement presentation, with no effect on the Company's consolidated financial position or results of operations. Estimates and Assumptions — The preparation of Interim Financial Statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the Interim Financial Statements and the reported amounts of revenue and expenses during the reporting periods. The most significant estimates in the Company’s Interim Financial Statements relate to revenue, intangible assets and goodwill, impairment of long-lived assets, general and professional liability, workers' compensation and healthcare claims included in accrued self-insurance liabilities, and income taxes. Actual results could differ from those estimates. Fair Value of Financial Instruments —The Company’s financial instruments consist principally of cash and cash equivalents, debt security investments, accounts receivable, insurance subsidiary deposits, accounts payable and borrowings. The Company believes all of the financial instruments’ recorded values approximate fair values because of their nature or respective short durations. Revenue Recognition — On January 1, 2018, the Company adopted Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (ASC 606) applying the modified retrospective method. The adoption of ASC 606 did not have a material impact on the measurement nor on the recognition of revenue of contracts, for which all revenue had not been recognized, as of January 1, 2018, therefore no cumulative adjustment has been made to the opening balance of retained earnings at the beginning of 2018. See Note 4, Revenue and Accounts Receivable. Accounts Receivable and Allowance for Doubtful Accounts — Accounts receivable consist primarily of amounts due from Medicare and Medicaid programs, other government programs, managed care health plans and private payor sources, net of estimates for variable consideration. The allowance for doubtful accounts reflects the Company’s best estimate of probable losses inherent in the accounts receivable balance. The Company determines the allowance based on known troubled accounts and other currently available evidence. See Note 4, Revenue and Accounts Receivable. Property and Equipment — Property and equipment are initially recorded at their historical cost. Repairs and maintenance are expensed as incurred. Depreciation is computed using the straight-line method over the estimated useful lives of the depreciable assets (ranging from three to 59 years). Leasehold improvements are amortized on a straight-line basis over the shorter of their estimated useful lives or the remaining lease term. Impairment of Long-Lived Assets — The Company reviews the carrying value of long-lived assets that are held and used in the Company’s operating subsidiaries for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of these assets is determined based upon expected undiscounted future net cash flows from the operating subsidiaries to which the assets relate, utilizing management’s best estimate, appropriate assumptions, and projections at the time. If the carrying value is determined to be unrecoverable from future operating cash flows, the asset is deemed impaired and an impairment loss would be recognized to the extent the carrying value exceeded the estimated fair value of the asset. The Company estimates the fair value of assets based on the estimated future discounted cash flows of the asset. Management has evaluated its long-lived assets and recorded an impairment charge of $155 during the three months ended March 31, 2018. The Company did not record an impairment charge during the three months ended March 31, 2019. Leases and Leasehold Improvements - The Company leases skilled nursing facilities, senior living facilities and commercial office space. On January 1, 2019, the Company adopted Accounting Standards Codification Topic 842, Leases (ASC 842), electing the transition method that allows it to apply the standard as of the adoption date and record a cumulative adjustment in retained earnings. The Company determines if an arrangement is a lease at the inception of each lease. At the inception of each lease, the Company performs an evaluation to determine whether the lease should be classified as an operating or finance lease. Operating leases are included in operating lease assets, current operating lease liabilities and noncurrent operating lease liabilities on the Company's condensed consolidated balance sheet. As the Company's leases do not provide an implicit rate, the Company uses its incremental borrowing rate based on the information available at lease commencement date in determining the present value of future lease payments. The Company estimates this rate based on prevailing financial market conditions, comparable company and credit analysis, and management judgment. The Company records rent expense for operating leases on a straight-line basis over the term of the lease. The lease term used for straight-line rent expense is calculated from the date the Company is given control of the leased premises through the end of the lease term. The lease term excludes lease renewals as the renewal rents are not at a bargain, there are no economic penalties for the Company to renew the lease, and it is not reasonably assured that the Company will exercise the extension options. The lease term used for this evaluation also provides the basis for establishing depreciable lives for buildings subject to lease and leasehold improvements. The Company recognizes lease expense for leases with an initial term of 12 months or less on a straight-line basis over the lease term. These leases are not recorded on the condensed consolidated balance sheet. Certain of the Company's lease agreements include rental payments that are adjusted periodically for inflation. The lease agreements do not contain any material residual value guarantees or material restrictive covenants. The Company does not have material subleases. See further discussion at Note 17, Leases. Intangible Assets and Goodwill — Definite-lived intangible assets consist primarily of patient base, facility trade names and customer relationships. Trade names at affiliated facilities are amortized over 30 years and customer relationships are amortized over a period of up to 20 years. The Company's indefinite-lived intangible assets consist of trade names, and Medicare and Medicaid licenses. The Company tests indefinite-lived intangible assets for impairment on an annual basis or more frequently if events or changes in circumstances indicate that the carrying amount of the intangible asset may not be recoverable. Goodwill represents the excess of the purchase price over the fair value of identifiable net assets acquired in business combinations. Goodwill is subject to annual testing for impairment. In addition, goodwill is tested for impairment if events occur or circumstances change that would reduce the fair value of a reporting unit below its carrying amount. The Company performs its annual test for impairment during the fourth quarter of each year. The Company did not identify any goodwill and intangible assets impairment during the three months ended March 31, 2019 and 2018. See further discussion at Note 11, Goodwill and Other Indefinite-Lived Intangible Assets. Self-Insurance — The Company is partially self-insured for general and professional liability up to a base amount per claim (the self-insured retention) with an aggregate, one-time deductible above this limit. Losses beyond these amounts are insured through third-party policies with coverage limits per claim, per location and on an aggregate basis for the Company. The combined self-insured retention is $500 per claim, subject to an additional one-time deductible of $750 for California affiliated operations and a separate, one-time, deductible of $1,000 for non-California operations. For all affiliated operations, except those located in Colorado, the third-party coverage above these limits is $1,000 per claim, $3,000 per operation, with a $5,000 blanket aggregate limit and an additional state-specific aggregate where required by state law. In Colorado, the third-party coverage above these