0001125376-21-000020 | 10-K | XBRL Viewer

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Cover Page - USD ($) $ in Thousands	12 Months Ended
Cover Page - USD ($) $ in Thousands	Dec. 31, 2020	Jan. 29, 2021	Jun. 30, 2020
Cover [Abstract]
Document Type	10-K
Document Quarterly Report	true
Document Period End Date	Dec. 31, 2020
Document Transition Report	false
Entity File Number	001-33757
Entity Registrant Name	ENSIGN GROUP, INC
Entity Incorporation, State or Country Code	DE
Entity Tax Identification Number	33-0861263
Entity Address, Address Line One	29222 Rancho Viejo Road, Suite 127
Entity Address, City or Town	San Juan Capistrano
Entity Address, State or Province	CA
Entity Address, Postal Zip Code	92675
City Area Code	949
Local Phone Number	487-9500
Title of 12(b) Security	Common Stock, par value $0.001 per share
Trading Symbol	ENSG
Security Exchange Name	NASDAQ
Entity Well-known Seasoned Issuer	Yes
Entity Voluntary Filers	No
Entity Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Large Accelerated Filer
Entity Small Business	false
Entity Emerging Growth Company	false
ICFR Auditor Attestation Flag	true
Entity Shell Company	false
Entity Public Float			$ 1,314,711
Entity Common Stock, Shares Outstanding		54,695,662
Documents Incorporated by Reference	Part III of this Form 10-K incorporates information by reference from the Registrant's definitive proxy statement for the Registrant's 2021 Annual Meeting of Stockholders to be filed within 120 days after the close of the fiscal year covered by this annual report.
Entity Central Index Key	0001125376
Current Fiscal Year End Date	--12-31
Document Fiscal Year Focus	2020
Document Fiscal Period Focus	FY
Amendment Flag	false

CONSOLIDATED BALANCE SHEETS - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Current assets:
Cash and cash equivalents	$ 236,562	$ 59,175
Accounts receivable—less allowance for doubtful accounts of $8,718 and $2,472 at December 31, 2020 and 2019, respectively	305,062	308,985
Investments—current	13,449	17,754
Prepaid income taxes	1,224	739
Prepaid expenses and other current assets	26,659	24,428
Total current assets	582,956	411,081
Property and equipment, net	778,244	767,565
Right-of-use assets	1,025,510	1,046,901
Insurance subsidiary deposits and investments	32,105	30,571
Escrow deposits	100	14,050
Deferred tax assets	32,424	4,615
Restricted and other assets	33,155	26,207
Intangible assets, net	2,899	3,382
Goodwill	54,469	54,469
Other indefinite-lived intangibles	3,716	3,068
Total assets	2,545,578	2,361,909
Current liabilities:
Accounts payable	50,901	44,973
Accrued wages and related liabilities (Note 3)	236,614	151,009
Lease liabilities—current	48,187	44,964
Accrued self-insurance liabilities—current	34,396	29,252
Advance payment liabilities (Note 3)	102,023	0
Other accrued liabilities	87,318	70,273
Current maturities of long-term debt	2,960	2,702
Total current liabilities	562,399	343,173
Long-term debt—less current maturities	112,544	325,217
Long-term lease liabilities—less current portion	950,320	973,983
Accrued self-insurance liabilities—less current portion	62,402	58,114
Other long-term liabilities	39,686	5,278
Total liabilities	1,727,351	1,705,765
Commitments and contingencies (Notes 15, 17 and 20)
Ensign Group, Inc. stockholders' equity:
Common stock: $0.001 par value; 100,000 shares authorized; 57,417 and 54,626 shares issued and outstanding at December 31, 2020, respectively, and 56,176 and 53,487 shares issued and outstanding at December 31, 2019, respectively	58	56
Additional paid-in capital	338,177	307,914
Retained earnings	551,055	391,523
Common stock in treasury, at cost, 2,791 and 2,079 shares at December 31, 2020 and 2019, respectively (Note 22)	(71,213)	(45,296)
Total Ensign Group, Inc. stockholders' equity	818,077	654,197
Non-controlling interest	150	1,947
Total equity	818,227	656,144
Total liabilities and equity	$ 2,545,578	$ 2,361,909

CONSOLIDATED BALANCE SHEETS (Parenthetical) - USD ($) $ in Thousands	Dec. 31, 2020	Dec. 31, 2019
Statement of Financial Position [Abstract]
Allowance for doubtful accounts	$ 8,718	$ 2,472
Common stock, par value (usd per share)	$ 0.001	$ 0.001
Common stock, shares authorized (in shares)	100,000,000	100,000,000
Common stock, shares issued (in shares)	57,417,000	56,176,000
Common stock, shares outstanding (in shares)	54,626,000	53,487,000
Common stock in treasury, at cost (in shares)	2,791,000	2,079,000

CONSOLIDATED STATEMENTS OF INCOME - USD ($) shares in Thousands, $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Total revenue	$ 2,402,596	$ 2,036,524	$ 1,754,601
Expense:
Cost of services	1,865,201	1,620,628	1,418,249
Return of unclaimed class action settlement (Note 20)	0	0	(1,664)
Rent—cost of services	129,926	124,789	117,676
General and administrative expense	129,743	110,873	90,563
Depreciation and amortization	54,571	51,054	44,864
Total expenses	2,179,441	1,907,344	1,669,688
Income from operations	223,155	129,180	84,913
Other income (expense):
Interest expense	(9,362)	(15,662)	(15,182)
Interest and other income	3,813	2,649	2,016
Other expense, net	(5,549)	(13,013)	(13,166)
Income before provision for income taxes	217,606	116,167	71,747
Provision for income taxes	46,242	23,954	12,685
Net income from continuing operations	171,364	92,213	59,062
Net income from discontinued operations, net of tax (Note 21)	0	19,473	33,466
Net income	171,364	111,686	92,528
Less:
Net income/(loss) attributable to noncontrolling interests in continuing operations	886	523	(431)
Net income attributable to noncontrolling interests in discontinued operations (Note 21)	0	629	595
Net income attributable to noncontrolling interests	886	1,152	164
Net income attributable to The Ensign Group, Inc.	170,478	110,534	92,364
Amounts attributable to The Ensign Group, Inc.:
Income from continuing operations attributable to The Ensign Group, Inc.	170,478	91,690	59,493
Income from discontinued operations, net of income tax (Note 21)	0	18,844	32,871
Net income attributable to The Ensign Group, Inc.	$ 170,478	$ 110,534	$ 92,364
Basic:
Continuing operations (in dollars per share)	$ 3.19	$ 1.72	$ 1.14
Discontinued operations (in dollars per share)	0	0.35	0.64
Basic income per share attributable to The Ensign Group, Inc. (in dollars per share)	3.19	2.07	1.78
Diluted:
Continuing operations (in dollars per share)	3.06	1.64	1.09
Discontinued operations (in dollars per share)	0	0.33	0.61
Diluted income per share attributable to The Ensign Group, Inc.(in dollars per share)	$ 3.06	$ 1.97	$ 1.70
Weighted average common shares outstanding:
Basic (in shares)	53,434	53,452	52,016
Diluted (in shares)	55,787	55,981	54,397
Service
Total revenue	$ 2,387,439	$ 2,031,266	$ 1,752,991
Rental
Total revenue	$ 15,157	$ 5,258	$ 1,610

