0001125376-22-000075 | 10-Q | XBRL Viewer

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Leases - Lessee Narrative (Details) $ in Thousands	3 Months Ended
Leases - Lessee Narrative (Details) $ in Thousands	Mar. 31, 2022 USD ($) facility renewal agreement	Mar. 31, 2021 USD ($)
Lessee, Lease, Description [Line Items]
Master lease agreements \| agreement	8
Lessee, operating lease, term of contract	10 years
Facilities under master lease arrangement	44
Right-of-use assets obtained in exchange for new and modified operating lease obligations \| $	$ 170,007	$ 37,471
Operating lease, weighted average remaining lease term	15 years 2 months 12 days
Operating lease, weighted average discount rate, percent	6.80%
Number of real estate properties	95
Cost of Sales and General and Administrative Expense
Lessee, Lease, Description [Line Items]
Rent expense \| $	$ 35,785	33,476
Minimum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, renewal term	10 years
Maximum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, renewal term	15 years
Affiliated Facility, Master Lease One
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term extension	14 years
Right-of-use assets obtained in exchange for new and modified operating lease obligations \| $	$ 120,349
CareTrust REIT
Lessee, Lease, Description [Line Items]
Skilled nursing, assisted living and independent living facilities	96
Master lease agreements \| agreement	9
Lessee, operating lease, renewal term	5 years
Operating leases of lessee, contingent rentals, basis spread on variable rate	2.50%
Rent expense \| $	$ 15,645	$ 14,080
CareTrust REIT \| Minimum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract	13 years
Lessee leasing arrangements, operating leases, number of renewal terms \| renewal	2
CareTrust REIT \| Maximum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract	20 years
Lessee leasing arrangements, operating leases, number of renewal terms \| renewal	3
CareTrust REIT \| Third Party Tenants Under Triple Net Lease Arrangements
Lessee, Lease, Description [Line Items]
Skilled nursing, assisted living and independent living facilities	95
CareTrust REIT \| Purchase Option
Lessee, Lease, Description [Line Items]
Skilled nursing, assisted living and independent living facilities	4
Various Landlords
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract	15 years
Lessee leasing arrangements, operating leases, number of renewal terms \| renewal	2
Lessee, operating lease, renewal term	5 years
Various Landlords \| Minimum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract	5 years
Various Landlords \| Minimum \| Equipment
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract	3 years
Various Landlords \| Maximum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract	20 years
Various Landlords \| Maximum \| Equipment
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract	5 years

Intangible Assets — Net (Tables)

3 Months Ended

Mar. 31, 2022

Intangible Assets, Net (Excluding Goodwill) [Abstract]

Schedule of Finite-Lived Intangible Assets


		March 31, 2022						December 31, 2021


	Weighted Average Life (Years)
		Gross Carrying Amount		Accumulated Amortization				Gross Carrying Amount		Accumulated Amortization
Intangible Assets						Net						Net


Assembled occupancy	0.4	$	196	$	(125)	$	71	$	68	$	(68)	$	—
Facility trade name	30.0	733		(397)		336		733		(391)		342
Customer relationships	18.4	4,582		(2,324)		2,258		4,582		(2,272)		2,310
Total		$	5,511	$	(2,846)	$	2,665	$	5,383	$	(2,731)	$	2,652

Schedule of Finite-Lived Intangible Assets, Future Amortization Expense

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


Year	Amount
2022 (remainder)	$	247
2023	234
2024	234
2025	234
2026	234
2027	234
Thereafter	1,248
	$	2,665

COVID-19 Update	3 Months Ended
COVID-19 Update	Mar. 31, 2022
Unusual or Infrequent Items, or Both [Abstract]
COVID-19 UPDATE	COVID-19 UPDATE The COVID-19 pandemic has continued to impact the Company's affiliated operations. In prior years, as part of the Coronavirus Aid, Relief, and Economic Security Act of 2020 (the CARES Act), the Company received cash distributions of relief fund payments (Provider Relief Funds) and funds authorized by U.S. Department of Health and Human Services (HHS) to be used to protect residents of nursing homes and long-term care (LTC) facilities from the impact of COVID-19. During the three months ended March 31, 2022, the Company did not receive Provider Relief Funds. During the three months ended March 31, 2021, the Company received and returned $9,139 in Provider Relief Funds. The Company may continue to receive additional funding in future periods. In fiscal year 2020, the Company applied for and received $105,255 through the Medicare Accelerated and Advance Payment Program under the CARES Act. 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 2020. In March 2021, the Company repaid the remaining funds of $102,023. The Family First Coronavirus Response Act was signed into law in 2020 to provide a temporary 6.2% increase to the Federal Medical Assistance Percentage (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 the funds are to be used to reimburse the recipient for healthcare related expenses that are attributable to COVID-19 and associated with providing patient care. In addition, increases in Medicaid rates can come from other areas of the state's budget outside of 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. As of March 31, 2022 and December 31, 2021, the Company had $1,499 and $1,781 in unapplied state relief funds, respectively. During the three months ended March 31, 2022 and 2021, the Company received an additional $17,317 and $15,645 in state relief funding and recognized $17,599 and $16,465, respectively, 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 Company paid $24,154 during the year ended December 31, 2021 and the remaining short-term balance of $24,155 is included in accrued wages and related liabilities within the condensed consolidated balance sheets as of March 31, 2022.

UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF STOCKHOLDERS' EQUITY (Parenthetical) - $ / shares	3 Months Ended
	Mar. 31, 2022	Mar. 31, 2021
Statement of Stockholders' Equity [Abstract]
Dividends per share (in dollars per share)	$ 0.0550	$ 0.0525