limits is $1,000 per claim and $3,000 per operation, which is independent of the aforementioned blanket aggregate limits that apply outside of Colorado. The self-insured retention and deductible limits for general and professional liability and workers' compensation for all states (except Texas, Washington and Wyoming for workers' compensation) are self-insured through the Captive, the related assets and liabilities of which are included in the accompanying condensed consolidated balance sheets. The Captive is subject to certain statutory requirements as an insurance provider. The Company’s policy is to accrue amounts equal to the actuarially estimated costs to settle open claims of insureds, as well as an estimate of the cost of insured claims that have been incurred but not reported. The Company develops information about the size of the ultimate claims based on historical experience, current industry information and actuarial analysis, and evaluates the estimates for claim loss exposure on a quarterly basis. Accrued general liability and professional malpractice liabilities on an undiscounted basis, net of anticipated insurance recoveries, were $43,200 and $42,635 as of March 31, 2019 and December 31, 2018, respectively. The Company’s operating subsidiaries are self-insured for workers’ compensation in California. To protect itself against loss exposure in California with this policy, the Company has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington and Wyoming, are under a loss sensitive plan that insures individual claims that exceed $350 per occurrence. In Washington and Wyoming, the operating subsidiaries' coverage is financed through premiums paid by the employers and employees. The claims and benefit payments are managed through a state insurance pool. Outside of California, Texas, Washington and Wyoming, the Company has purchased insurance coverage that insures individual claims that exceed $350 per accident. In all states except Washington and Wyoming, the Company accrues amounts equal to the estimated costs to settle open claims, as well as an estimate of the cost of claims that have been incurred but not reported. The Company uses actuarial valuations to estimate the liability based on historical experience and industry information. Accrued workers’ compensation liabilities are recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets and were $25,171 and $24,624 as of March 31, 2019 and December 31, 2018, respectively. In addition, the Company has recorded an asset and equal liability of $7,360 and $6,969 at March 31, 2019 and December 31, 2018, respectively, in order to present the ultimate costs of malpractice and workers' compensation claims and the anticipated insurance recoveries on a gross basis. See Note 12, Restricted and Other Assets. The Company self-funds medical (including prescription drugs) and dental healthcare benefits to the majority of its employees. The Company is fully liable for all financial and legal aspects of these benefit plans. To protect itself against loss exposure with this policy, the Company has purchased individual stop-loss insurance coverage that insures individual claims that exceed $300 for each covered person with an additional one-time aggregate individual stop loss deductible of $75. Beginning 2016, the Company's policy does not include the additional one-time aggregate individual stop loss deductible of $75. The Company’s accrued liability under these plans recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets was $6,063 and $5,823 as of March 31, 2019 and December 31, 2018, respectively. The Company believes that adequate provision has been made in the Interim Financial Statements for liabilities that may arise out of patient care, workers’ compensation, healthcare benefits and related services provided to date. The amount of the Company’s reserves was determined based on an estimation process that uses information obtained from both company-specific and industry data. This estimation process requires the Company to continuously monitor and evaluate the life cycle of the claims. Using data obtained from this monitoring and the Company’s assumptions about emerging trends, the Company, with the assistance of an independent actuary, develops information about the size of ultimate claims based on the Company’s historical experience and other available industry information. The most significant assumptions used in the estimation process include determining the trend in costs, the expected cost of claims incurred but not reported and the expected costs to settle or pay damage awards with respect to unpaid claims. The self-insured liabilities are based upon estimates, and while management believes that the estimates of loss are reasonable, the ultimate liability may be in excess of or less than the recorded amounts. Due to the inherent volatility of actuarially determined loss estimates, it is reasonably possible that the Company could experience changes in estimated losses that could be material to net income. If the Company’s actual liability exceeds its estimates of loss, its future earnings, cash flows and financial condition would be adversely affected. Income Taxes — Deferred tax assets and liabilities are established for temporary differences between the financial reporting basis and the tax basis of the Company’s assets and liabilities at tax rates in effect when such temporary differences are expected to reverse. The Company generally expects to fully utilize its deferred tax assets; however, when necessary, the Company records a valuation allowance to reduce its net deferred tax assets to the amount that is more likely than not to be realized. In determining the need for a valuation allowance or the need for and magnitude of liabilities for uncertain tax positions, the Company makes certain estimates and assumptions. These estimates and assumptions are based on, among other things, knowledge of operations, markets, historical trends and likely future changes and, when appropriate, the opinions of advisors with knowledge and expertise in certain fields. Due to certain risks associated with the Company’s estimates and assumptions, actual results could differ. Noncontrolling Interest — The noncontrolling interest in a subsidiary is initially recognized at estimated fair value on the acquisition date and is presented within total equity in the Company's condensed consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to The Ensign Group, Inc. in its condensed consolidated statements of income and net income per share is calculated based on net income attributable to The Ensign Group, Inc.'s stockholders. The carrying amount of the noncontrolling interest is adjusted based on an allocation of subsidiary earnings based on ownership interest. Share-Based Compensation — The Company measures and recognizes compensation expense for all share-based payment awards made to employees and directors including employee stock options based on estimated fair values, ratably over the requisite service period of the award. Net income has been reduced as a result of the recognition of the fair value of all stock options and restricted stock awards issued, the amount of which is contingent upon the number of future grants and other variables. Recent Accounting Pronouncements — Except for rules and interpretive releases of the Securities and Exchange Commission (SEC) under authority of federal securities laws and a limited number of grandfathered standards, the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) is the sole source of authoritative GAAP literature recognized by the FASB and applicable to the Company. For any new pronouncements announced, the Company considers whether the new pronouncements could alter previous generally accepted accounting principles and determines whether any new or modified principles will have a material impact on the Company's reported financial position or operations in the near term. The applicability of any standard is subject to the formal review of the Company's financial management and certain standards are under consideration. Recent Accounting Standards Adopted