CONSOLIDATED STATEMENTS OF STOCKHOLDERS' EQUITY - USD ($) shares in Thousands, $ in Thousands	Total	Cumulative Effect, Period of Adoption, Adjustment	Common Stock	Additional Paid-In Capital	Retained Earnings	Retained Earnings Cumulative Effect, Period of Adoption, Adjustment	Treasury Stock	Non-Controlling Interest
Balance at beginning of period (in shares) at Dec. 31, 2017			51,360				1,932
Balance at beginning of period at Dec. 31, 2017	$ 500,059		$ 53	$ 266,058	$ 264,691		$ (38,405)	$ 7,662
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)			1,224
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	9,369		$ 2	9,367
Dividends declared	(9,615)				(9,615)
Employee stock award compensation	8,959			8,959
Noncontrolling interest attributable to subsidiary equity plan	1,378				(2,539)			3,917
Distribution to noncontrolling interest holder	(338)							(338)
Net income attributable to noncontrolling interest	164							164
Net income attributable to the Ensign Group, Inc.	92,364				92,364
Balance at end of period (in shares) at Dec. 31, 2018			52,584				1,932
Balance at end of period at Dec. 31, 2018	$ 602,340	$ 9,030	$ 55	284,384	344,901	$ 9,030	$ (38,405)	11,405
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Dividends per share (in dollars per share)	$ 0.1825
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)			1,050
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	$ 11,785		$ 1	11,784
Shares of common stock used to satisfy tax withholding obligations (in shares)			9				9
Shares of common stock used to satisfy tax withholding obligations	(485)						$ (485)
Dividends declared	(10,370)				(10,370)
Employee stock award compensation	11,746			11,746
Repurchase of common stock (Note 21) (in shares)			(138)				(138)
Repurchase of common stock	(6,406)						$ (6,406)
Distribution of net assets to Pennant (Note 21)	(84,433)				(71,181)			(13,252)
Dividends received from Pennant (Note 21)	11,600				11,600
Repurchase of common stock attributable to subsidiary equity plan	(394)							(394)
Noncontrolling interest attributable to subsidiary equity plan	594				(2,991)			3,585
Distribution to noncontrolling interest holder	(549)							(549)
Net income attributable to noncontrolling interest	1,152							1,152
Net income attributable to the Ensign Group, Inc.	110,534				110,534
Balance at end of period (in shares) at Dec. 31, 2019			53,487				2,079
Balance at end of period at Dec. 31, 2019	$ 656,144		$ 56	307,914	391,523		$ (45,296)	1,947
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Dividends per share (in dollars per share)	$ 0.1925
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)			1,851
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	$ 15,741		$ 2	15,739
Shares of common stock used to satisfy tax withholding obligations (in shares)			20				20
Shares of common stock used to satisfy tax withholding obligations	(917)						$ (917)
Dividends declared	(10,946)				(10,946)
Employee stock award compensation	14,524			14,524
Repurchase of common stock (Note 21) (in shares)			(692)				(692)
Repurchase of common stock	(25,000)						$ (25,000)
Distribution to noncontrolling interest holder	(2,683)							(2,683)
Net income attributable to noncontrolling interest	886							886
Net income attributable to the Ensign Group, Inc.	170,478				170,478
Balance at end of period (in shares) at Dec. 31, 2020			54,626				2,791
Balance at end of period at Dec. 31, 2020	$ 818,227		$ 58	$ 338,177	$ 551,055		$ (71,213)	$ 150
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Dividends per share (in dollars per share)	$ 0.2025

CONSOLIDATED STATEMENTS OF STOCKHOLDERS' EQUITY (Parenthetical) - $ / shares	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Statement of Stockholders' Equity [Abstract]
Dividends per share (in dollars per share)	$ 0.2025	$ 0.1925	$ 0.1825

CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2020	Dec. 31, 2019	Dec. 31, 2018
Cash flows from operating activities:
Net income	$ 171,364	$ 111,686	$ 92,528
Net income from discontinued operations, net of tax	0	(19,473)	(33,466)
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation and amortization	54,571	51,054	44,864
Impairment of long-lived assets	2,681	4,144	9,145
Amortization of deferred financing fees	840	1,090	1,175
Amortization of deferred gain on sale-leaseback			(658)
Non-cash leasing arrangement	451	318	0
Write-off of deferred financing fees	0	329	0
Deferred income taxes	(27,809)	3,490	1,353
Provision for doubtful accounts	7,058	2,444	2,477
Stock-based compensation	14,524	11,322	8,367
Cash received from insurance proceeds related to reconstruction of damaged properties and business interruptions	0	1,599	2,568
Loss/(gain) on insurance claims and disposal of assets	625	(3,026)	(1,038)
Income tax refund	0	0	11,000
Change in operating assets and liabilities
Accounts receivable	2,171	(60,424)	(10,459)
Prepaid income taxes	(485)	5,600	2,228
Prepaid expenses and other assets	(9,474)	(7,247)	1,677
Deferred employer portion of social security taxes under CARES Act	(48,309)	0
Operating lease obligations	(724)	(7,763)	0
Accounts payable	6,627	4,457	1,768
Accrued wages and related liabilities	64,539	47,386	27,565
Other accrued liabilities	17,536	11,353	4,550
Accrued self-insurance liabilities	10,293	6,286	5,740
Other long-term liabilities	10,254	4,302	(1,232)
Net cash provided by continuing operating activities	373,351	168,927	170,152
Net cash provided by discontinued operating activities (Note 21)	0	23,296	40,150
Net cash provided by operating activities	373,351	192,223	210,302
Cash flows from investing activities:
Purchase of property and equipment	(50,326)	(71,541)	(50,894)
Cash payments for business acquisitions (Note 8)	0	(6,455)	0
Cash payments for asset acquisitions (Note 8)	(24,997)	(141,595)	(84,721)
Escrow deposits	(100)	(14,050)	(7,271)
Escrow deposits used to fund acquisitions	14,050	7,271	137
Cash proceeds from the sale of assets and insurance proceeds	1,212	8,051	4,772
Purchases of investments	(21,708)	(12,332)	(3,074)
Maturities of investments	24,479	8,857	0
Other restricted assets	(1,276)	(2,236)	(289)
Net cash used in continuing investing activities	(58,666)	(224,030)	(141,340)
Net cash used in discontinued investing activities (Note 21)	0	(22,985)	(9,871)
Net cash used in investing activities	(58,666)	(247,015)	(151,211)
Cash flows from financing activities:
Proceeds from revolving credit facility and other debt (Note 15)	417,200	1,380,000	845,000
Payments on revolving credit facility and other debt (Note 15)	(629,745)	(1,296,654)	(914,939)
Issuance of common stock upon exercise of options	12,654	8,503	9,369
Repurchase of shares of common stock to satisfy tax withholding obligations	(917)	(485)	0
Repurchase of shares of common stock (Note 22)	(25,000)	(6,406)	0
Dividends paid	(10,830)	(10,190)	(9,419)
Dividends received from Pennant	0	11,600	0
Cash retained by Pennant at spin-off	0	(47)	0
Non-controlling interest distribution	(2,683)	(549)	(338)
Payments of deferred financing costs	0	(2,494)	(18)
Proceeds from CARES Act Provider Relief Fund and Medicare Advance Payment Program(Note 3)	246,955	0	0
Repayments of CARES Act Provider Relief Fund and Medicare Advance Payment Program(Note 3)	(144,932)	0	0
Net cash (used in)/provided by continuing financing activities	(137,298)	83,278	(70,345)
Net cash used in discontinued financing activities	0	(394)	0
Net cash (used in)/provided by financing activities	(137,298)	82,884	(70,345)
Net increase/(decrease) in cash and cash equivalents	177,387	28,092	(11,254)
Cash and cash equivalents beginning of period, including cash of discontinued operations	59,175	31,083	42,337
Cash and cash equivalents end of period, including cash of discontinued operations	236,562	59,175	31,083
Less cash of discontinued operations at end of period	0	0	41
Cash and cash equivalents end of period	236,562	59,175	31,042
Cash paid during the period for:
Interest	9,920	14,275	15,992
Income taxes	74,365	20,158	19,653
Lease liabilities	129,569	141,541	0
Non-cash financing and investing activity:
Accrued capital expenditures	3,400	4,100	3,500
Accrued dividends declared	2,868	2,705	2,525
Note receivable from insurance settlement and sale of ancillary business	5,500	0	126
Right-of-use assets obtained in exchange for new operating lease obligations	24,599	203,163	0
Distribution of net assets to Pennant	$ 0	$ 84,433	$ 0