Commitments and Contingencies	3 Months Ended
Commitments and Contingencies	Mar. 31, 2022
Commitments and Contingencies Disclosure [Abstract]
COMMITMENTS AND CONTINGENCIES	COMMITMENTS AND CONTINGENCIES Regulatory Matters — Laws and regulations governing Medicare and Medicaid programs are complex and subject to review and interpretation. Compliance with such laws and regulations is evaluated regularly, the results of which can be subject to future governmental review and interpretation, and can include significant regulatory action including fines, penalties, and exclusion from certain governmental programs. Included in these laws and regulations is monitoring performed by the Office of Civil Rights which covers the Health Insurance Portability and Accountability Act of 1996, the terms of which require healthcare providers (among other things) to safeguard the privacy and security of certain patient protected health information. Cost-Containment Measures — Both government and private pay sources have instituted cost-containment measures designed to limit payments made to providers of healthcare services, and there can be no assurance that future measures designed to limit payments made to providers will not adversely affect the Company. Indemnities — From time to time, the Company enters into certain types of contracts that contingently require the Company to indemnify parties against third-party claims. These contracts primarily include (i) certain real estate leases, under which the Company may be required to indemnify property owners or prior facility operators for post-transfer environmental or other liabilities and other claims arising from the Company’s use of the applicable premises, (ii) operations transfer agreements, in which the Company agrees to indemnify past operators of facilities the Company acquires against certain liabilities arising from the transfer of the operation and/or the operation thereof after the transfer to the Company's independent operating subsidiary, (iii) certain lending agreements, under which the Company may be required to indemnify the lender against various claims and liabilities, and (iv) certain agreements with the Company’s officers, directors and others, under which the Company may be required to indemnify such persons for liabilities arising out of the nature of their relationship to the Company. The terms of such obligations vary by contract and, in most instances, do not expressly state or include a specific or maximum dollar amount. Generally, amounts under these contracts cannot be reasonably estimated until a specific claim is asserted. Consequently, because no claims have been asserted, no liabilities have been recorded for these obligations on the Company’s condensed consolidated balance sheets for any of the periods presented. In connection with the spin-off transaction that occurred in October 2019, certain landlords required, in exchange for their consent to the transaction, that the Company's lease guarantees remain in place for a certain period of time following the spin-off. These guarantees could result in significant additional liabilities and obligations for the Company if Pennant were to default on their obligations under their leases with respect to these properties. U.S. House of Representatives Select Subcommittee Request — In 2020, the U.S. House of Representatives Select Subcommittee on the Coronavirus Crisis launched a nation-wide investigation into the COVID-19 pandemic, which included the impact of the coronavirus on residents and employees in nursing homes. In June 2020, the Company received a document and information request from the House Select Subcommittee in connection with its investigation. The Company has cooperated in responding to this inquiry. However, it is not possible to predict the ultimate outcome of any such investigation or whether and what other investigations or regulatory responses may result from the investigation, which could have a material adverse effect on our reputation, business, financial condition, and results of operations. Litigation — The skilled nursing business involves a significant risk of liability given the age and health of the patients and residents served by the Company's independent operating subsidiaries. The Company, its independent operating subsidiaries, and others in the industry are subject to an increasing number of claims and lawsuits, including professional liability claims, alleging that services provided have resulted in personal injury, elder abuse, wrongful death or other related claims. In addition, the Company, its independent operating subsidiaries, and others in the industry are subject to claims and lawsuits in connection with COVID-19 and a facility's preparation for and/or response to COVID-19. The defense of these lawsuits may result in significant legal costs, regardless of the outcome, and can result in large settlement amounts or damage awards. In addition to the potential lawsuits and claims described above, the Company and its independent operating subsidiaries are also subject to potential lawsuits under the Federal False Claims Act and comparable state laws alleging submission of fraudulent claims for services to any healthcare program (such as Medicare or Medicaid) or other payor. A violation may provide the basis for exclusion from Federally-funded healthcare programs. Such exclusions could have a correlative negative impact on the Company’s financial performance. Under the qui tam or "whistleblower" provisions of the False Claims Act, a private individual with knowledge of fraud or potential fraud may bring a claim on behalf of the Federal Government and receive a percentage of the Federal Government's recovery. Due to these whistleblower incentives, qui tam lawsuits have become more frequent. For example, and despite the decision of the U.S. Department of Justice to decline to participate in litigation based on the subject matter of its previously issued Civil Investigative Demand, the involved qui tam relator has continued on with the lawsuit and is pursuing claims that the Company and certain of its independent operating subsidiaries have allegedly violated the False Claims Act and/or the Anti-Kickback Statute. In addition to the Federal False Claims Act, some states, including California, Arizona and Texas, have enacted similar whistleblower and false claims laws and regulations. Further, the Deficit Reduction Act of 2005 created incentives for states to enact anti-fraud legislation modeled on the Federal False Claims Act. As such, the Company and its independent operating subsidiaries could face increased scrutiny, potential liability and legal expenses and costs based on claims under state false claims acts in markets in which its independent operating subsidiaries do business. In May 2009, Congress passed the Fraud Enforcement and Recovery Act (FERA) which made significant changes to the Federal False Claims Act and expanded the types of activities subject to prosecution and whistleblower liability. Following changes by FERA, health care providers face significant penalties for the knowing retention of government overpayments, even if no false claim was involved. Health care providers can now be liable for knowingly and improperly avoiding or decreasing an obligation to pay money or property to the government. This includes the retention of any government overpayment. The government can argue, therefore, that a Federal False Claims Act violation can occur without any affirmative fraudulent action or statement, as long as the action or statement is knowingly improper. In addition, FERA extended protections against retaliation for whistleblowers, including protections not only for employees, but also contractors and agents. Thus, an employment relationship is generally not required in order to qualify for protection against retaliation for whistleblowing. Healthcare litigation (including class action litigation) is common and is filed based upon a wide variety of claims and theories, and the Company's independent operating subsidiaries are routinely subjected to varying types of claims, including class action "staffing" suits where the allegation is understaffing at the facility level. These class-action “staffing” suits have the potential to result in large jury verdicts and settlements, and may result in significant legal costs. The Company expects the plaintiffs' bar to continue to be aggressive in their pursuit of these staffing and similar claims. While the Company has been able to settle these claims without an ongoing material adverse effect on its business, future claims could be brought that may materially affect its business, financial condition and results of operations. Other claims and suits, including class actions, continue to be filed against the Company and other companies in its industry. The Company and its independent operating subsidiaries have been subjected to, and are currently involved in, class action litigation alleging violations (alone or in combination) of state and federal wage and hour laws as related to the alleged failure to pay wages, to timely provide and authorize meal and rest breaks, and related causes of action. The Company does not believe that the ultimate resolution of these actions will have an ongoing material adverse effect on the Company’s business, cash flows, financial condition or results of operations. The Company and its independent operating subsidiaries have been, and continue to be, subject to claims, findings and legal actions that arise in the ordinary course of the various businesses, including healthcare and non-healthcare services. These claims include, but are not limited to, potential claims filed by residents, customers, patients and responsible parties related to patient care and treatment (professional negligence claims); to non-care based activities of certain of the subsidiaries; and to employment related claims filed by current or former employees. A significant increase in the number of these claims, or an increase in the amounts owing should plaintiffs be successful in their prosecution of these claims, could materially adversely affect the Company’s business, financial condition, results of operations and cash flows. In addition, these claims could impact the Company's ability to procure insurance to cover its exposure related to the various services provided by its independent operating subsidiaries to their residents, customers and patients. The Company and its independent subsidiaries are also subject to requests for information and investigations by other State and Federal governmental entities (e.g., offices of the attorney general and offices of the inspector general). The Company cannot predict or provide any assurance as to the possible outcome of any inquiry, investigation or litigation. If any such inquiry, investigation or litigation were to proceed, and the Company and its independent operating subsidiaries are subjected to, alleged to be liable for, or agree to a settlement of, claims or obligations under Federal Medicare statutes, the Federal False Claims Act, or similar state and federal statutes and related regulations, or if the Company or its independent operating subsidiaries are alleged or found to be liable on theories of general or professional negligence or wage and hour violations, the Company's business, financial condition and results of operations and cash flows could be materially and adversely affected and its stock price could be adversely impacted. Among other things, any settlement or litigation could involve the payment of substantial sums to settle any alleged violations, and may also include the assumption of specific procedural and financial obligations by the Company or its independent operating subsidiaries under a corporate integrity agreement and/or other such arrangement. Medicare Revenue Recoupments — The Company's independent operating entities are subject to regulatory reviews relating to the provision of Medicare services, billings and potential overpayments as a result of Recovery Audit Contractors (RAC), Program Safeguard Contractors, and Medicaid Integrity Contractors programs (collectively referred to as Reviews). For several months during the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) suspended its Targeted Probe and Educate Program. Beginning in August 2020, CMS resumed Targeted Probe and Educate Program activity. If an operation fails a Review and/or subsequent Reviews, the operation could then be subject to extended review or an extrapolation of the identified error rate to billings in the same time period. The Company anticipates that these Reviews could increase in frequency in the future. As of March 31, 2022 and since, 19 of the Company's independent operating subsidiaries had Reviews scheduled, on appeal, or in a dispute resolution process. Concentrations Credit Risk — The Company has significant accounts receivable balances, the collectability of which is dependent on the availability of funds from certain governmental programs, primarily Medicare and Medicaid. These receivables represent the only significant concentration of credit risk for the Company. The Company does not believe there are significant credit risks associated with these governmental programs. The Company believes that an appropriate allowance has been recorded for the possibility of these receivables proving uncollectible, and continually monitors and adjusts these allowances as necessary. The Company’s receivables from Medicare and Medicaid payor programs accounted for 53.9% and 54.0% of its total accounts receivable as of March 31, 2022 and December 31, 2021, respectively. Revenue from reimbursement under the Medicare and Medicaid programs accounted for 73.4% and 74.1% of the Company's revenue for the three months ended March 31, 2022 and 2021, respectively. Cash in Excess of FDIC Limits — The Company currently has bank deposits with financial institutions in the U.S. that exceed FDIC insurance limits. FDIC insurance provides protection for bank deposits up to $250. In addition, the Company has uninsured bank deposits with a financial institution outside the U.S. As of April 26, 2022, the Company had approximately $1,512 in uninsured cash deposits. All uninsured bank deposits are held at high quality credit institutions.