by the Company In February 2016, the FASB established Topic 842, Leases, by issuing Accounting Standards Update (ASU) No. 2016-02, which requires lessees to recognize leases with terms longer than 12 months on the balance sheet and disclose key information about leasing arrangements. Leases will be classified as either finance or operating, with classification affecting the pattern of expense recognition in the income statement. The classification criteria for distinguishing between operating and finance (previously capital) leases are substantially similar to the previous lease guidance, but with no explicit bright lines. The Company adopted the standard as of January 1, 2019, electing the transition method that allows it to apply the standard as of the adoption date and record a cumulative adjustment in retained earnings, if applicable. The Company has elected the package of practical expedients permitted under the transition guidance, which among other things, allows the Company to carry forward the historical lease classification. The new standard also provides practical expedients for an entity’s ongoing accounting. The Company has made an accounting policy to keep leases, with an initial term of 12 months, or less off of the balance sheet and recognize those lease payments in the consolidated statements of income on a straight-line basis over the lease term. The Company has also elected the practical expedient to not separate lease and non-lease components for all of its leases as the non-lease components are not significant to the overall lease costs. The adoption of this standard resulted in recognition of net lease assets and lease liabilities of $1,051,148 and $1,029,240, respectively, on its condensed consolidated balance sheets as of January 1, 2019. The Company recorded an adjustment, net of tax, of $9,030 to retained earnings, on the adoption date, related to a deferred gain on a previous sale-leaseback transaction, which resulted in an increase in rent expense of $658 annually, as we are no longer able to recognize the gain in our consolidated statement of income as a result of the new lease standard. In addition, initial direct costs associated with its lease agreements and favorable lease assets of $26,939 were classified into right of used assets on the adoption date. The standard does not materially affect the Company's consolidated net earnings or have a notable impact on liquidity or debt-covenant compliance under the current agreements. See further discussion at Note 17, Leases. Prior to the adoption of ASC 842, the Company recognized revenue related to its senior living residency agreements in accordance with the provisions of ASC 840, Leases ("ASC 840"). Subsequent to the adoption of ASU 2016-02, Leases, lessors are required to separately recognize and measure the lease component of a contract with a customer utilizing the provisions of ASC 842 and the non-lease components utilizing the provisions of ASC 606, Revenue from Contracts with Customers. To separately account for the components, the transaction price is allocated among the components based upon the estimated stand alone selling prices of the components. Additionally, certain components of a contract which were previously included within the lease element recognized in accordance with ASC 840 prior to the adoption of ASU 2016-02 (such as common area maintenance services, other basic services, and executory costs) are recognized as non-lease components subject to the provisions of ASC 606 subsequent to the adoption of ASU 2016-02. Entities are required to recognize a cumulative effect adjustment to beginning retained earnings as of the initial application date of ASU 2016-02 for changes to amounts recognized for these certain components for the transition from ASC 840 to ASC 606. However, entities are permitted to elect the practical expedient under ASU 2018-11, Leases, allowing lessors to not separate non-lease components from the associated lease components when certain criteria are met. Entities that elect to utilize the lease/non-lease component combination practical expedient under ASU 2018-11 upon initial application of ASC 842 are required to apply the practical expedient to all new and existing transactions within a class of underlying assets that qualify for the expedient as of the initial application date with a cumulative effect adjustment to beginning retained earnings as of the initial application date for any changes recognized related to existing transactions. Upon adoption of ASU 2016-02 and ASU 2018-11, the Company elected the lessor practical expedient within ASU 2018-11. The Company recognizes revenue under these resident agreements based upon the predominant component, either the lease or non-lease component, of the contracts rather than allocating the consideration and separately accounting for it under ASC Topic 842 and ASC Topic 606. The Company has concluded that the non-lease components of the agreements with respect to its senior living communities are the predominant component of the contract, therefore, the Company recognizes revenue for these residents agreements under ASC Topic 606. The timing and pattern of revenue recognition is substantially the same as that prior to the adoption of these standards. In June 2018, the FASB issued ASU 2018-07, which simplifies several aspects of the accounting for nonemployee share-based payment transactions resulting from expanding the scope of Topic 718, Compensation-Stock Compensation, to include share-based payment transactions for acquiring goods and services from nonemployees. The amendments specify that Topic 718 applies to all share-based payment transactions in which a grantor acquires goods or services to be used or consumed in a grantor’s own operations by issuing share-based payment awards. The amendments also clarify that Topic 718 does not apply to share-based payments used to effectively provide (1) financing to the issuer or (2) awards granted in conjunction with selling goods or services to customers as part of a contract accounted for under Topic 606, Revenue from Contracts with Customers. The Company adopted this guidance effective January 1, 2019. The adoption of this guidance did not have a material impact on its consolidated financial statements and related disclosures. Accounting Standards Recently Issued But Not Yet Adopted by the Company In August 2018, the FASB issued amended guidance to simplify fair value measurement disclosure requirements. The new provisions eliminate the requirements to disclose (1) transfers between Level 1 and Level 2 of the fair value hierarchy, (2) policies related to valuation processes and the timing of transfers between levels of the fair value hierarchy, and (3) net asset value disclosure of estimates of timing of future liquidity events. The FASB also modified disclosure requirements of Level 3 fair value measurements. This guidance is effective for annual periods beginning after December 15, 2019, which will be the Company's fiscal year 2020, with early adoption permitted. The adoption of this standard is not expected to have a material impact on the Company's consolidated financial statements. In January 2017, the FASB issued amended authoritative guidance to simplify and reduce the cost and complexity of the goodwill impairment test. The new provisions eliminate step 2 from the goodwill impairment test and shifts the concept of impairment from a measure of loss when comparing the implied fair value of goodwill to its carrying amount to comparing the fair value of a reporting unit with its carrying amount. The FASB also eliminated the requirements for any reporting unit with a zero or negative carrying amount to perform a qualitative assessment or step 2 of the goodwill impairment test. The new guidance does not amend the optional qualitative assessment of goodwill impairment. This guidance is effective for annual periods beginning after December 15, 2019, which will be the Company's fiscal year 2020, with early adoption permitted. The adoption of this standard is not expected to have a material impact on the Company's consolidated financial statements.