Description of Business	12 Months Ended
Description of Business	Dec. 31, 2020
Organization, Consolidation and Presentation of Financial Statements [Abstract]
DESCRIPTION OF BUSINESS	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 December 31, 2020, the Company operated 228 facilities and other ancillary operations located in Arizona, California, Colorado, Idaho, Iowa, Kansas, Nebraska, Nevada, South Carolina, Texas, Utah, Washington and Wisconsin. 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 and other ancillary services. The Company's operating subsidiaries have a collective capacity of approximately 23,200 operational skilled nursing beds and 2,300 senior living units. As of December 31, 2020, the Company operated 164 facilities under long-term lease arrangements, and had options to purchase 11 of those 164 facilities. The Company's real estate portfolio includes 94 owned real estate properties, which included 64 facilities operated and managed by the Company, 31 senior living operations leased to and operated by The Pennant Group, Inc. as part of the Spin-Off, and the Service Center location. Of those 31 senior living operations, two are located on the same real estate properties as skilled nursing facilities that the Company owns and operates. Certain of the Company’s wholly-owned independent subsidiaries, collectively referred to as the Service Center, provide specific 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 liabilities, 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. Segment Updates — In the fourth quarter of 2020, the Company began reporting the results of its real estate portfolio as a new segment. The Company now has two reportable segments: (1) transitional and skilled services and (2) real estate. Refer to Note 7, Business Segments, for additional information. Corresponding items of segment information for prior periods have been recast to reflect the change of the Company’s segment structure. The Company believes that this structure reflects its current operational and financial management, and provides the best structure for the Company to focus on growth and investing opportunities while maintaining financial discipline.