Other Accrued Liabilities (Tables)

3 Months Ended

Mar. 31, 2022

Payables and Accruals [Abstract]

Schedule of Other Accrued Liabilities

Other accrued liabilities consists of the following:


	March 31, 2022		December 31, 2021


Quality assurance fee	$	6,652	$	6,474
Refunds payable	36,074		34,814
Resident advances	6,936		9,337
Unapplied state relief funds	1,499		1,781
Cash held in trust for patients	5,952		6,430

Dividends payable	3,042		3,035
Property taxes	7,716		9,124
Income tax payable	10,416		—
Legal finding accrued	3,626		—
Other	18,248		18,415
Other accrued liabilities	$	100,161	$	89,410

Restricted and Other Assets - Narrative (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2022	Mar. 31, 2021
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Gain (loss) on deferral investment	$ (1,202)	$ 306
Deferral investment income (expense)	$ (1,211)	$ 351

Restricted and Other Assets (Details) - USD ($) $ in Thousands	Mar. 31, 2022	Dec. 31, 2021
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Debt issuance costs, net	$ 1,776	$ 1,953
Long-term insurance losses recoverable asset	7,206	6,755
Deposits with landlords	14,429	13,705
Capital improvement reserves with landlords and lenders	6,315	7,103
Deferred compensation plan investments	25,446	17,530
Restricted and other assets	$ 55,172	$ 47,046

Description of Business	3 Months Ended
Description of Business	Mar. 31, 2022
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, engaged in the ownership, acquisition, development and leasing of skilled nursing, senior living and other healthcare-related properties and other ancillary businesses. As of March 31, 2022, the Company operated 250 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 25,500 operational skilled nursing beds and 2,700 senior living units. As of March 31, 2022, the Company operated 179 facilities under long-term lease arrangements, and had options to purchase 11 of those 179 facilities. The Company's real estate portfolio includes 102 owned real estate properties, which included 71 facilities operated and managed by the Company, 32 senior living operations leased to and operated by The Pennant Group, Inc. (Pennant) as part of the spin-off transaction that occurred in October 2019, and the Service Center location. Of those 32 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 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. In January of 2022, the Company formed a captive real estate investment trust (REIT), which owns and manages its real estate business, called Standard Bearer Healthcare REIT, Inc. (Standard Bearer). The Company expects the REIT structure will provide it with an efficient vehicle for future acquisitions of properties that could be operated by Ensign affiliates or other third parties. Refer to Note 7, Standard Bearer for additional information on Standard Bearer. 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 Quarterly 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. Other Information — The accompanying condensed consolidated financial statements as of March 31, 2022 and for the three months ended March 31, 2022 and 2021 (collectively, the Interim Financial Statements) are unaudited. Certain information and note disclosures normally included in annual consolidated financial statements have been condensed or omitted, as permitted under applicable rules and regulations. Readers of the Interim Financial Statements should refer to the Company’s audited consolidated financial statements and notes thereto for the year ended December 31, 2021 which are included in the Company’s Annual Report on Form 10-K, File No. 001-33757 (the Annual Report) filed with the Securities and Exchange Commission (SEC). Management believes that the Interim Financial Statements reflect all adjustments which are of a normal and recurring nature necessary to present fairly the Company’s financial position and results of operations in all material respects. The results of operations presented in the Interim Financial Statements are not necessarily representative of operations for the entire year.

Revenue and Accounts Receivable - Disaggregation of Revenue (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2022	Mar. 31, 2021
Disaggregation of Revenue [Line Items]
Total revenue	$ 713,445	$ 627,253
Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	709,156	623,276
Rental revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 4,289	$ 3,977
Customer Concentration Risk \| Revenue Benchmark \| Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	100.00%	100.00%
Medicaid \| Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 266,348	$ 231,358
Medicaid \| Customer Concentration Risk \| Revenue Benchmark \| Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	37.60%	37.10%
Medicare \| Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 208,411	$ 190,303
Medicare \| Customer Concentration Risk \| Revenue Benchmark \| Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	29.40%	30.50%
Medicaid — skilled \| Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 45,949	$ 39,993
Medicaid — skilled \| Customer Concentration Risk \| Revenue Benchmark \| Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	6.40%	6.50%
Total Medicaid and Medicare \| Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 520,708	$ 461,654
Total Medicaid and Medicare \| Customer Concentration Risk \| Revenue Benchmark
Disaggregation of Revenue [Line Items]
Concentration risk	73.40%	74.10%
Total Medicaid and Medicare \| Customer Concentration Risk \| Revenue Benchmark \| Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	73.40%	74.10%
Managed care \| Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 127,786	$ 108,345
Managed care \| Customer Concentration Risk \| Revenue Benchmark \| Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	18.00%	17.40%
Private and other \| Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 60,662	$ 53,277
Private and other \| Customer Concentration Risk \| Revenue Benchmark \| Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	8.60%	8.50%