Revenue and Accounts Receivable

3 Months Ended

Mar. 31, 2019

REVENUE AND ACCOUNTS RECEIVABLE [Abstract]

Revenue and Accounts receivable [Text Block]

REVENUE AND ACCOUNTS RECEIVABLE

The Company's revenue is derived primarily from providing healthcare services to its patients. Revenues are recognized when services are provided to the patients at the amount that reflects the consideration to which the Company expects to be entitled from patients and third-party payors, including Medicaid, Medicare and insurers (private and Medicare replacement plans), in exchange for providing patient care. The healthcare services in transitional and skilled, home health and hospice patient contracts include routine services in exchange for a contractual agreed-upon amount or rate. Routine services are treated as a single performance obligation satisfied over time as services are rendered. As such, patient care services represent a bundle of services that are not capable of being distinct. Additionally, there may be ancillary services which are not included in the daily rates for routine services, but instead are treated as separate performance obligations satisfied at a point in time, if and when those services are rendered.

Revenue recognized from healthcare services are adjusted for estimates of variable consideration to arrive at the transaction price. The Company determines the transaction price based on contractually agreed-upon amounts or rate, adjusted for estimates of variable consideration. The Company uses the expected value method in determining the variable component that should be used to arrive at the transaction price, using contractual agreements and historical reimbursement experience within each payor type. The amount of variable consideration which is included in the transaction price may be constrained, and is included in net revenue only to the extent that it is probable that a significant reversal in the amount of the cumulative revenue recognized will not occur in a future period. If actual amounts of consideration ultimately received differ from the Company’s estimates, the Company adjusts these estimates, which would affect net revenue in the period such variances become known.

Revenue from the Medicare and Medicaid programs accounted for 67.9% of the Company's revenue for both the three months ended March 31, 2019 and 2018. Settlement with Medicare and Medicaid payors for retroactive adjustments due to audits and reviews are considered variable consideration and are included in the determination of the estimated transaction price. These settlements are estimated based on the terms of the payment agreement with the payor, correspondence from the payor and the Company’s historical settlement activity. Consistent with healthcare industry practices, any changes to these revenue estimates are recorded in the period the change or adjustment becomes known based on final settlement. The Company recorded adjustments to revenue which were not material to the Company's consolidated revenue or Interim Financial Statements for the three months ended March 31, 2019 and 2018.

Disaggregation of Revenue

The Company disaggregates revenue from contracts with its patients by reportable operating segments and payors. The Company determines that disaggregating revenue into these categories achieves the disclosure objectives to depict how the nature, amount, timing and uncertainty of revenue and cash flows are affected by economic factors. A reconciliation of disaggregated revenue to segment revenue as well as revenue by payor is provided in Note 7, Business Segments.

The Company’s service specific revenue recognition policies are as follows:

Transitional and Skilled Nursing Revenue

The Company’s revenue is derived primarily from providing long-term healthcare services to patients and is recognized on the date services are provided at amounts billable to individual patients, adjusted for estimates for variable consideration. For patients under reimbursement arrangements with third-party payors, including Medicaid, Medicare and private insurers, revenue is recorded based on contractually agreed-upon amounts or rate, adjusted for estimates for variable consideration, on a per patient, daily basis or as services are performed.

Senior Living Revenue

The Company's senior living revenue consists of fees for basic housing and assisted living care. Accordingly, we record revenue when services are rendered on the date services are provided at amounts billable to individual residents. Residency agreements are generally for a term of 30 days, with resident fees billed monthly in advance. For residents under reimbursement arrangements with Medicaid, revenue is recorded based on contractually agreed-upon amounts or rates on a per resident, daily basis or as services are rendered.

Home Health Revenue

Medicare Revenue

Net service revenue is recorded under the Medicare prospective payment system based on a 60-day episode payment rate that is subject to adjustment based on certain variables including, but not limited to: (a) an outlier payment if the patient’s care was unusually costly; (b) a low utilization adjustment if the number of visits was fewer than five; (c) a partial payment if the patient transferred to another provider or transferred from another provider before completing the episode; (d) a payment adjustment based upon the level of therapy services; (e) the number of episodes of care provided to a patient, regardless of whether the same home health provider provided care for the entire series of episodes; (f) changes in the base episode payments established by the Medicare program; (g) adjustments to the base episode payments for case mix and geographic wages; and (h) recoveries of overpayments.

The Company makes adjustments to Medicare revenue on completed episodes to reflect differences between estimated and actual payment amounts, an inability to obtain appropriate billing documentation and other reasons unrelated to credit risk. Therefore, the Company believes that its reported net service revenue and patient accounts receivable will be the net amounts to be realized from Medicare for services rendered.

In addition to revenue recognized on completed episodes, the Company also recognizes a portion of revenue associated with episodes in progress. Episodes in progress are 60-day episodes of care that begin during the reporting period, but were not completed as of the end of the period. As such, the Company estimates revenue and recognizes it on a daily basis. The primary factors underlying this estimate are the number of episodes in progress at the end of the reporting period, expected Medicare revenue per episode and the Company’s estimate of the average percentage complete based on visits performed.