Summary of Significant Accounting Policies	12 Months Ended
Summary of Significant Accounting Policies	Dec. 31, 2020
Accounting Policies [Abstract]
SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES	SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Basis of Presentation — The accompanying consolidated financial statements (the 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 operations, senior living operations and related ancillary services. All intercompany transactions and balances have been eliminated in consolidation. The Company presents noncontrolling interests within the equity section of its consolidated balance sheets and the amount of consolidated net income that is attributable to The Ensign Group, Inc. and the noncontrolling interest in its consolidated statements of income. The consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest. Additionally, 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 are 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 years ended December 31, 2020, 2019 and 2018. During the first quarter of 2019, the Company completed the sale of one of its senior living operations for a sale price of $1,838. The sale transaction did not meet the criteria of discontinued operations as it did not represent a strategic shift that had, or will have, a major effect on the Company's operations and financial results. Reclassifications — Prior period results reflect reclassifications, for comparative purposes, related to the change in the Company's segment structure. Refer to Note 7, Business Segments, for additional information related to segments. Historically, the Company only presented total revenue for all revenue services. As a result of the change in segments, the presentation of the Company's service revenue and rental revenue are presented separately on the Company's Consolidated Statements of Income. The reclassifications had no effect on the reported consolidated results of operations. Estimates and Assumptions — The preparation of 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 Financial Statements and the reported amounts of revenue and expenses during the reporting periods. The most significant estimates in the Company’s Financial Statements relate to revenue, acquired property and equipment, intangible assets and goodwill, right-of-use-assets, impairment of long-lived assets, lease liabilities, general and professional liabilities, 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. Contracts insuring the lives of certain employees who are eligible to participate in non-qualified deferred compensation plans are held in a rabbi trust. Cash surrender value of the contracts is based on performance measurement funds that shadow the deferral investment allocations made by participants in the deferred compensation plan. The fair value of the pooled investment funds is derived using Level 2 inputs. Service Revenue Recognition — The Company recognizes revenue in accordance with Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (ASC 606). See Note 4, Revenue and Accounts Receivable. Rental Revenue Recognition — The Company recognizes rental revenue for operating leases on a straight-line basis over the lease term when collectability of all minimum lease payments is probable (ASC 842). 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. Cash and Cash Equivalents — Cash and cash equivalents consist of bank term deposits, money market funds and treasury bill related investments with original maturities of three months or less at time of purchase and therefore approximate fair value. The fair value of money market funds is determined based on “Level 1” inputs, which consist of unadjusted quoted prices in active markets that are accessible at the measurement date for identical, unrestricted assets. The Company places its cash and short-term investments with high credit quality financial institutions. Insurance Subsidiary Deposits and Investments — The Company's captive insurance subsidiary cash and cash equivalents, deposits and investments are designated to support long-term insurance subsidiary liabilities and have been classified as short-term and long-term assets based on the timing of expected future payments of the Company's captive insurance liabilities. The majority of these deposits and investments are currently held in AA, A and BBB rated debt security investments and the remainder is held in a bank account with a high credit quality financial institution. The Company evaluates securities for other-than-temporary impairment (OTTI) on at least a quarterly basis, and more frequently when economic or market conditions warrant such an evaluation. If securities are in an unrealized loss position, the Company considers the extent and duration of the unrealized loss, and the financial condition and near-term prospects of the issuer. The Company also assesses whether it intends to sell, or it is more likely than not that it will be required to sell, a security in an unrealized loss position before recovery of its amortized cost basis. If either of the criteria regarding intent or requirement to sell is met, the entire difference between amortized cost and fair value is recognized as impairment through earnings. For the years ended December 31, 2020, 2019 and 2018, the Company did not recognize any OTTI for its investments. 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. 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. As of December 31, 2020, the Company does not have any leases that are classified as finance leases. Rights and obligations of operating leases are included as right-of-use assets, current lease liabilities and long-term lease liabilities on the Company's 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 utilized a third-party valuation specialist to assist in estimating the incremental borrowing rate. 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. Renewals are not assumed in the determination of the lease term unless they are deemed to be reasonably assured at the inception of the lease. 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 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. 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 determined there were impairment charges of $2,681, $3,203 and $5,492 during the years ended December 31, 2020, 2019 and 2018, respectively. The Company also recorded an impairment charge of $443 to right-of-use assets during the year ended December 31, 2019. Intangible Assets and Goodwill — Definite-lived intangible assets consist primarily of patient base, facility trade names and customer relationships. Patient base is amortized over a period of four to eight months, depending on the classification of the patients and the level of occupancy in a new acquisition on the acquisition date. 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. During the years ended December 31, 2019 and 2018, the Company recorded impairment charges of $498 and $3,653, respectively, to goodwill and intangible assets. The Company did not identify any goodwill or intangible asset impairment during the year ended December 31, 2020. Self-Insurance — The Company is partially self-insured for general and professional liability claims 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 liabilities and workers' compensation liabilities for all states (except Texas and Washington for workers' compensation) are self-insured through the Captive, the related assets and liabilities of which are included in the accompanying 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 actuarial 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. The Company uses actuarial valuations to estimate the liability based on historical experience and industry information. The Company’s operating subsidiaries are self-insured for workers’ compensation liabilities 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. Subsequently, for the 2021 fiscal year, the individual claims level increased to $625 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, are under a loss sensitive plan that insures individual claims that exceed $350 per occurrence. In Washington, 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 and Washington, the Company has purchased insurance coverage that insures individual claims that exceed $350 per accident. In all states except Washington, 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. In addition, the Company has recorded an asset and equal liability of $7,138 and $7,999 at December 31, 2020 and 2019, respectively, in order to present the ultimate costs of malpractice and workers' compensation claims and the anticipated insurance recoveries on a gross basis. 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 for fiscal year 2020. The individual claims level increased to $500 for each covered person for the 2021 fiscal year. The Company believes that adequate provision has been made in the 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 liabilities exceed its estimates of losses, 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 consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to The Ensign Group, Inc. in its consolidated statements of income. 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. Stock-Based Compensation — The Company measures and recognizes compensation expense for all stock-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 August 2020, the SEC issued final rules 33-10825 and 34-89670 “Modernization of Regulation S-K Items 101, 103, and 105,” which amend the disclosure requirements in Item 101, Description of Business; Item 103, Legal Proceedings; and Item 105, Risk Factors of Regulation S-K. Consistent with the SEC’s ongoing efforts to modernize Regulation S-K disclosure requirements, the amendments aim to improve the readability of disclosures, reduce repetition, and eliminate immaterial information. Amendments to disclosure requirements include changes to the description of business and risk factors to a principles-based approach, providing more flexibility to tailor disclosures, while disclosure amendments to legal proceedings continue to reflect the current, more prescriptive approach. The final rules are effective for all registration statements, annual reports and quarterly reports filed on or after November 9, 2020. The Company has reflected the changes throughout this Annual Report. 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. The Company adopted this standard effective January 1, 2020 and determined there was no 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. The Company adopted this standard effective January 1, 2020 and determined there was no material impact on the Company's consolidated financial statements. In June 2016, the FASB issued Accounting Standards Update (ASU) 2016-13 “Financial Instruments – Credit Losses (Topic 326): Measurement of Credit Losses on Financial Instruments”, which replaces the existing incurred loss impairment model with an expected credit loss model and requires a financial asset measured at amortized cost to be presented at the net amount expected to be collected. The Company adopted this standard effective January 1, 2020 and determined there was no material impact on the Company's consolidated financial statements. Accounting Standards Recently Issued but Not Yet Adopted by the Company In December 2019, the FASB issued ASU 2019-12 "Simplifying the Accounting for Income Taxes (Topic 740)" as part of its simplification initiative to reduce the cost and complexity in accounting for income taxes. ASU 2019-12 removes certain exceptions related to the approach for intra-period tax allocation, the methodology for calculating income taxes in an interim period and the recognition of deferred tax liabilities for outside basis differences. ASU 2019-12 also amends other aspects of the guidance to help simplify and promote consistent application of GAAP. The guidance is effective for interim and annual periods beginning after December 15, 2020, which will be the Company's fiscal year 2021, with early adoption permitted. The Company has adopted this standard on January 1, 2021 and determined there was no material impact on the Company's financial position, results of operations and liquidity. In February 2020, the FASB issued ASU 2020-04 "Reference Rate Reform (Topic 848)," which provides temporary, optional practical expedients and exceptions to enable a smoother transition to the new reference rates which will replace LIBOR and other reference rates expected to be discontinued. Adoption of the provisions of ASU 2020-04 is optional. The amendments are effective for all entities from the beginning of the interim period that includes the issuance date of the ASU. An entity may elect to apply the amendments prospectively through December 31, 2022. The Company is currently evaluating the impact of ASU 2020-04 on its financial position, results of operations and liquidity. In May 2020, the SEC issued Final Rule Release No. 33-10786 “Amendments to Financial Disclosures about Acquired and Disposed Businesses” (“SEC Rule 33-10786”), which amends the disclosure requirements applicable to acquisitions and dispositions of businesses. Amendments within SEC Rule 33-10786 primarily impact (1) the tests and thresholds used to determine the significance of acquisitions and dispositions; (2) the form and content of pro forma information required to be disclosed in connection with significant acquisitions and dispositions; (3) acquiree financial statement requirements; and (4) thresholds used to determine the significance of acquisitions and dispositions of real estate operations, and related financial statement requirements, among others. The amendments are effective for all SEC registrants beginning January 1, 2021, with early adoption permitted. The Company has adopted this standard on January 1, 2021 and determined there was no material impact on the Company's consolidated financial statements. In November 2020, the SEC issued final rules 33-10890 and 34-90459 “Management’s Discussion and Analysis, Selected Financial Data, and Supplementary Financial Information,” which modernizes and simplifies certain disclosure requirements of Regulation S-K. Certain key rule amendments eliminate the requirement to disclose Selected Financial Data; Selected Quarterly Financial Data, with certain exceptions; the impact of inflation and changing prices, provided the impact is not material; off-balance sheet arrangements in tabular form; and the aggregate amount of contractual obligations in tabular form. The final rules also amended various aspects of Item 303, “Management’s Discussion and Analysis of Financial Condition and Results of Operations,” among others. The final rules are effective for all registration statements, annual reports and quarterly reports filed on or after August 9, 2021, with early adoption permitted. The Company is currently evaluating the impact of the disclosure changes in its Annual Report.

