The Ensign Group Q1 2026 Earnings Report

The Ensign Group EPS Results

• Actual EPS: $1.85
• Consensus EPS: $1.79
• Beat/Miss: Beat by +$0.06
• One Year Ago EPS: $1.52

The Ensign Group Revenue Results

• Actual Revenue: $1.39 billion
• Expected Revenue: $1.40 billion
• Beat/Miss: Missed by -$6.83 million
• YoY Revenue Growth: +18.40%

The Ensign Group Announcement Details

• Quarter: Q1 2026
• Date: 4/30/2026
• Time: After Market Closes
• Conference Call Date: Friday, May 1, 2026
• Conference Call Time: 1:00PM ET

The Ensign Group (NASDAQ:ENSG) is a diversified provider of post-acute healthcare services in the United States, operating a network of skilled nursing, assisted living, independent living, home health and hospice care centers. The company’s model emphasizes integrated care by employing multidisciplinary teams—including nursing staff, therapists and physicians—to deliver personalized rehabilitation and long-term care services for seniors and other patients recovering from injury, illness or surgery.

Through its owned and managed centers, The Ensign Group offers a broad spectrum of rehabilitation services such as physical, occupational and speech therapy. Its assisted and independent living communities provide day-to-day support, social activities and continuity of care for residents who require varying levels of supervision. Home health services extend the company’s therapeutic expertise into patients’ homes, while hospice programs focus on comfort and quality of life for individuals with life-limiting conditions.

Founded in 1999 by Jeffrey M. Willis and headquartered in Mission Viejo, California, The Ensign Group has grown from a single skilled nursing facility to a coast-to-coast operator serving hundreds of locations across multiple states. The company’s strategic focus on facility-level leadership and on-site clinical management supports consistent quality standards and operational efficiencies throughout its network.

Led by founder and Chief Executive Officer Jeffrey M. Willis, supported by a senior leadership team with extensive experience in healthcare administration, The Ensign Group continues to expand its footprint through selective acquisitions and partnerships. Its regional operating offices collaborate closely with center management to maintain regulatory compliance, foster community relationships and implement best practices in patient care.

The Ensign Group Q1 2026 Earnings Call Transcript

Key Takeaways

• Positive Sentiment: Reported a record quarter/year and issued 2026 guidance of $7.41–$7.61 diluted EPS and $5.77B–$5.84B in revenue (midpoint up ~14.3% vs 2025).
• Positive Sentiment: Emphasized strong clinical performance — Ensign same-store operations outperformed peers in recent CMS data (e.g., +24% state, +33% county) and saw all-time high same-store occupancy (83.8%) with notable Medicare and managed care revenue and skilled-day growth.
• Positive Sentiment: Continued expansion and balance-sheet strength — added 17 operations this quarter (1,371 beds) and 82 since 2024, grew Standard Bearer REIT to 154 properties, and reported >$1.0B available capital with a lease-adjusted net debt/EBITDA of 1.77x.
• Negative Sentiment: Management cautioned the M&A market is more seller-friendly and valuations have risen, which can increase purchase prices, CapEx and ramp time, and flagged sensitivity of guidance to reimbursement changes, seasonality and acquisition integration risks.

Presentation

[Operator]

Ladies and gentlemen, thank you for joining us, and welcome to The Ensign Group Inc. First Quarter 2026 Earnings Conference Call. After today's prepared remarks, we will host a question-and-answer session. If you would like to ask a question, please press star one on your telephone keypad. To withdraw your question, press star one again. I will now hand the conference over to Mr. Keetch. Please go ahead.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

Thank you, Operator, and welcome everyone. We filed our earnings press release yesterday, and it is available on the investor relations section of our website at ensigngroup.net. A replay of this call will also be available on our website until 5:00 P.M. Pacific on May 29, 2026. We want to remind anyone that may be listening to a replay of this call that all the statements made are as of today, May 1, 2026, and these statements have not been or will be updated subsequent to today's call. Also, any forward-looking statements made today are based on management's current expectations, assumptions and beliefs about our business and the environment in which we operate. These statements are subject to risks and uncertainties that could cause our actual results to materially differ from those expressed or implied on today's call.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