Leases - Lessee Lease Cost (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2022	Mar. 31, 2021
Lessee, Lease, Description [Line Items]
Operating lease expense	$ 41,437	$ 37,209
Amortization of deferred rent	124	112
Rent - cost of services
Lessee, Lease, Description [Line Items]
Operating lease expense	35,762	33,456
Variable lease, cost	937	584
General and administrative expense
Lessee, Lease, Description [Line Items]
Operating lease expense	23	20
Depreciation and amortization
Lessee, Lease, Description [Line Items]
Operating lease expense	289	290
Variable lease costs
Lessee, Lease, Description [Line Items]
Variable lease, cost	$ 5,363	$ 3,443

Restricted and Other Assets (Tables)

3 Months Ended

Mar. 31, 2022

Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]

Schedule of Restricted and Other Assets

Restricted and other assets consist of the following:




	March 31, 2022		December 31, 2021
Debt issuance costs, net	$	1,776	$	1,953
Long-term insurance losses recoverable asset	7,206		6,755
Deposits with landlords	14,429		13,705
Capital improvement reserves with landlords and lenders	6,315		7,103
Deferred compensation plan investments	25,446		17,530

Restricted and other assets	$	55,172	$	47,046

Summary of Significant Accounting Policies - Recent Accounting Pronouncements (Details) - Revolving credit facility with Truist - Truist - USD ($)	1 Months Ended
	Apr. 28, 2022	Apr. 08, 2022	Oct. 01, 2019
Debt Instrument [Line Items]
Line of credit facility, maximum borrowing capacity			$ 350,000,000
Subsequent Event
Debt Instrument [Line Items]
Letter of credit increase	$ 250,000,000
Line of credit facility, maximum borrowing capacity		$ 600,000,000

Leases - Lessor Narrative (Details)	Mar. 31, 2022 facility	Mar. 31, 2022 seniorLivingCommunity	Mar. 31, 2022 operation	Oct. 31, 2019 operation	Oct. 01, 2019
Lessor, Lease, Description [Line Items]
Number of real estate properties	95
Spinoff \| Minimum
Lessor, Lease, Description [Line Items]
Lessor, operating lease, term of contract					14 years
Spinoff \| Maximum
Lessor, Lease, Description [Line Items]
Lessor, operating lease, term of contract					16 years
The Pennant Group, Inc. \| Spinoff \| Senior Living Facilities
Lessor, Lease, Description [Line Items]
Number of real estate properties		32	3	29

Fair Value Measurements - Investments (Details) - USD ($) $ in Thousands	Mar. 31, 2022	Dec. 31, 2021
Debt Security, Corporate, US
Schedule of Held-to-maturity Securities [Line Items]
Debt security investments classified as held to maturity and carried at amortized cost	$ 50,117	$ 50,330

Business Segments

3 Months Ended

Mar. 31, 2022

Segment Reporting [Abstract]

BUSINESS SEGMENTS

In conjunction with the formation Standard Bearer in January 2022, the Company's Chief Executive Officer, who is its chief operating decision maker, or CODM, began reviewing the results of Standard Bearer instead of all real estate properties. Accordingly, the Company revised its former real estate segment to include only real estate properties that are part of Standard Bearer. This change in organizational structure demonstrates that Standard Bearer's real estate is a core part of the Company's expansion of its real estate investment strategy. As of the first quarter of 2022, the Company has two reportable segments: (1) skilled services, which includes the operation of skilled nursing facilities and rehabilitation therapy services and (2) Standard Bearer, which is comprised of selected real estate properties owned by Standard Bearer and leased to skilled nursing and senior living operators. Segment information for prior period has been recast to reflect the change of the Company’s segment structure.

As of March 31, 2022, the skilled services segment includes 217 skilled nursing operations and 23 campus operations that provide both skilled nursing and rehabilitative care services and senior living services. The Company's Standard Bearer segment consists of 95 owned real estate properties. These properties include 67 operations the Company operated and managed and 30 senior living operations that are leased to and operated by third parties. Of the 30 real estate operations leased to third parties, 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 ten stand-alone senior living operations and 23 campus operations that provide both skilled nursing and rehabilitative care services and senior living services, mobile diagnostics, medical transportation, other real estate 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. 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.

The accounting policies of the reportable segments are the same as those described in Note 2, Summary of Significant Accounting Policies. Intercompany revenue is eliminated in consolidation, along with corresponding intercompany expenses. Segment income and loss is defined as profit or loss from operations before provision for income taxes, excluding gain or loss from sale of real estate, insurance recoveries and impairment charges from operations. Included in segment income for Standard Bearer is expense for intercompany services provided by the Service Center as described in Note 7, Standard Bearer, as it is part of the CODM financial information.

The following tables set forth financial information for the segments:


	Three Months Ended March 31, 2022
	Skilled Services		Standard Bearer		All Other(1)		Intercompany Elimination		Total
Service revenue(2)	$	686,771	$	—	$	25,467	$	(3,082)	$	709,156
Rental revenue(3)	—		17,193		1,863		(14,767)		4,289
Total revenue	$	686,771	$	17,193	$	27,330	$	(17,849)	$	713,445
Segment income (loss)	98,256		6,900		(38,930)		—		66,226


Depreciation and amortization	7,901		5,021		1,754		—		14,676
Interest expense(4)	$	—	$	3,562	$	358	$	(1,852)	$	2,068

(1) All other primarily includes all ancillary operations, stand-alone senior living operations and the Service Center.

(2) Intercompany service revenue represents service revenue generated by ancillary operations provided to the Company's affiliated wholly-owned healthcare facilities and management service revenue generated by the Service Center with Standard Bearer. Intercompany service revenue is eliminated in consolidation along with corresponding intercompany cost of service.

(3) Intercompany rental revenue represents rental income generated by both Standard Bearer and other real estate properties with Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation along with corresponding intercompany rent expense.

(4) Included in interest expense in Standard Bearer is interest expense incurred from intercompany debt arrangements between Standard Bearer and The Ensign Group, Inc. The intercompany interest expense is eliminated in the "Intercompany Elimination" column.