COVID-19 UPDATE	12 Months Ended
COVID-19 UPDATE	Dec. 31, 2020
Subsequent Events [Abstract]
COVID-19 UPDATE	COVID-19 UPDATE The outbreak of the 2019 coronavirus disease (COVID-19), which was declared a global pandemic by the World Health Organization (WHO) on March 11, 2020, and the related responses by public health and governmental authorities to contain and combat its outbreak and spread, continues to spread and impact healthcare operations across the United States, including the markets in which the Company operates. The Centers for Disease Control and Prevention (CDC) has stated that older adults are at a higher risk for serious illness from the coronavirus. As the COVID-19 pandemic continues, the Company monitors the impact of the pandemic on its operations and financial condition. In response to the COVID-19 pandemic, Congress passed the Coronavirus Aid, Relief, and Economic Security Act of 2020 (the CARES Act), which was signed into law on March 27, 2020, and which authorized the cash distribution of relief funds to healthcare providers. On April 10, 2020, the Company began to receive CARES Act provider relief fund payments (Provider Relief Fund) from the U.S. Department of Health and Human Services (HHS). In July 2020, HHS announced a new $5.0 billion Provider Relief Fund distribution to be used to protect residents of nursing homes and long-term care facilities from the impact of COVID-19. The amount of funding received is based upon a facility’s COVID-19 infection and mortality rates. In order to qualify, facilities must demonstrate COVID-19 infection rates below the rate of infection in the counties which they are located and demonstrate mortality rates below nationally established performance thresholds for nursing home residents infected with COVID-19. Facilities that qualify during each of the monthly performance periods, running from September 2020 through December 2020, are eligible for additional funds based upon their aggregate performance on these infection and mortality measures. During 2020, the Company's affiliated operations have directly or indirectly received, in the aggregate, approximately $141,700 in Provider Relief Funds. As of December 31, 2020, the Company has returned all of the funds received to an agent of HHS; however the Company may continue to receive additional funding related to the $5.0 billion Provider Relief Fund distribution in future periods. Subsequent to December 31, 2020, the Company received and returned another $5,060 in funding. Additionally, the Company applied for and received $105,255 through the Medicare Accelerated and Advance Payment Program under the CARES Act for the year ended December 31, 2020. The purpose of the program is to assist in providing needed liquidity to care delivery providers. The Company repaid $3,232 of the funds in July 2020. In October 2020, the Centers for Medicare and Medicaid Services (CMS) released updated payment guidance to extend the repayment period beginning one year from the date the accelerated or advance payment was issued. The repayments may occur through lump sum payments or recoupment of future Medicare billings. Any unpaid funds will begin accruing interest 15 months after the repayment period. The Company's required repayment period is currently scheduled to start in April 2021. As of December 31, 2020, the Company has classified $102,023 the remaining cash receipts as a short-term liability. On March 18, 2020, the President signed into law The Family First Coronavirus Response Act, which provided a temporary 6.2% increase to the Federal Medical Assistance Percent (FMAP) effective January 1, 2020. The law permits states to retroactively change their state's Medicaid program rates effective as of January 1, 2020. The law provides discretion to each state and specifies that the funds are to be used to reimburse the recipient for healthcare related expenses that are attributable to COVID-19 associated with providing patient care. In addition, increases in Medicaid rates can also come from other areas of the state budgets outside of the FMAP funding. Revenues from these additional payments are recognized in accordance with ASC 606, subject to variable consideration constraints. In certain operations where the Company received additional payments that exceeded expenses incurred related to COVID-19, the Company characterized such payments as variable revenue that required additional consideration and accordingly, the amount of state relief revenue recognized is limited to the actual COVID-19 related expenses incurred. For the year ended December 31, 2020, the Company received $51,927 in state relief funding, of which, $45,407 was recognized as revenue. The CARES Act also provides for deferred payment of the employer portion of social security taxes through the end of 2020, with 50% of the deferred amount due by December 31, 2021 and the remaining 50% due by December 31, 2022. The Company recorded $48,309 of deferred payments of social security taxes as a liability during 2020. The total balance is included in accrued wages and related liabilities of $24,155 for the short-term amount and the remaining $24,154 is included in other long-term liabilities within the consolidated balance sheets as of December 31, 2020.

Revenue and Accounts Receivable

12 Months Ended

Dec. 31, 2020

Revenue from Contract with Customer [Abstract]

REVENUE AND ACCOUNTS RECEIVABLE

Service Revenue

The Company's service revenue is derived primarily from providing healthcare services to its patients. Revenue is 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 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 on a per day basis, 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 74.5%, 70.6% and 71.0% for the years ended December 31, 2020, 2019 and 2018, respectively. Settlements 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 the final settlement. The Company recorded adjustments to revenue which were not material to the Company's consolidated revenue for the years ended December 31, 2020, 2019 and 2018.

Rental Revenue

The Company's rental revenues are primarily generated by leasing healthcare-related properties through triple-net lease arrangements, under which the tenant is solely responsible for the costs related to the property. Revenue is recognized on a straight-line basis over the lease term if it has been deemed probable of collection. The Company has elected the single component practical expedient, which allows a lessor, by class of underlying asset, not to allocate the total consideration to the lease and non-lease components based on their relative stand-alone selling prices where certain criteria are met. This single component practical expedient requires the Company to account for the lease component and non-lease component(s) associated with that lease as a single component if (1) the timing and pattern of transfer of the lease component and the non-lease component(s) associated with it are the same and (2) the lease component would be classified as an operating lease if it were accounted for separately. If the Company determines that the lease component is the predominant component, it accounts for the single component as an operating lease in accordance with the new lease standards. Conversely, the Company is required to account for the combined component under the revenue recognition standard if it determines that the non-lease component is the predominant component. As a result of this assessment, rental revenues from the lease of real estate assets that qualify for this expedient are accounted for as a single component under the new lease standards. The components of the Company's operating leases qualify for the single component presentation.

Tenant reimbursements related to property taxes and insurance are neither considered lease nor non-lease components under the new lease standards. Lessee payments for taxes and insurance paid directly to a third party, on behalf of the Company, are excluded from variable lease payments and rental revenue in the Company’s consolidated statements of income (net presentation). Otherwise, tenant reimbursements for taxes and insurance which are paid by the Company directly to a third party are classified as additional rental revenue and expense and recognized by the Company on a gross basis.

Disaggregation of Revenue

The Company disaggregates revenue from contracts with its patients by 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.

Revenue by Payor

The Company’s revenue is derived primarily from providing 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.

Service revenue for the years ended December 31, 2020, 2019 and 2018 is summarized in the following tables:


	Year Ended December 31,
	2020				2019				2018
	Revenue		% of Revenue		Revenue		% of Revenue		Revenue		% of Revenue
Medicaid	$	900,249	37.7	%	$	802,952	39.5	%	$	691,276	39.4	%
Medicare	727,374		30.5		499,353		24.6		436,580		24.9
Medicaid — skilled	149,846		6.3		132,889		6.5		117,686		6.7
Total Medicaid and Medicare	1,777,469		74.5		1,435,194		70.6		1,245,542		71.0
Managed care	367,095		15.4		351,054		17.3		301,866		17.2
Private and other(1)	242,875		10.1		245,018		12.1		205,583		11.8
Service revenue	$	2,387,439	100.0	%	$	2,031,266	100.0	%	$	1,752,991	100.0	%

(1) Private and other payors also includes revenue from all payors generated in other ancillary services for the years ended December 31, 2020, 2019 and 2018.

In addition to the service revenue above, the Company's rental revenue derived from triple-net lease arrangements with third parties is $15,157, $5,258 and $1,610 for the years ended December 31, 2020, 2019 and 2018.

Balance Sheet Impact

Included in the Company’s consolidated balance sheets are contract balances, 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 and contract assets as of December 31, 2020 and 2019, or activity during the years ended December 31, 2020 and 2019.

Accounts receivable as of December 31, 2020 and 2019, is summarized in the following table:



	Year Ended December 31,
	2020		2019
Medicaid	$	102,077	$	125,443
Managed care	61,743		70,015
Medicare	80,904		53,163
Private and other payors	69,056		62,836
	313,780		311,457
Less: allowance for doubtful accounts	(8,718)		(2,472)
Accounts receivable, net	$	305,062	$	308,985

Practical Expedients and ExemptionsAs 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.

- Definition

The entire disclosure of revenue from contract with customer to transfer good or service and to transfer nonfinancial asset. Includes, but is not limited to, disaggregation of revenue, credit loss recognized from contract with customer, judgment and change in judgment related to contract with customer, and asset recognized from cost incurred to obtain or fulfill contract with customer. Excludes insurance and lease contracts.