Non-Medicare Revenue

Episodic Based Revenue - The Company recognizes revenue in a similar manner as it recognizes Medicare revenue for episodic-based rates that are paid by other insurance carriers, including Medicare Advantage programs; however, these rates can vary based upon the negotiated terms.

Non-episodic Based Revenue - Revenue is recorded on an accrual basis based upon the date of service at amounts equal to its established or estimated per visit rates, as applicable.

Hospice Revenue

Revenue is recorded on an accrual basis based upon the date of service at amounts equal to the estimated payment rates. The estimated payment rates are daily rates for each of the levels of care the Company delivers. The payment is adjusted for an inability to obtain appropriate billing documentation or authorizations acceptable to the payor and other reasons unrelated to credit risk. Additionally, as Medicare hospice revenue is subject to an inpatient cap and an overall payment cap, the Company monitors its provider numbers and estimates amounts due back to Medicare if a cap has been exceeded. The Company records these adjustments as a reduction to revenue and increases to other accrued liabilities.

Prior period results reclassifications, for comparative purposes, for only presenting total revenue for all revenue services. In the prior year, the Company presented its senior living revenue due to the adoption of ASC 606. This reclassification had no effect on the reported results of operations.

Revenue for the three months ended March 31, 2019 and 2018 is summarized in the following tables:



	Three Months Ended March 31,
	2019				2018
	Revenue		% of Revenue		Revenue		% of Revenue
Medicaid	$	195,003	35.5	%	$	167,625	34.1	%
Medicare	147,720		26.9		139,314		28.3
Medicaid — skilled	30,451		5.5		27,042		5.5
Total Medicaid and Medicare	373,174		67.9		333,981		67.9
Managed care	89,848		16.4		83,716		17.0
Private and other payors⁽¹⁾	86,192		15.7		74,437		15.1
Revenue	$	549,214	100.0	%	$	492,134	100.0	%

(1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended March 31, 2018 and 2017.

Balance Sheet Impact

Included in the Company’s condensed consolidated balance sheet are contract assets, comprised of billed accounts receivable and unbilled receivables, which are the result of the timing of revenue recognition, billings and cash collections, as well as, contract liabilities, which primarily represent payments the Company receives in advance of services provided. The Company had no material contract liabilities as of March 31, 2019 and December 31, 2018, or activity during the three months ended March 31, 2019 and 2018.

Accounts receivable as of March 31, 2019 and December 31, 2018 is summarized in the following table:



	March 31, 2019			December 31, 2018
Medicaid	$	123,268		$	117,984
Managed care	61,991			54,682
Medicare	53,879			50,994
Private and other payors	55,943			55,325
	295,081			278,985
Less: allowance for doubtful accounts	(3,380		)	(2,886		)
Accounts receivable, net	$	291,701		$	276,099

Practical Expedients and Exemptions

As the Company’s contracts with its patients have an original duration of one year or less, the Company uses the practical expedient applicable to its contracts and does not consider the time value of money. Further, because of the short duration of these contracts, the Company has not disclosed the transaction price for the remaining performance obligations as of the end of each reporting period or when the Company expects to recognize this revenue. In addition, the Company has applied the practical expedient provided by ASC 340, Other Assets and Deferred Costs, and all incremental customer contract acquisition costs are expensed as they are incurred because the amortization period would have been one year or less.

Computation of Net Income Per Common Share

3 Months Ended

Mar. 31, 2019

COMPUTATION OF NET INCOME PER COMMON SHARE [Abstract]

Earnings Per Share [Text Block]

COMPUTATION OF NET INCOME PER COMMON SHARE

Basic net income per share is computed by dividing income from continuing operations attributable to stockholders of The Ensign Group, Inc. by the weighted average number of outstanding common shares for the period. The computation of diluted net income per share is similar to the computation of basic net income per share except that the denominator is increased to include the number of additional common shares that would have been outstanding if the dilutive potential common shares had been issued.

A reconciliation of the numerator and denominator used in the calculation of basic net income per common share follows:



	Three Months Ended March 31,
	2019		2018
Numerator:
Net income	$	27,607	$	23,293
Less: net income attributable to noncontrolling interests	235		161
Net income attributable to The Ensign Group, Inc.	$	27,372	$	23,132

Denominator:
Weighted average shares outstanding for basic net income per share	53,081		51,585
Basic net income per common share attributable to The Ensign Group, Inc.	$	0.52	$	0.45

A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows:



	Three Months Ended March 31,
	2019		2018
Numerator:
Net income	$	27,607	$	23,293
Less: net income attributable to noncontrolling interests	235		161
Net income attributable to The Ensign Group, Inc.	$	27,372	$	23,132

Denominator:
Weighted average common shares outstanding	53,081		51,585
Plus: incremental shares from assumed conversion⁽¹⁾	2,617		1,933
Adjusted weighted average common shares outstanding	55,698		53,518
Diluted net income per common share attributable to The Ensign Group, Inc.	$	0.49	$	0.43

(1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 489 and 937 for the three months ended March 31, 2019 and 2018, respectively.

Fair Value Measurements

3 Months Ended

Mar. 31, 2019

Fair Value Disclosures [Abstract]

Fair Value Disclosures [Text Block]

FAIR VALUE MEASUREMENTS

Fair value measurements are based on a three-tier hierarchy that prioritizes the inputs used to measure fair value. These tiers include: Level 1, defined as observable inputs such as quoted market prices in active markets; Level 2, defined as inputs other than quoted prices included within Level 1 that are observable for the asset or liability, either directly or indirectly; and Level 3, defined as unobservable inputs for which little or no market data exists, therefore requiring an entity to develop its own assumptions.