	Three Months Ended March 31, 2021
	Skilled Services		Standard Bearer		All Other(1)		Intercompany Elimination		Total
Service revenue(2)	$	601,036	$	—	$	23,919	$	(1,679)	$	623,276
Rental revenue(3)	—		14,069		1,810		(11,902)		3,977
Total revenue	$	601,036	$	14,069	$	25,729	$	(13,581)	$	627,253
Segment income (loss)	88,931		7,713		(34,298)		—		62,346
Gain on sale of real estate	—		—		—		—		440
Income before provision for income taxes	—		—		—		—		$	62,786
Depreciation and amortization	7,475		4,155		2,029		—		13,659
Interest expense(4)	$	—	$	1,641	$	—	$	—	$	1,641

(1) All other primarily includes all ancillary operations, stand-alone senior living operations and the Service Center.

(2) Intercompany service revenue represents service revenue generated by ancillary operations provided to the Company's affiliated wholly-owned healthcare facilities. Intercompany service revenue is eliminated in consolidation along with corresponding intercompany cost of service.

(3) Intercompany rental revenue represents rental income generated by both Standard Bearer and other real estate properties with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation along with corresponding intercompany rent expense.

Service revenue by major payor source were as follows:


	Three Months Ended March 31, 2022
	Skilled Services		Other Service Revenue		Total Service Revenue		Revenue %
Medicaid(1)	$	261,587	$	4,761	$	266,348	37.6	%
Medicare	208,411		—		208,411		29.4
Medicaid-skilled	45,949		—		45,949		6.4
Subtotal	515,947		4,761		520,708		73.4
Managed care	127,786		—		127,786		18.0
Private and other(2)	43,038		17,624		60,662		8.6
Total service revenue	$	686,771	$	22,385	$	709,156	100.0	%

(1) Medicaid payor includes revenue generated from senior living operations and revenue related to FMAP.

(2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services.


	Three Months Ended March 31, 2021
	Skilled Services		Other Service Revenue		Total Service Revenue		Revenue %
Medicaid(1)	$	227,741	$	3,617	$	231,358	37.1	%
Medicare	190,303		—		190,303		30.5
Medicaid-skilled	39,993		—		39,993		6.5
Subtotal	458,037		3,617		461,654		74.1
Managed care	108,345		—		108,345		17.4
Private and other(2)	34,654		18,623		53,277		8.5
Total service revenue	$	601,036	$	22,240	$	623,276	100.0	%

(1) Medicaid payor includes revenue generated from senior living operations and revenue related to FMAP.

(2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services.

In addition to the service revenue above, the Company's rental revenue derived from triple-net lease arrangements with third parties is $4,289 and $3,977, respectively, for the three months ended March 31, 2022 and 2021. This revenue is included in both Standard Bearer and the all other category.

- 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=123359005&loc=d3e8924-108599

Reference 2: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 34
-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e8981-108599

Reference 3: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
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-Section 50
-Paragraph 21
-Subparagraph (a)
-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e8721-108599

Reference 4: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
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-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e9031-108599

Reference 5: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 32
-Subparagraph (f)
-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e8933-108599

Reference 6: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 32
-Subparagraph (e)
-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e8933-108599

Reference 7: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
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-Section 50
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Reference 8: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
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Reference 9: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
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-Paragraph 32
-Subparagraph (d)
-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e8933-108599

Reference 10: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
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-Paragraph 22
-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e8736-108599

Reference 11: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
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-Paragraph 42
-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e9054-108599

Reference 12: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
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-Paragraph 15
-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e8657-108599

Reference 13: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-SubTopic 10
-Section 50
-Paragraph 21
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-URI http://asc.fasb.org/extlink&oid=123359005&loc=d3e8721-108599

Reference 14: http://www.xbrl.org/2003/role/disclosureRef
-Publisher FASB
-Name Accounting Standards Codification
-Topic 280
-URI http://asc.fasb.org/topic&trid=2134510

+ Details

Other Accrued Liabilities (Details) - USD ($) $ in Thousands	Mar. 31, 2022	Dec. 31, 2021	Mar. 31, 2021
Payables and Accruals [Abstract]
Quality assurance fee	$ 6,652	$ 6,474
Refunds payable	36,074	34,814
Resident advances	6,936	9,337
Unapplied state relief funds	1,499	1,781
Cash held in trust for patients	5,952	6,430
Dividends payable	3,042	3,035	$ 2,886
Property taxes	7,716	9,124
Income tax payable	10,416	0
Legal finding accrued	3,626	0
Other	18,248	18,415
Other accrued liabilities	$ 100,161	$ 89,410

UNAUDITED CONDENSED CONSOLIDATED BALANCE SHEETS - USD ($) $ in Thousands	Mar. 31, 2022	Dec. 31, 2021
Current assets:
Cash and cash equivalents	$ 248,546	$ 262,201
Accounts receivable—less allowance for doubtful accounts of $13,212 and $11,213 at March 31, 2022 and December 31, 2021, respectively	339,886	328,731
Investments—current	12,093	13,763
Prepaid income taxes	0	5,452
Prepaid expenses and other current assets	32,586	29,562
Total current assets	633,111	639,709
Property and equipment, net	906,777	888,434
Right-of-use assets	1,294,931	1,138,872
Insurance subsidiary deposits and investments	38,024	36,567
Escrow deposits	400	0
Deferred tax assets	32,883	33,147
Restricted and other assets	55,172	47,046
Intangible assets, net	2,665	2,652
Goodwill	76,869	60,469
Other indefinite-lived intangibles	3,727	3,727
Total assets	3,044,559	2,850,623
Current liabilities:
Accounts payable	56,850	58,116
Accrued wages and related liabilities (Note 3)	251,194	278,770
Lease liabilities—current	57,902	52,181
Accrued self-insurance liabilities—current	43,728	40,831
Other accrued liabilities	100,161	89,410
Current maturities of long-term debt	3,723	3,760
Total current liabilities	513,558	523,068
Long-term debt—less current maturities	152,010	152,883
Long-term lease liabilities—less current portion	1,207,104	1,056,515
Accrued self-insurance liabilities—less current portion	71,602	69,308
Other long-term liabilities	28,272	27,135
Total liabilities	1,972,546	1,828,909
Commitments and contingencies (Notes 16, 18 and 19)
Ensign Group, Inc. stockholders' equity:
Common stock: $0.001 par value; 100,000 shares authorized; 58,385 and 55,308 shares issued and outstanding at March 31, 2022, respectively, and 58,134 and 55,190 shares issued and outstanding at December 31, 2021, respectively	58	58
Additional paid-in capital	383,181	369,760
Retained earnings	781,290	733,992
Common stock in treasury, at cost, 3,077 and 2,944 shares at March 31, 2022 and December 31, 2021, respectively (Note 20)	(92,939)	(83,042)
Total Ensign Group, Inc. stockholders' equity	1,071,590	1,020,768
Non-controlling interest	423	946
Total equity	1,072,013	1,021,714
Total liabilities and equity	$ 3,044,559	$ 2,850,623

Options and Awards

3 Months Ended

Mar. 31, 2022

Share-based Payment Arrangement [Abstract]

OPTIONS AND AWARDS

Stock-based compensation expense consists of stock-based payment awards made to employees and directors, including employee stock options and restricted stock awards, based on estimated fair values. As stock-based compensation expense recognized in the Company’s condensed consolidated statements of income for the three months ended March 31, 2022 and 2021 was based on awards ultimately expected to vest, it has been reduced for estimated forfeitures. The Company estimates forfeitures at the time of grant and, if necessary, revises the estimate in subsequent periods if actual forfeitures differ.