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-URI http://asc.fasb.org/topic&trid=49130388

Reference 2: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 10
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130551-203045

Reference 3: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 13
-Subparagraph (b)(2)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130556-203045

Reference 4: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
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-Section 50
-Paragraph 12
-Subparagraph (b)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

Reference 5: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
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-Section 50
-Paragraph 9
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130550-203045

Reference 6: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
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-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (e)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

Reference 7: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (d)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

Reference 9: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 15
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130558-203045

Reference 10: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 606
-SubTopic 10
-Section 50
-Paragraph 12
-Subparagraph (c)
-URI http://asc.fasb.org/extlink&oid=121604090&loc=SL49130554-203045

+ Details

Computation of Net Income Per Common Share

12 Months Ended

Dec. 31, 2020

Earnings Per Share [Abstract]

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:


	Year Ended December 31,
		2020		2019		2018
Numerator:
Net income from continuing operations		$	171,364	$	92,213	$	59,062
Less: net income/(loss) attributable to noncontrolling interests in continuing operations		886		523		(431)
Net income from continuing operations attributable to The Ensign Group, Inc.		170,478		91,690		59,493
Net income from discontinued operations, net of tax		—		19,473		33,466
Less: net income attributable to noncontrolling interests in discontinued operations		—		629		595
Net income from discontinued operations, net of tax		—		18,844		32,871
Net income attributable to The Ensign Group, Inc.		$	170,478	$	110,534	$	92,364

Denominator:
Weighted average shares outstanding for basic net income per share		53,434		53,452		52,016
Basic net income per common share:
Income from continuing operations		$	3.19	$	1.72	$	1.14
Income from discontinued operations		—		0.35		0.64
Net income attributable to The Ensign Group, Inc.		$	3.19	$	2.07	$	1.78

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


	Year Ended December 31,
		2020		2019		2018
Numerator:
Net income from continuing operations		$	171,364	$	92,213	$	59,062
Less: net income/(loss) attributable to noncontrolling interests in continuing operations		886		523		(431)
Net income from continuing operations attributable to The Ensign Group, Inc.		170,478		91,690		59,493
Net income from discontinued operations, net of tax		—		19,473		33,466
Less: net income attributable to noncontrolling interests in discontinued operations		—		629		595
Net income from discontinued operations, net of tax		—		18,844		32,871
Net income attributable to The Ensign Group, Inc.		$	170,478	$	110,534	$	92,364

Denominator:
Weighted average common shares outstanding		53,434		53,452		52,016
Plus: incremental shares from assumed conversion (1)		2,353		2,529		2,381
Adjusted weighted average common shares outstanding		55,787		55,981		54,397
Diluted net income per common share:
Income from continuing operations		$	3.06	$	1.64	$	1.09
Income from discontinued operations		—		0.33		0.61
Net income attributable to The Ensign Group, Inc.		$	3.06	$	1.97	$	1.70

(1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 956, 250 and 220 for the years ended December 31, 2020, 2019 and 2018, respectively

Fair Value Measurements	12 Months Ended
Fair Value Measurements	Dec. 31, 2020
Fair Value Disclosures [Abstract]
FAIR VALUE MEASUREMENTS	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 fair value of cash and cash equivalents of $236,562 and $59,175 as of December 31, 2020 and 2019, respectively, is derived using Level 1 inputs. The Company's other financial assets include contracts insuring the lives of certain employees who are eligible to participate in non-qualified deferred compensation plans which are held in a rabbi trust. The cash surrender value of these contracts is based on performance measurement funds that shadow the deferral investment allocations made by participants in the deferred compensation plan. As of December 31, 2020, the fair value of the pooled investment funds of $6,577 is derived using Level 2 inputs. As of December 31, 2019, Company had no pooled investment funds as the cash surrender value of life insurance related to the deferred compensation plan was not implemented. The Company's non-financial assets, which includes goodwill, intangible assets, property and equipment and right-of-use assets, 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. Debt Security Investments - Held to Maturity At December 31, 2020 and 2019, the Company had approximately $45,554 and $48,325, 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 December 31, 2020, the debt security investments were held in AA, A and BBB rated debt securities. The Company believes its debt security investments that were in an unrealized loss position as of December 31, 2020 were not other-than-temporarily impaired, nor has any event occurred subsequent to that date, including the developments related to Coronavirus (COVID-19), that would indicate any other-than-temporary impairment.

- 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

12 Months Ended

Dec. 31, 2020

Segment Reporting [Abstract]

BUSINESS SEGMENTS

In the fourth quarter of 2020, the Company's Chief Executive Officer, who is its chief operating decision maker, or CODM, began reviewing the results of its real estate portfolio. Accordingly, the Company began reporting a new segment as it continues to expand its real estate investment strategy. The Company now has two reportable segments: (1) transitional and skilled services, which includes the operation of skilled nursing facilities and rehabilitation therapy services and (2) real estate, which is comprised of properties owned by the Company and leased to skilled nursing and assisted living operations where the properties are subject to triple-net long-term leases, including operations that are owned and operated by the Company. Prior to this new segment structure, the Company had one reportable segment, transitional and skilled services. Corresponding items of segment information for prior periods have been recast to reflect the change of the Company’s segment structure.

As of December 31, 2020, transitional and skilled services segment includes 195 skilled nursing operations and 24 campus operations that provide both skilled nursing and rehabilitative care services and senior living services. The Company's real estate segment includes 94 owned real estate properties. These properties include 64 operations the Company operated and managed, real estate properties of 31 senior living operations that are leased to and operated by Pennant and the Service Center location, which continues to lease office space to various third parties. Of the 31 real estate operations leased to Pennant, two senior living operations are located on the same real estate properties as skilled nursing facilities that the Company owns and operates. The Company also reports an “All Other” category that includes results from its senior living operations, which includes nine stand alone senior living operations and 24 campus operations that provide both skilled nursing and rehabilitative care services and senior living services, mobile diagnostics, medical transportation and other ancillary operations. Services included in the “All Other” category are insignificant individually, and therefore do not constitute a reportable segment.

The Company’s reportable segments are significant operating segments that offer differentiated services. The Company's CODM reviews financial information for each operating segment to evaluate performance and allocate capital resources. The Company believes this structure reflects its current operational and financial management and provides the best structure to maximize the quality of care and investment strategy provided, while maintaining financial discipline. The Company's CODM does not review assets by segment in his resource allocation and therefore assets by segment are not disclosed below.

Beginning in the fourth quarter of 2020, segment income and loss was changed from profit or loss from operations before interest and provision for income taxes to profit or loss from operations before provision for income taxes, excluding gain or loss from sale of real estate and impairment charges from operations. Prior period presentation has been revised to reflect the new measurement.

With the exception of intercompany rental revenue, the accounting policies of the reportable segments are the same as those described in Note 2, Summary of Significant Accounting Policies. Rental revenue from Ensign-affiliated operations are based on mutually agreed-upon base rent that are subject to change from time to time. Intercompany revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of the related healthcare facilities. Included in the real estate segment income is interest expense related to the borrowings to fund real estate acquisitions. Interest revenue is related to the investment accounts that the Service Center manages on behalf of the Company and is included in the "All Other" category.

The following tables set forth financial information for the segments:


	Year Ended December 31, 2020
	Transitional and Skilled Services		Real Estate		All Other(1)		Intercompany Elimination(2)		Total
Service revenue	$	2,288,182	$	—	$	99,257	$	—	$	2,387,439
Rental revenue	—		61,275		—		(46,118)		15,157
Total revenue	$	2,288,182	$	61,275	$	99,257	$	(46,118)	$	2,402,596
Segment income (loss)	327,812		31,323		(138,776)		—		220,359
Loss on sale of real estate and impairment charges									(2,753)
Income before provision for income taxes									$	217,606
Depreciation and amortization	28,585		18,218		7,768		—		54,571
Other expense, net(3)	$	—	$	9,350	$	(3,801)	$	—	$	5,549

(1) General and administrative expense are included in the "all other" category.

(2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities.

(3) Other expense, net includes interest expense and interest revenue.