Listeners should not place undue reliance on forward-looking statements and are encouraged to review our SEC filings for a more complete discussion of factors that could impact our results. Except as required by federal securities laws, Ensign and its independent subsidiaries do not undertake to publicly update or revise any forward-looking statements where changes arise as a result of new information, future events, changing circumstances, or for any other reason. In addition, The Ensign Group, Inc. is a holding company with no direct operating assets, employees, or revenues. Certain of our independent subsidiaries, collectively referred to as the service center, provide accounting, payroll, human resources, information technology, legal, risk management, and other services to the other independent subsidiaries through contractual relationships.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

In addition, our captive insurance subsidiary, which we refer to as the insurance captive, provides certain claims-made coverage to our operating companies for general and professional liability as well as for workers' compensation insurance liabilities. Ensign also owns Standard Bearer Healthcare REIT, which is a captive real estate investment trust that invests in healthcare properties and enters into lease agreements with certain independent subsidiaries of Ensign, as well as third-party tenants that are unaffiliated with the Ensign Group. The words Ensign, company, we, our, and us refer to The Ensign Group, Inc. and its consolidated subsidiaries. All of our independent subsidiaries, the service center, Standard Bearer Healthcare REIT, and the insurance captive, are operated by separate independent companies that have their own management, employees, and assets.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

References herein to the consolidated company and its assets and activities, as well as the use of the words we, us, our, and similar terms are not meant to imply, nor should it be construed as meaning that The Ensign Group has direct operating assets, employees or revenue, or that any of the subsidiaries are operated by The Ensign Group. Also, we supplement our GAAP reporting with non-GAAP metrics. When viewed together with our GAAP results, we believe that these measures can provide a more complete understanding of our business, but they should not be relied upon to the exclusion of GAAP reports. A GAAP to non-GAAP reconciliation is available in yesterday's press release and is available in our Form 10-Q. With that, I'll turn the call over to Barry Port, our CEO. Barry?

[Barry Port, CEO at The Ensign Group]

Our local leaders and their teams continue to be an example of excellence in healthcare services as they earn the trust of patients, families, and their local healthcare communities through high-quality outcomes. As each operation solidifies its reputation in respective markets, they're not only seeing more patients, but they're also being entrusted to care for increasingly complex cases, including a larger share of Medicare, managed care, and other skilled patients. This is only possible because of the extraordinary clinical outcomes achieved by our dedicated and talented caregivers. As we've said many times, our consistent financial performance is a direct reflection of a relentless patient-focused culture, one that empowers our frontline teams to deliver exceptional care in a family-like environment where people genuinely care about one another.

[Barry Port, CEO at The Ensign Group]

On the census front, our same-store and transitioning occupancy reached new record highs during the quarter of 84.3% and 85.1% respectively. On the skilled mix front, our same-store and transitioning operations skilled revenue and days increased by 9.6% and 5.1% respectively over the prior year quarter, and Medicare revenue increased by 9.8% and 9.2% respectively. We also wanted to comment on some of the recent noise around managed care volumes. What we are seeing in Ensign-affiliated operations does not support the concern of a broad-based slowdown in skilled nursing demand. While hospital and managed care volumes may ebb and flow as patients move through the system, that volatility tends to normalize for us, resulting in consistently strong occupancy and skilled mix trends as demonstrated by our current and recent quarter results.

[Barry Port, CEO at The Ensign Group]

In fact, between Q4 and Q1, we saw growth across all skilled payers. Our same-store and transitioning managed care and Medicare census increased sequentially by 6.2% and 8.3% respectively. The primary driver of these improvements continues to be the expanding trust from the communities we serve, earned through consistent high-quality outcomes. Likewise, regarding commentary around increased clinical reviews and heightened scrutiny of post-acute utilization, this is not new. Our experience over many years is that this dynamic refines demand rather than reduces it. Our admission trends have remained consistently strong. As patient acuity continues to rise and payers look to move patients efficiently to lower cost settings, we have not seen any meaningful system-wide reduction in admissions or skilled mix. The patients who truly need skilled nursing are still coming.