The following table summarizes the financial assets and liabilities measured at fair value on a recurring basis as of March 31, 2019 and December 31, 2018:



	March 31, 2019						December 31, 2018
	Level 1		Level 2		Level 3		Level 1		Level 2		Level 3
Cash and cash equivalents	$	37,824	$	—	$	—	$	31,083	$	—	$	—

The Company's non-financial assets, which includes goodwill, intangible assets and property and equipment, are not required to be measured at fair value on a recurring basis. However, on a periodic basis, or whenever events or changes in circumstances indicate that their carrying value may not be recoverable, the Company assesses its long-lived assets for impairment. When impairment has occurred, such long-lived assets are written down to fair value. See Note 3, Summary of Significant Accounting Policies for further discussion of the Company's significant accounting policies.

Debt Security Investments - Held to Maturity

At March 31, 2019 and December 31, 2018, the Company had approximately $46,974 and $44,850, respectively, in debt security investments which were classified as held to maturity and carried at amortized cost. The carrying value of the debt securities approximates fair value based on Level 1 inputs. The Company has the intent and ability to hold these debt securities to maturity. Further, as of March 31, 2019, the debt security investments were held in AA, A and BBB rated debt securities.

- Definition

The entire disclosure for the fair value of financial instruments (as defined), including financial assets and financial liabilities (collectively, as defined), and the measurements of those instruments as well as disclosures related to the fair value of non-financial assets and liabilities. Such disclosures about the financial instruments, assets, and liabilities would include: (1) the fair value of the required items together with their carrying amounts (as appropriate); (2) for items for which it is not practicable to estimate fair value, disclosure would include: (a) information pertinent to estimating fair value (including, carrying amount, effective interest rate, and maturity, and (b) the reasons why it is not practicable to estimate fair value; (3) significant concentrations of credit risk including: (a) information about the activity, region, or economic characteristics identifying a concentration, (b) the maximum amount of loss the entity is exposed to based on the gross fair value of the related item, (c) policy for requiring collateral or other security and information as to accessing such collateral or security, and (d) the nature and brief description of such collateral or security; (4) quantitative information about market risks and how such risks are managed; (5) for items measured on both a recurring and nonrecurring basis information regarding the inputs used to develop the fair value measurement; and (6) for items presented in the financial statement for which fair value measurement is elected: (a) information necessary to understand the reasons for the election, (b) discussion of the effect of fair value changes on earnings, (c) a description of [similar groups] items for which the election is made and the relation thereof to the balance sheet, the aggregate carrying value of items included in the balance sheet that are not eligible for the election; (7) all other required (as defined) and desired information.

+ References + Details

Business Segments

3 Months Ended

Mar. 31, 2019

Segment Reporting [Abstract]

Segment Reporting Disclosure [Text Block]

BUSINESS SEGMENTS

The Company has three reportable operating segments: (1) transitional and skilled services, which includes the operation of skilled nursing facilities; (2) senior living services, which includes the operation of assisted and independent living facilities; and (3) home health and hospice services, which includes the Company's home health, hospice and home care businesses. The Company's Chief Executive Officer, who is its chief operating decision maker, or CODM, reviews financial information at the operating segment level.

The Company also reports an “all other” category that includes results from its mobile diagnostics and other ancillary operations. These operations are neither significant individually nor in aggregate, and therefore do not constitute a reportable segment. The reporting segments are business units that offer different services and are managed separately to provide greater visibility into those operations.

As of March 31, 2019, transitional and skilled services included 166 wholly-owned affiliated skilled nursing operations and 24 campuses that provide skilled nursing and rehabilitative care services and senior living services. The Company provided room and board and social services through 55 wholly-owned affiliated senior living operations and 24 campuses as mentioned above. Home health, hospice and home care services were provided to patients through 56 affiliated agencies. As of March 31, 2019, the Company held majority membership interests in other ancillary operations, which operating results are included in the "all other" category.

The Company evaluates performance and allocates capital resources to each segment based on an operating model that is designed to maximize the quality of care provided and profitability. General and administrative expenses are not allocated to any segment for purposes of determining segment profit or loss, and are included in the "all other" category in the selected segment financial data that follows. The accounting policies of the reporting segments are the same as those described in Note 3, Summary of Significant Accounting Policies. The Company's CODM does not review assets by segment in his resource allocation and therefore assets by segment are not disclosed below.

Segment revenues by major payor source were as follows:



	Three Months Ended March 31, 2019
	Transitional and Skilled Services		Senior Living Services		Home Health and Hospice Services		All Other			Total Revenue		Revenue %
Medicaid	$	181,294	$	9,802	$	3,907	$	—		$	195,003	35.5	%
Medicare	116,701		—		31,019		—			147,720		26.9
Medicaid-skilled	30,451		—		—		—			30,451		5.5
Subtotal	328,446		9,802		34,926		—			373,174		67.9
Managed care	83,172		—		6,676		—			89,848		16.4
Private and other	37,640		30,892		4,515		13,145		(1)	86,192		15.7
Total revenue	$	449,258	$	40,694	$	46,117	$	13,145		$	549,214	100.0	%

(1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended March 31, 2019.



	Three Months Ended March 31, 2018
	Transitional and Skilled Services		Senior Living Services		Home Health and Hospice Services		All Other			Total Revenue		Revenue %
Medicaid	$	156,511	$	8,264	$	2,850	$	—		$	167,625	34.1	%
Medicare	111,953		—		27,361		—			139,314		28.3
Medicaid-skilled	27,042		—		—		—			27,042		5.5
Subtotal	295,506		8,264		30,211		—			333,981		67.9
Managed care	77,800		—		5,916		—			83,716		17.0
Private and other	33,710		27,849		3,631		9,247		(1)	74,437		15.1
Total revenue	$	407,016	$	36,113	$	39,758	$	9,247		$	492,134	100.0	%

(1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended March 31, 2018.