	Year Ended December 31, 2019
	Transitional and Skilled Services		Real Estate		All Other(1)		Intercompany Elimination(2)		Total
Service revenue	$	1,934,243	$	—	$	97,023	$	—	$	2,031,266
Rental revenue	—		49,868		—		(44,610)		5,258
Total revenue	$	1,934,243	$	49,868	$	97,023	$	(44,610)	$	2,036,524
Segment income (loss)	225,910		17,479		(125,797)		—		117,592
Loss on sale of real estate and impairment charges									(1,425)
Income before provision for income taxes									$	116,167
Depreciation and amortization	27,837		15,196		8,021		—		51,054
Other expense, net(3)	$	—	$	15,612	$	(2,599)	$	—	$	13,013

(1) General and administrative expense is included in the "all other" category

(3) Other expense, net includes interest expense and interest revenue.


	Year Ended December 31, 2018
	Transitional and Skilled Services		Real Estate		All Other(1)		Intercompany Elimination(2)		Total
Service revenue	$	1,678,849	$	—	$	74,142	$	—	$	1,752,991
Rental revenue	—		40,177		—		(38,567)		1,610
Total revenue	$	1,678,849	$	40,177	$	74,142	$	(38,567)	$	1,754,601
Segment income (loss)	175,552		11,853		(106,611)		—		80,794
Loss on sale of real estate and impairment charges									(9,047)
Income before provision for income taxes									$	71,747
Depreciation and amortization	25,016		12,035		7,813		—		44,864
Other expense, net(3)	$	—	$	15,148	$	(1,982)	$	—	$	13,166

(1) General and administrative expense is included in the "all other" category

(3) Other expense, net includes interest expense and interest revenue.

Service revenue by major payor source were as follows:


	Year Ended December 31, 2020
	Transitional and Skilled Services		All Other			Total Service Revenue		Revenue %
Medicaid	$	886,991	$	13,258	(1)	$	900,249	37.7	%
Medicare	727,374		—			727,374		30.5
Medicaid-skilled	149,846		—			149,846		6.3
Subtotal	1,764,211		13,258			1,777,469		74.5
Managed care	367,095		—			367,095		15.4
Private and other	156,876		85,999		(2)	242,875		10.1
Total service revenue	$	2,288,182	$	99,257		$	2,387,439	100.0	%

(1) Medicaid payor includes revenue generated from senior living operations for the year ended December 31, 2020.

(2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the year ended December 31, 2020.


	Year Ended December 31, 2019
	Transitional and Skilled Services		All Other			Total Service Revenue		Revenue %
Medicaid	$	789,873	$	13,079	(1)	$	802,952	39.5	%
Medicare	499,353		—			499,353		24.6
Medicaid-skilled	132,889		—			132,889		6.5
Subtotal	1,422,115		13,079			1,435,194		70.6
Managed care	351,054		—			351,054		17.3
Private and other	161,074		83,944		(2)	245,018		12.1
Total service revenue	$	1,934,243	$	97,023		$	2,031,266	100.0	%

(1) Medicaid payor includes revenue generated from senior living operations for the year ended December 31, 2019.

(2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the year ended December 31, 2019.


	Year Ended December 31, 2018
	Transitional and Skilled Services		All Other			Total Service Revenue		Revenue %
Medicaid	$	678,749	$	12,527	(1)	$	691,276	39.4	%
Medicare	436,580		—			436,580		24.9
Medicaid-skilled	117,686		—			117,686		6.7
Subtotal	1,233,015		12,527			1,245,542		71.0
Managed care	301,866		—			301,866		17.2
Private and other	143,968		61,615		(2)	205,583		11.8
Total service revenue	$	1,678,849	$	74,142		$	1,752,991	100.0	%

(1) Medicaid payor includes revenue generated from senior living operations for the year ended December 31, 2018.

(2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the year ended

December 31, 2018.

- Definition

The entire disclosure for reporting segments including data and tables. Reportable segments include those that meet any of the following quantitative thresholds a) it's reported revenue, including sales to external customers and intersegment sales or transfers is 10 percent or more of the combined revenue, internal and external, of all operating segments b) the absolute amount of its reported profit or loss is 10 percent or more of the greater, in absolute amount of 1) the combined reported profit of all operating segments that did not report a loss or 2) the combined reported loss of all operating segments that did report a loss c) its assets are 10 percent or more of the combined assets of all operating segments.

+ References

Reference 1: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 31
-URI http://asc.fasb.org/extlink&oid=120311839&loc=d3e8924-108599

Reference 2: http://www.xbrl.org/2003/role/disclosureRef
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-Name Accounting Standards Codification
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Reference 3: http://www.xbrl.org/2003/role/disclosureRef
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Reference 4: http://www.xbrl.org/2003/role/disclosureRef
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Reference 5: http://www.xbrl.org/2003/role/disclosureRef
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-Publisher FASB
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-URI http://asc.fasb.org/topic&trid=2134510

+ Details

Acquisitions

12 Months Ended

Dec. 31, 2020

Business Combinations [Abstract]

ACQUISITIONS

The Company's subsidiaries acquisition focus 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 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, a real estate affiliated subsidiary will acquire the property of facilities that have previously been operated under third-party leases.

Accounting Standards Codification Topic 805, Clarifying the Definition of a Business (ASC 805) defined the definition of a business to assist entities with evaluating when a set of transferred assets and activities is deemed to be a business. Determining whether a transferred set constitutes a business is important because the accounting for a business combination differs from that of an asset acquisition. The definition of a business also affects the accounting for dispositions. When substantially all of the fair value of assets acquired is concentrated in a single asset, or a group of similar assets, the assets acquired would not represent a business and business combination accounting would not be required. All of the Company's acquisitions in 2020 was concentrated in property and equipment and, accordingly these transactions were classified as asset acquisitions.

2020 Acquisitions

During the year ended December 31, 2020, the Company expanded its operations and real estate portfolio through a combination of long-term leases and real estate purchases, with the addition of five stand-alone skilled nursing operations, one stand-alone independent living operation and one campus operation. Of these acquisitions, four relate to purchases of owned properties, increasing our real estate portfolio. These new operations added a total of 507 operational skilled nursing beds and 298 operational senior living units operated by the Company's affiliated operating subsidiaries. The aggregate purchase price for these acquisitions during the year ended December 31, 2020 was $24,997.

For the acquisitions made through long-term leases, 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 Company entered into a separate operations transfer agreement with the prior operator as part of each transaction.

The fair value of assets for all acquisitions was concentrated in property and equipment and, accordingly these transactions were classified as asset acquisitions.

During the first quarter of 2020, the Company entered into a long-term lease agreement to transfer two senior living operations to Pennant. Ensign affiliates retained ownership of the real estate for these two senior living communities.

Subsequent Event

Subsequent to December 31, 2020, the Company expanded its operations through long-term leases with the addition of four stand-alone skilled nursing operations. The addition of these operations added 447 operational skilled nursing beds to be operated by the Company's affiliated operating subsidiaries. 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 Company entered into a separate operations transfer agreement with the prior operator as part of each transaction.

2019 Acquisitions

During the year ended December 31, 2019, the Company expanded its operations and real estate portfolio through a combination of long-term leases and real estate purchases, with the addition of 22 stand-alone skilled nursing operations, one stand-alone senior living operations and four campus operations. Of these acquisitions, 15 relate to purchases of owned properties, further expanding our real estate portfolio. The addition of these operations added a total of 3,142 operational skilled nursing beds and 407 operational senior living units 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. In addition, the Company invested in real estate and Medicare and Medicaid licenses during the year. The aggregate purchase price for these acquisitions during the year ended December 31, 2019 was $148,974.