2017 Omnibus Incentive Plan - The Company has one active stock incentive plan, the 2017 Omnibus Incentive Plan (the 2017 Plan). The 2017 Plan provided for the issuance of 6,881 shares of common stock which are to be proportionally adjusted in the event of any Equity Restructuring. The number of shares available to be issued under the 2017 Plan were adjusted to 8,118 shares of common stock in order to reflect the proportional adjustments as part of the spin-off transaction that occurred in October 2019. The number of shares available to be issued under the 2017 Plan will be reduced by (i) one share for each share that relates to an option or stock appreciation right award and (ii) 2.5 shares for each share which relates to an award other than a stock option or stock appreciation right award (a full-value award). Granted non-employee director options vest and become exercisable in three equal annual installments, or the length of the term if less than three years, on the completion of each year of service measured from the grant date. All other options generally vest over five years at 20% per year on the anniversary of the grant date. Options expire ten years from the date of grant. As of March 31, 2022, there were approximately 1,723 unissued shares of common stock available for issuance under this plan.

The Company uses the Black-Scholes option-pricing model to recognize the value of stock-based compensation expense for stock option awards. Determining the appropriate fair-value model and calculating the fair value of stock option awards at the grant date requires judgment, including estimating stock price volatility, expected option life, and forfeiture rates. The fair-value of the restricted stock awards at the grant date is based on the market price on the grant date, adjusted for forfeiture rates. The Company develops estimates based on historical data and market information, which can change significantly over time.

Stock Options

The Company granted 164 stock options during the three months ended March 31, 2022. The Company used the following assumptions for stock options granted during the three months ended March 31, 2022 and 2021:


Grant Year	Options Granted	Weighted Average Risk-Free Rate	Expected Life	Weighted Average Volatility	Weighted Average Dividend Yield
2022	164	1.8%	6.1 years	42.3%	0.3%
2021	136	0.8%	6.3 years	42.2%	0.2%

For the three months ended March 31, 2022 and 2021, the following represents the exercise price and fair value displayed at grant date for stock option grants:


Grant Year	Granted	Weighted Average Exercise Price		Weighted Average Fair Value of Options
2022	164	$	79.79	$	33.56
2021	136	$	83.64	$	33.99

The weighted average exercise price equaled the weighted average fair value of common stock on the grant date for all options granted during the three months ended March 31, 2022 and 2021 and therefore, the intrinsic value was $0 at the date of grant.

The following table represents the employee stock option activity during the three months ended March 31, 2022:


	Number of Options Outstanding	Weighted Average Exercise Price		Number of Options Vested	Weighted Average Exercise Price of Options Vested









January 1, 2022	4,038	$	36.60	2,183	$	21.02
Granted	164	79.79		—	—
Forfeited	(31)	52.39		—	—
Exercised	(147)	18.86		—	—
March 31, 2022	4,024	$	38.89	2,172	$	22.57

The following summary information reflects stock options outstanding, vested and related details as of March 31, 2022:


	Stock Options Outstanding							Stock Options Vested

				Number Outstanding	Black-Scholes Fair Value		Remaining Contractual Life (Years)	Vested and Exercisable
Year of Grant	Exercise Price
2012	$5.56	-	$6.75	29	$	89	0	29
2013	6.76	-	9.74	140	538		1	140
2014	8.94	-	16.05	582	2,795		2	582
2015	18.20	-	21.39	260	2,018		3	260
2016	15.93	-	16.86	242	1,430		4	242
2017	15.80	-	19.41	288	1,692		5	228
2018	22.49	-	32.71	499	4,834		6	287
2019	41.07	-	45.76	633	9,934		7	253
2020	44.84	-	59.49	589	11,600		8	126
2021	73.47	-	83.64	598	19,614		9	25
2022	$79.79			164	5,509		10	—
Total				4,024	$	60,053		2,172

The aggregate intrinsic value of options outstanding, vested and expected to vest as of March 31, 2022 and December 31, 2021 is as follows:





Options	March 31, 2022		December 31, 2021
Outstanding	$	205,704	$	191,242
Vested	146,474		137,382
Expected to vest	53,305		48,548

The intrinsic value is calculated as the difference between the market value of the underlying common stock and the exercise price of the options. The aggregate intrinsic value of options that vested during the three months ended March 31, 2022 and 2021 was $6,351 and $8,545, respectively. The total intrinsic value of options exercised during the three months ended March 31, 2022 and 2021 was $9,502 and $17,241, respectively.

Restricted Stock Awards

The Company granted 112 and 90 restricted stock awards during the three months ended March 31, 2022 and 2021, respectively. All awards were granted at an issue price of $0 and generally vest over five years. The fair value per share of restricted awards granted during the three months ended March 31, 2022 and 2021 ranged from $73.17 to $79.79 and $83.64 to $84.70, respectively. The fair value per share includes quarterly stock awards to non-employee directors.

A summary of the status of the Company's non-vested restricted stock awards as of March 31, 2022 and changes during the three months ended March 31, 2022 is presented below:


	Non-Vested Restricted Awards	Weighted Average Grant Date Fair Value








Nonvested at January 1, 2022	549	$	52.16
Granted	112	75.46
Vested	(110)	64.99
Forfeited	(8)	51.13
Nonvested at March 31, 2022	543	$	54.39

During the three months ended March 31, 2022, the Company granted four automatic quarterly stock awards to non-employee directors for their service on the Company's board of directors. The fair value per share of these stock awards was $77.39 based on the market price on the grant date.

Long-Term Incentive Plan

On August 27, 2019, the Board approved the Long-Term Incentive Plan (the 2019 LTI Plan). The 2019 LTI Plan provides that certain employees of the Company who assisted in the consummation of the spin-off transaction that occurred in October 2019 are granted shares of restricted stock upon the successful completion of the spin-off. The 2019 LTI Plan provides for the issuance of 500 shares of Pennant restricted stock. The shares are vested over five years at 20% per year on the anniversary of the grant date. If a recipient is terminated or voluntarily leaves the Company, all shares subject to restriction or not yet vested shall be entirely forfeited. The total stock-based compensation related to the 2019 LTI Plan was approximately $195 and $201 for the three months ended March 31, 2022 and 2021, respectively.