The following table sets forth selected financial data consolidated by business segment:



	Three Months Ended March 31, 2019
	Transitional and Skilled Services(4)		Senior Living Services(4)		Home Health and Hospice Services		All Other(3)			Elimination			Total
Revenue from external customers	$	449,258	$	40,694	$	46,117	$	13,145		$	—		$	549,214
Intersegment revenue(1)	715		—		—		1,712			(2,427		)	—
Total revenue	$	449,973	$	40,694	$	46,117	$	14,857		$	(2,427	)	$	549,214
Segment income (loss)(2)	$	58,764	$	5,038	$	6,868	$	(32,866	)	$	—		$	37,804
Interest expense, net of interest income													$	(3,097	)
Income before provision for income taxes													$	34,707
Depreciation and amortization	$	8,614	$	1,900	$	260	$	1,824		$	—		$	12,598

(1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines.

(2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, senior living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $715. Including these expenses, home health and hospice services segment income would be $6,153. Transitional and skilled services, senior living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines that are included in the "All Other" category of $1,712.

(3) General and administrative expense are included in the "All Other" category.

(4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment.



	Three Months Ended March 31, 2018
	Transitional and Skilled Services(4)		Senior Living Services(4)		Home Health and Hospice Services		All Other(3)			Elimination			Total
Revenue from external customers	$	407,016	$	36,113	$	39,758	$	9,247		$	—		$	492,134
Intersegment revenue(1)	689		—		—		1,082			(1,771		)	—
Total revenue	$	407,705	$	36,113	$	39,758	$	10,329		$	(1,771	)	$	492,134
Segment income (loss)(2)	$	46,195	$	4,662	$	6,058	$	(23,936	)	$	—		$	32,979
Interest expense, net of interest income													$	(3,165	)
Income before provision for income taxes													$	29,814
Depreciation and amortization	$	7,802	$	1,597	$	245	$	1,978		$	—		$	11,622

(1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines.

(2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, senior living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $689. Including these expenses, home health and hospice services segment income would be $5.369. Transitional and skilled services, senior living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines that are included in the "All Other" category of $1,082.

(3) General and administrative expense is included in the "All Other" category.

The Company completed the sale of one of its senior living operations for an aggregate sale price of $1,838 during the three months ended March 31, 2019. The sale transaction does not meet the criteria of discontinued operations as it does not represent a strategic shift that has, or will have, a major effect on the Company's operations and financial results.

Acquisitions	3 Months Ended
Acquisitions	Mar. 31, 2019
Business Combinations [Abstract]
Business Combination Disclosure [Text Block]	ACQUISITIONS The acquisition focus of the subsidiaries is to purchase or lease operations that are complementary to the current affiliated operations, accretive to the business or otherwise advance the Company's strategy. The results of all operating subsidiaries are included in the accompanying Interim Financial Statements subsequent to the date of acquisition. Acquisitions are accounted for using the acquisition method of accounting. The Company's affiliated operations also enter into long-term leases that may include options to purchase the facilities. As a result, from time to time, the affiliated operations will acquire facilities that have been operating under third-party leases. During the three months ended March 31, 2019, the Company expanded its operations through a combination of a long-term lease and real estate purchases, with the addition of two stand-alone skilled nursing operations, one home health agency and one hospice agency. The Company did not acquire any material assets or assume any liabilities other than the tenant's post-assumption rights and obligations under the long-term lease. The addition of these operations added a total of 218 operational skilled nursing beds to be operated by the Company's affiliated operating subsidiaries. The Company also invested in new ancillary services that are complementary to its existing businesses. The Company entered into a separate operations transfer agreement with the prior operator as part of each transaction. The aggregate purchase price for these acquisitions during the three months ended March 31, 2019 was $14,691. During the first quarter of 2019, the fair value of assets for two of the acquisitions was concentrated in property and equipment and as such, these transactions were classified as asset acquisitions in accordance with Accounting Standards Codification Topic 805, Clarifying the Definition of a Business (ASC 805). The purchase price for the two asset acquisitions was $5,763, which mainly consisted of building and improvements of $5,033. The fair value of assets for the remaining three acquisitions was concentrated in goodwill and as such, these transactions were classified as business acquisitions in accordance with ASC 805. The purchase price for the three business combinations was $8,928, which mainly consisted of goodwill and indefinite-lived intangible assets of $7,101. The Company also entered into a note payable with the seller of $924. As of the date of this filing, the preliminary allocation of the purchase price for the acquisitions in the first quarter was not finalized as necessary valuation information was not yet available. During the first quarter of 2018, all of the fair value of the assets acquired were concentrated in property and equipment and as such, the transactions were classified as asset acquisitions in accordance with ASC 805. During the three months ended March 31, 2018, the aggregate purchase price for those acquisitions was $4,447. The Company’s acquisition strategy has been focused on identifying both opportunistic and strategic acquisitions within its target markets that offer strong opportunities for return on invested capital. The operating subsidiaries acquired by the Company are frequently underperforming financially and can have regulatory and clinical challenges to overcome. Financial information, especially with underperforming operating subsidiaries, is often inadequate, inaccurate or unavailable. Consequently, the Company believes that prior operating results are not a meaningful representation of the Company’s current operating results or indicative of the integration potential of its newly acquired operating subsidiaries. The businesses acquired during the three months ended March 31, 2019 were not material acquisitions to the Company individually or in the aggregate. Accordingly, pro forma financial information is not presented. These acquisitions have been included in the March 31, 2019 condensed consolidated balance sheets of the Company, and the operating results have been included in the condensed consolidated statements of operations of the Company since the dates the Company gained effective control. Subsequent to March 31, 2019, the Company expanded its operations through a combination of a long-term lease and real estate purchases, with the addition of five stand-alone skilled nursing operations, one stand-alone senior living operation, two campus operations, two hospice agencies and two home care agencies. The Company did not acquire any material assets or assume any liabilities other than the tenant's post-assumption rights and obligations under the long-term lease. The addition of these operations added a total of 810 operational skilled nursing beds and 222 assisted living units to be operated by the Company's operating subsidiaries. The Company entered into a separate operations transfer agreement with the prior operator as part of each transaction. The aggregate purchase price for these acquisitions was $35,060. As of the date of this report, the preliminary allocation of the purchase price for the acquisitions subsequent to March 31, 2019 were not completed as necessary valuation information was not yet available. As such, the determination whether these acquisitions should be classified as business combinations or asset acquisitions under ASC 805 will be determined upon completion of the allocation of the purchase price.