The fair value of assets for 30 of the acquisitions was concentrated in property and equipment and as such, these transactions were classified as asset acquisitions. The purchase price for the asset acquisitions was $141,595. The fair value of assets for the remaining one acquisition was concentrated in goodwill and as such, the transaction was classified as a business combination. The purchase price for the business combination was $7,379. The Company also entered into a note payable with the seller of $924, which was subsequently paid off in the second quarter of 2019 and was included as payments of debt in the consolidated statement of cash flows.

In connection with the Spin-Off, the Company transferred the assets of two stand-alone senior living operations, two home health agencies, five hospice agencies and two home care agencies that were purchased for an aggregate price of $18,780. The Company retained the real estate for one stand-alone senior living operation.

2018 Acquisitions

During the year ended December 31, 2018, the Company expanded its operations and real estate portfolio through a combination of long-term leases and real estate purchases, with the addition of four stand-alone skilled nursing operations and three campus operations. Of these acquisitions, six relate to purchases of owned properties, further expanding our real estate portfolio. The addition of these operations added 744 operational skilled nursing beds and 264 senior living units to be operated by the Company's affiliated operating subsidiaries. In addition, with the stand-alone skilled nursing operation acquisition, the Company acquired real estate that included an adjacent long-term acute care hospital that is currently operated by a third party under a lease arrangement. In addition, in June 2018, the Company acquired an office building for a purchase price of $30,959 to accommodate its growing Service Center team. The aggregate purchase price for these acquisitions during the year ended December 31, 2018 was $84,721, which the fair value of assets for all these acquisitions was concentrated in property and equipment and as such, these transactions were classified as asset acquisitions.

The Company did not acquire any material assets or assume any liabilities other than tenant's post-assumption rights and obligations under the long-term lease. The Company entered into a separate operations transfer agreement with the prior operator as part of each transaction.

In connection with the Spin-Off, the Company transferred the assets of the seven stand-alone senior living operations, four home health agencies, three hospice agencies and two home care agencies which were purchased for an aggregate price of $5,318. The Company retained the real estate for three stand-alone senior living operations.

The table below presents the allocation of the purchase price for the operations acquired during the years ended December 31, 2020, 2019 and 2018, excluding assets that were contributed to Pennant that occurred during the Spin-Off.


	Year Ended December 31,
	2020		2019		2018
Land	$	9,496	$	34,377	$	16,851
Building and improvements	14,178		101,217		65,136
Equipment, furniture, and fixtures	568		6,024		1,638
Assembled occupancy	107		638		202
Definite-lived intangible assets	—		440		—
Goodwill	—		5,382		—
Favorable leases	—		294		534
Lease acquisition	—		—		360
Other indefinite-lived intangible assets	648		602		—

Total acquisitions	$	24,997	$	148,974	$	84,721

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. The operations acquired by the Company are frequently underperforming financially and can have regulatory and clinical challenges to overcome. Financial information, especially with underperforming operations, 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 assets acquired during the year ended December 31, 2020 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 December 31, 2020 consolidated balance sheets of the Company, and the operating results have been included in the consolidated statements of operations of the Company since the date the Company gained effective control.

Property and Equipment — Net

12 Months Ended

Dec. 31, 2020

Property, Plant and Equipment [Abstract]

PROPERTY AND EQUIPMENT— Net

PROPERTY AND EQUIPMENT - NET

Property and equipment, net consists of the following:



	December 31,
	2020		2019
Land	$	101,236	$	91,740
Buildings and improvements	555,416		531,538
Leasehold improvements	129,727		127,983
Equipment	233,453		212,808
Furniture and fixtures	4,409		4,453
Construction in progress	3,008		3,409
	1,027,249		971,931
Less: accumulated depreciation	(249,005)		(204,366)
Property and equipment, net	$	778,244	$	767,565

The Company completed the sale of real estate for $7,138 during the year ended December 31, 2019, of which a gain of $2,861 was recognized during the year ended December 31, 2019 related to the transaction. In addition, the Company evaluated its long-lived assets and recorded an impairment charge of $2,681, $3,203 and $5,492 for the fiscal years ended 2020, 2019 and 2018, respectively.

See also Note 8, Acquisitions for information on acquisitions during the years ended December 31, 2020, 2019 and 2018.

Intangible Assets — Net

12 Months Ended

Dec. 31, 2020

Intangible Assets, Net (Excluding Goodwill) [Abstract]

INTANGIBLE ASSETS — NET

INTANGIBLE ASSETS - NET



	Weighted Average Life (Years)	December 31,
		2020						2019

		Gross Carrying Amount		Accumulated Amortization				Gross Carrying Amount		Accumulated Amortization
Intangible Assets						Net						Net
Lease acquisition costs	1.7	$	360	$	(360)	$	—	$	360	$	(349)	$	11
Favorable leases	2.1	534		(534)		—		534		(448)		86
Assembled occupancy	0.4	39		(26)		13		2,982		(2,818)		164
Facility trade name	30.0	733		(366)		367		733		(342)		391
Customer relationships	18.2	4,640		(2,121)		2,519		4,640		(1,910)		2,730
Total		$	6,306	$	(3,407)	$	2,899	$	9,249	$	(5,867)	$	3,382

During the years ended December 31, 2020 and 2019, amortization expense was $1,813 and $3,660, respectively, of which $1,223 and $1,981 was related to the amortization of right-of-use assets, respectively. During the year ended December 31, 2018, amortization expense was $2,736. In addition, the Company identified intangible assets which became fully amortized during the prior year and removed these fully amortized balances from the gross asset and accumulated amortization amounts. During the year ended December 31, 2018, the Company recorded an impairment charge to intangible assets of $140. The Company did not record any impairment charge to intangible assets during the year ended December 31, 2020 and 2019.

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


Year	Amount

2021	247
2022	234
2023	234
2024	234
2025	234
Thereafter	1,716
	$	2,899

Goodwill and Other Indefinite-Lived Intangible Assets

12 Months Ended

Dec. 31, 2020

Goodwill and Intangible Assets Disclosure [Abstract]

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 a goodwill impairment test by comparing the carrying value of each reporting unit to its respective fair value. The Company determines the estimated fair value of each reporting unit using a discounted cash flow analysis. The fair value of the reporting unit is the implied fair value of goodwill. In the event a reporting unit's carrying value exceeds its fair value, an impairment loss will be recognized. An impairment loss is measured by the difference between the carrying value of the reporting unit and its fair value.

The Company performs its goodwill impairment test annually and evaluates goodwill when events or changes in circumstances indicate that its carrying value may not be recoverable. The Company performs the annual impairment testing of goodwill using October 1 as the measurement date. The Company completed its goodwill impairment test as of October 1, 2020 and did not record any impairment charge to goodwill or other intangible assets. Management determined that the improvements in operations and related forecasted cash flows were slower than anticipated at the time of acquisition, resulting in the impairment to goodwill for fiscal years 2019 and 2018 for other ancillary services.

The Company anticipates that the majority of total goodwill recognized will be fully deductible for tax purposes as of December 31, 2020.

All of the Company's acquisitions during the year ended December 31, 2020 were classified as asset acquisitions and accordingly, no goodwill was recognized for these acquisitions. There were no other activities in goodwill during the year ended December 31, 2020. Provided that goodwill corresponds to the acquisition of a business and not merely the acquisition of real estate property, the Company's real estate segment appropriately does not carry a goodwill balance. The following table represents the goodwill value by transitional and skilled service segment and "all other" category, which includes other ancillary services, as of December 31, 2020:

Goodwill

Transitional and Skilled Services

All Other

Total