Stock-based compensation expense recognized for the Company's equity incentive plans and long-term incentive plan for the three months ended March 31, 2022 and 2021 was as follows:


	Three Months Ended March 31,
		2022		2021
Stock-based compensation expense related to stock options		$	2,520	$	1,733
Stock-based compensation expense related to restricted stock awards		2,302		1,838
Stock-based compensation expense related to stock options and restricted stock awards to non-employee directors		345		483
Total		$	5,167	$	4,054

In future periods, the Company expects to recognize approximately $37,341 and $28,325 in stock-based compensation expense for unvested options and unvested restricted stock awards, respectively, that were outstanding as of March 31, 2022. Future stock-based compensation expense will be recognized over 3.7 and 3.4 weighted average years for unvested options and restricted stock awards, respectively. There were 1,852 unvested and outstanding options as of March 31, 2022, of which 1,746 shares are expected to vest. The weighted average contractual life for options outstanding, vested and expected to vest as of March 31, 2022 was 6.0 years.

Revenue and Accounts Receivable (Tables)

3 Months Ended

Mar. 31, 2022

Revenue from Contract with Customer [Abstract]

Disaggregation of Revenue

Service revenue for the three months ended March 31, 2022 and 2021 is summarized in the following tables:



	Three Months Ended March 31,
	2022				2021
	Revenue		% of Revenue		Revenue		% of Revenue
Medicaid(1)	$	266,348	37.6	%	$	231,358	37.1	%
Medicare	208,411		29.4		190,303		30.5
Medicaid — skilled	45,949		6.4		39,993		6.5
Total Medicaid and Medicare	520,708		73.4		461,654		74.1
Managed care	127,786		18.0		108,345		17.4
Private and other(2)	60,662		8.6		53,277		8.5
Service revenue	$	709,156	100.0	%	$	623,276	100.0	%

(1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP.

(2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services.

Schedule of Accounts, Notes, Loans and Financing Receivable

Accounts receivable as of March 31, 2022 and 2021, is summarized in the following table:


	March 31, 2022		December 31, 2021


Medicaid	$	128,574	$	123,647
Managed care	82,500		79,722
Medicare	61,884		59,797
Private and other payors	80,140		76,778
	353,098		339,944
Less: allowance for doubtful accounts	(13,212)		(11,213)
Accounts receivable, net	$	339,886	$	328,731

UNAUDITED CONDENSED CONSOLIDATED BALANCE SHEETS (Parenthetical) - USD ($) $ in Thousands	Mar. 31, 2022	Dec. 31, 2021
Statement of Financial Position [Abstract]
Allowance for doubtful accounts	$ 13,212	$ 11,213
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)	58,385,000	58,134,000
Common stock, shares outstanding (in shares)	55,308,000	55,190,000
Common stock in treasury, at cost (in shares)	3,077,000	2,944,000

Revenue and Accounts Receivable - Accounts Receivable (Details) - USD ($) $ in Thousands	Mar. 31, 2022	Dec. 31, 2021
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	$ 353,098	$ 339,944
Less: allowance for doubtful accounts	(13,212)	(11,213)
Accounts receivable, net	339,886	328,731
Medicaid
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	128,574	123,647
Managed care
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	82,500	79,722
Medicare
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	61,884	59,797
Private and other payors
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	$ 80,140	$ 76,778

Options and Awards - Exercise Price and Fair Value (Details) - $ / shares shares in Thousands	3 Months Ended
	Mar. 31, 2022	Mar. 31, 2021
Share-based Payment Arrangement [Abstract]
Granted (in shares)	164	136
Weighted Average Exercise Price (in dollars per share)	$ 79.79	$ 83.64
Weighted Average Fair Value of Options (in dollars per share)	$ 33.56	$ 33.99

Debt - Schedule of Long-term Debt (Details) - USD ($) $ in Thousands	Mar. 31, 2022	Dec. 31, 2021
Debt Instrument [Line Items]
Less: current maturities	$ (3,723)	$ (3,760)
Less: debt issuance costs, net	(3,255)	(3,324)
Long-term debt—less current maturities	152,010	152,883
Mortgage loans and promissory notes \| Mortgage loans and promissory notes
Debt Instrument [Line Items]
Mortgage loans and promissory notes	$ 158,988	$ 159,967

Business Segments - Revenue by Segment (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2022	Mar. 31, 2021
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 713,445	$ 627,253
Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	709,156	623,276
Rental revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 4,289	$ 3,977
Revenue Benchmark \| Customer Concentration Risk \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	100.00%	100.00%
Total Medicaid and Medicare \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 520,708	$ 461,654
Total Medicaid and Medicare \| Revenue Benchmark \| Customer Concentration Risk
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	73.40%	74.10%
Total Medicaid and Medicare \| Revenue Benchmark \| Customer Concentration Risk \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	73.40%	74.10%
Medicaid \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 266,348	$ 231,358
Medicaid \| Revenue Benchmark \| Customer Concentration Risk \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	37.60%	37.10%
Medicare \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 208,411	$ 190,303
Medicare \| Revenue Benchmark \| Customer Concentration Risk \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	29.40%	30.50%
Medicaid — skilled \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 45,949	$ 39,993
Medicaid — skilled \| Revenue Benchmark \| Customer Concentration Risk \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	6.40%	6.50%
Managed care \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 127,786	$ 108,345
Managed care \| Revenue Benchmark \| Customer Concentration Risk \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	18.00%	17.40%
Private and other \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 60,662	$ 53,277
Private and other \| Revenue Benchmark \| Customer Concentration Risk \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	8.60%	8.50%
Operating Segments \| Skilled Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 686,771	$ 601,036
Operating Segments \| Skilled Services \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	686,771	601,036
Operating Segments \| Skilled Services \| Rental revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0
Operating Segments \| Total Medicaid and Medicare \| Skilled Services \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	515,947	458,037
Operating Segments \| Medicaid \| Skilled Services \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	261,587	227,741
Operating Segments \| Medicare \| Skilled Services \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	208,411	190,303
Operating Segments \| Medicaid — skilled \| Skilled Services \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	45,949	39,993
Operating Segments \| Managed care \| Skilled Services \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	127,786	108,345
Operating Segments \| Private and other \| Skilled Services \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	43,038	34,654
Other Service Revenue \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	22,385	22,240
Other Service Revenue \| Total Medicaid and Medicare \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	4,761	3,617
Other Service Revenue \| Medicaid \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	4,761	3,617
Other Service Revenue \| Medicare \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0
Other Service Revenue \| Medicaid — skilled \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0
Other Service Revenue \| Managed care \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0
Other Service Revenue \| Private and other \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	17,624	18,623
Intercompany Elimination
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	(17,849)	(13,581)
Intercompany Elimination \| Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	(3,082)	(1,679)
Intercompany Elimination \| Rental revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ (14,767)	$ (11,902)