Property and Equipment

3 Months Ended

Mar. 31, 2019

Property, Plant and Equipment [Abstract]

Property, Plant and Equipment Disclosure [Text Block]

PROPERTY AND EQUIPMENT— Net

Property and equipment, net consist of the following:



	March 31, 2019			December 31, 2018
Land	$	60,895		$	60,420
Buildings and improvements	417,204			411,096
Equipment	210,224			202,346
Furniture and fixtures	5,194			5,079
Leasehold improvements	115,344			112,935
Construction in progress	12,893			9,729
	821,754			801,605
Less: accumulated depreciation	(194,354		)	(182,731		)
Property and equipment, net	$	627,400		$	618,874

See also Note 8, Acquisitions for information on acquisitions during the three months ended March 31, 2019 and 2018.

Intangible Assets - Net

3 Months Ended

Mar. 31, 2019

Intangible Assets, Net (Excluding Goodwill) [Abstract]

Intangible Assets Disclosure [Text Block]

INTANGIBLE ASSETS — Net



	Weighted Average Life (Years)	March 31, 2019							December 31, 2018
		Gross Carrying Amount		Accumulated Amortization					Gross Carrying Amount		Accumulated Amortization
Intangible Assets		Gross Carrying Amount		Accumulated Amortization			Net		Gross Carrying Amount		Accumulated Amortization			Net
Lease acquisition costs	1.7	$	360	$	(185	)	175		$	843	$	(251	)	$	592
Favorable leases	2.1	534		(249		)	285		35,650		(8,724		)	26,926
Assembled occupancy	0.4	2,964		(2,951		)	13		2,936		(2,870		)	66
Facility trade name	30.0	733		(324		)	409		733		(317		)	416
Customer relationships	16.7	5,110		(1,861		)	3,249		4,670		(1,670		)	3,000
Total		$	9,701	$	(5,570	)	$	4,131	$	44,832	$	(13,832	)	$	31,000

Amortization expense was $893 and $615 for the three months ended March 31, 2019 and 2018, respectively. The majority of favorable leases were reclassed to right-of-use assets as of March 31, 2019, as a part of the adoption of ASC 842. See Note 17, Leases.

Estimated amortization expense for each of the years ending December 31 is as follows:



Year	Amount
2019 (remainder)	$	868
2020	345
2021	249
2022	249
2023	237
2024	234
Thereafter	1,949
	$	4,131

Goodwill and Other Indefinite-Lived Intangible Assets

3 Months Ended

Mar. 31, 2019

Indefinite-Lived Intangible Assets (Including Goodwill) [Abstract]

Goodwill and Other Indefinite-Lived Intangibles [Text Block]

GOODWILL AND OTHER INDEFINITE-LIVED INTANGIBLE ASSETS

The Company tests goodwill during the fourth quarter of each year or more often if events or circumstances indicate there may be impairment. The Company performs its analysis for each reporting unit that constitutes a business for which discrete financial information is produced and reviewed by operating segment management and provides services that are distinct from the other components of the operating segment, in accordance with the provisions of Accounting Standards Codification topic 350, Intangibles—Goodwill and Other (ASC 350). This guidance provides the option to first assess qualitative factors to determine whether it is more likely than not that the fair value of a reporting unit is less than its carrying value, a "Step 0" analysis. If, based on a review of qualitative factors, it is more likely than not that the fair value of a reporting unit is less than its carrying value, the Company performs "Step 1" of the traditional two-step goodwill impairment test by comparing the net assets of each reporting unit to their respective fair values. The Company determines the estimated fair value of each reporting unit using a discounted cash flow analysis. In the event a unit's net assets exceed its fair value, an implied fair value of goodwill must be determined by assigning the unit's fair value to each asset and liability of the unit. The excess of the fair value of the reporting unit over the amounts assigned to its assets and liabilities is the implied fair value of goodwill. An impairment loss is measured by the difference between the goodwill carrying value and the implied fair value.

The Company anticipates that the majority of total goodwill recognized will be fully deductible for tax purposes as of March 31, 2019. See further discussion of goodwill acquired at Note 8, Acquisitions.

The following table represents activity in goodwill by segment as of and for the three months ended March 31, 2019:



	Goodwill
	Transitional and Skilled Services		Senior Living Services		Home Health and Hospice Services		All Other		Total
January 1, 2019	$	45,486	$	3,958	$	27,250	$	3,783	$	80,477
Additions	—		—		1,154		5,431		6,585
March 31, 2019	$	45,486	$	3,958	$	28,404	$	9,214	$	87,062

Other indefinite-lived intangible assets consists of the following:



	March 31, 2019		December 31, 2018
Trade name	$	1,245	$	1,217
Medicare and Medicaid licenses	26,873		26,385
	$	28,118	$	27,602

Consolidated Statement of Stockholders' Equity (Parenthetical) - $ / shares	3 Months Ended
	Mar. 31, 2019	Mar. 31, 2018
Statement of Stockholders' Equity [Abstract]
Dividends Per Share	$ 0.0475	$ 0.0450