Intangible Assets — Net - Schedule of Finite Lived Intangible Assets (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2022	Dec. 31, 2021
Acquired Finite-Lived Intangible Assets [Line Items]
Gross Carrying Amount	$ 5,511	$ 5,383
Accumulated Amortization	(2,846)	(2,731)
Net	$ 2,665	2,652
Assembled occupancy
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	4 months 24 days
Gross Carrying Amount	$ 196	68
Accumulated Amortization	(125)	(68)
Net	$ 71	0
Facility trade name
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	30 years
Gross Carrying Amount	$ 733	733
Accumulated Amortization	(397)	(391)
Net	$ 336	342
Customer relationships
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	18 years 4 months 24 days
Gross Carrying Amount	$ 4,582	4,582
Accumulated Amortization	(2,324)	(2,272)
Net	$ 2,258	$ 2,310

UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF INCOME - USD ($) shares in Thousands, $ in Thousands	3 Months Ended
	Mar. 31, 2022	Mar. 31, 2021
Total revenue	$ 713,445	$ 627,253
Expense:
Cost of services	555,641	482,186
Rent—cost of services	35,762	33,456
General and administrative expense	38,256	34,273
Depreciation and amortization	14,676	13,659
Total expenses	644,335	563,574
Income from operations	69,110	63,679
Other income (expense):
Interest expense	(2,068)	(1,641)
Other (expense) income	(816)	748
Other expense, net	(2,884)	(893)
Income before provision for income taxes	66,226	62,786
Provision for income taxes	16,138	12,949
Net income	50,088	49,837
Less:
Net (loss) income attributable to noncontrolling interests	(252)	631
Net income attributable to The Ensign Group, Inc.	$ 50,340	$ 49,206
Net income per share attributable to The Ensign Group, Inc.:
Basic (in dollars per share)	$ 0.92	$ 0.91
Diluted (in dollars per share)	$ 0.89	$ 0.86
Weighted average common shares outstanding:
Basic (in shares)	54,667	54,192
Diluted (in shares)	56,871	56,891
Service revenue
Total revenue	$ 709,156	$ 623,276
Rental revenue
Total revenue	$ 4,289	$ 3,977

Goodwill and Other Indefinite-Lived Intangible Assets - Indefinite-Lived Intangible Assets (Details) - USD ($) $ in Thousands	Mar. 31, 2022	Dec. 31, 2021
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 3,727	$ 3,727
Trade name
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	889	889
Medicare and Medicaid licenses
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 2,838	$ 2,838

Other Accrued Liabilities

3 Months Ended

Mar. 31, 2022

Payables and Accruals [Abstract]

OTHER ACCRUED LIABILITIES

Other accrued liabilities consists of the following:


	March 31, 2022		December 31, 2021


Quality assurance fee	$	6,652	$	6,474
Refunds payable	36,074		34,814
Resident advances	6,936		9,337
Unapplied state relief funds	1,499		1,781
Cash held in trust for patients	5,952		6,430

Dividends payable	3,042		3,035
Property taxes	7,716		9,124
Income tax payable	10,416		—
Legal finding accrued	3,626		—
Other	18,248		18,415
Other accrued liabilities	$	100,161	$	89,410

Quality assurance fee represents the aggregate of amounts payable to Arizona, California, Colorado, Idaho, Iowa, Kansas, Nebraska, Nevada, Utah, Washington and Wisconsin as a result of a mandated fee based on patient days or licensed beds. Refunds payable includes payables related to overpayments, duplicate payments and credit balances from various payor sources. Resident advances occur when the Company receives payments in advance of services provided. Resident deposits include refundable deposits to patients. Cash held in trust for patients reflects monies received from or on behalf of patients. Maintaining a trust account for patients is a regulatory requirement and, while the trust assets offset the liabilities, the Company assumes a fiduciary responsibility for these funds. The cash balance related to this liability is included in other current assets in the condensed consolidated balance sheets.

Revenue and Accounts Receivable - Revenue from Medicare and Medicaid Programs (Details)	3 Months Ended
	Mar. 31, 2022	Mar. 31, 2021
Customer Concentration Risk \| Revenue Benchmark \| Total Medicare and Medicaid
Disaggregation of Revenue [Line Items]
Concentration risk	73.40%	74.10%

Options and Awards - Options Outstanding by Exercise Price (Details) $ / shares in Units, shares in Thousands, $ in Thousands	3 Months Ended
	Mar. 31, 2022 USD ($) $ / shares shares
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Number outstanding (in shares)	4,024
Black-Scholes Fair Value \| $	$ 60,053
Stock options vested and exercisable (in shares)	2,172
2012
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 5.56
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 6.75
Number outstanding (in shares)	29
Black-Scholes Fair Value \| $	$ 89
Remaining Contractual Life (Years)	0 years
Stock options vested and exercisable (in shares)	29
2013
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 6.76
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 9.74
Number outstanding (in shares)	140
Black-Scholes Fair Value \| $	$ 538
Remaining Contractual Life (Years)	1 year
Stock options vested and exercisable (in shares)	140
2014
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 8.94
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 16.05
Number outstanding (in shares)	582
Black-Scholes Fair Value \| $	$ 2,795
Remaining Contractual Life (Years)	2 years
Stock options vested and exercisable (in shares)	582
2015
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 18.20
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 21.39
Number outstanding (in shares)	260
Black-Scholes Fair Value \| $	$ 2,018
Remaining Contractual Life (Years)	3 years
Stock options vested and exercisable (in shares)	260
2016
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 15.93
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 16.86
Number outstanding (in shares)	242
Black-Scholes Fair Value \| $	$ 1,430
Remaining Contractual Life (Years)	4 years
Stock options vested and exercisable (in shares)	242
2017
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 15.80
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 19.41
Number outstanding (in shares)	288
Black-Scholes Fair Value \| $	$ 1,692
Remaining Contractual Life (Years)	5 years
Stock options vested and exercisable (in shares)	228
2018
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 22.49
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 32.71
Number outstanding (in shares)	499
Black-Scholes Fair Value \| $	$ 4,834
Remaining Contractual Life (Years)	6 years
Stock options vested and exercisable (in shares)	287
2019
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 41.07
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 45.76
Number outstanding (in shares)	633
Black-Scholes Fair Value \| $	$ 9,934
Remaining Contractual Life (Years)	7 years
Stock options vested and exercisable (in shares)	253
2020
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 44.84
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 59.49
Number outstanding (in shares)	589
Black-Scholes Fair Value \| $	$ 11,600
Remaining Contractual Life (Years)	8 years
Stock options vested and exercisable (in shares)	126
2021
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 73.47
Exercise price, upper range limit (in dollars per share) \| $ / shares	$ 83.64
Number outstanding (in shares)	598
Black-Scholes Fair Value \| $	$ 19,614
Remaining Contractual Life (Years)	9 years
Stock options vested and exercisable (in shares)	25
2022
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) \| $ / shares	$ 79.79
Number outstanding (in shares)	164
Black-Scholes Fair Value \| $	$ 5,509
Remaining Contractual Life (Years)	10 years
Stock options vested and exercisable (in shares)	0