[Barry Port, CEO at The Ensign Group]

We're simply seeing a continued shift towards higher acuity admissions, which plays directly into our strengths. We have built our model around being the provider of choice in our local markets through strong clinical capabilities, deep hospital relationships, and the ability to care for more complex patient types. As payers become more disciplined, that does not reduce our volume. In fact, in many cases, it shifts volumes, more specifically, higher acuity volume towards operators who can deliver outcomes. It is also important to remember that Ensign's model is highly diversified across many geographies, payers, referral sources, and local community partners. We are not dependent on any single payer, region, or utilization trend.

[Barry Port, CEO at The Ensign Group]

Even when one plan tightens in a specific market, we have consistently offset that through other market share gains, stronger referral relationships, higher acuity admissions, and growth across other channels. Our clinical leaders also continue to drive outstanding outcomes, which is particularly impressive given our growth over the past several years. According to the most recently published CMS data, same-store affiliated facilities outperformed their peers in annual survey results by 22% at the state level and 31% at the county level. This is especially notable given that many of these facilities were one or two star at acquisition. Additionally, our same-store operations outperformed industry peers in 5-star quality measures by 24% nationally and 20% at a state level.

[Barry Port, CEO at The Ensign Group]

In fact, we ended the quarter with 85% of all of our operations at four or five-star quality measures. These results reinforce our position as the provider of choice in our markets and demonstrate our ability to create long-term value through sustained clinical excellence. This clinical strength depends on attracting and retaining exceptional talent. We are encouraged by the depth of talent continuing to join our organization. On the retention side, we're seeing improvements in turnover, stable wage growth, and reduced reliance on agency staffing, even with increased occupancy. We are especially proud of the exceptionally low turnover among our directors of nursing, which has declined by 32% over the past two years. This level of leadership stability is a key driver of consistent high-quality care.

[Barry Port, CEO at The Ensign Group]

In addition, we continue to acquire new operations with significant long-term upside and expect to maintain a healthy pace of growth. Since 2024, we have successfully sourced, underwritten, and closed and transitioned 99 new operations across several markets, many of which are already performing at or above expectations. We also continue to benefit from powerful demographic tailwinds, which we expect to further support census momentum that we are seeing across our portfolio. While we're pleased with our current record same-store occupancy, we are equally excited about the remaining organic growth opportunity. At 84% occupancy, we still have meaningful runway, with many of our most mature operations consistently achieving occupancy rates in the mid 90% range. This embedded growth remains one of the most compelling drivers of our long-term performance.

[Barry Port, CEO at The Ensign Group]

Due to the strength of the first quarter and the acquisitions we announced yesterday, we are increasing our annual 2026 earnings guidance to $7.48-$7.62 per diluted share, up from our original guidance of $7.41-$7.61. We are also increasing our annual revenue guidance to $5.81 billion-$5.86 billion, up from $5.77 billion-$5.84 billion. The midpoint of our earnings guidance represents a 15% increase over 2025 and 37% growth over 2024. We remain highly confident in 2026 and expect our local teams to continue executing, innovating, and integrating new operations while delivering strong results. Next, I'll ask Chad to add some additional insights regarding our recent growth. Chad?

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

Thank you, Barry. During the quarter at Ensign, we accelerated our growth by adding 22 new operations, including 21 real estate assets, bringing the number of operations acquired during 2025 and since to 71. These recent additions include 20 in Texas, one in Arizona, and one in Wisconsin. In total, we added 2,662 new skilled nursing beds, 100 senior living units, and 55 independent living units across three states. This growth brings the number of operations in our recently acquired group of operations to 17.4% of our entire portfolio. We were thrilled to complete these acquisitions and to expand our presence in some key markets in each of these states, particularly in Texas.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

Like in the recent Stonehenge acquisition we closed in Utah, the Texas portfolio is made up of very new, high-quality construction in populated and growing metro areas. While some of those deals may take a bit longer to generate the returns we expect, we've seen these deals pay off over time as our leaders implement the proper adjustments to key clinical and financial systems, along with establishing a culture of ownership and accountability. We continue to learn from and improve our transition process and believe that those lessons are showing through in the performance of our recently acquired acquisitions. In particular, as we continue to scale, we have leadership spread across many mature markets.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

Enhancing ability to make larger deals smaller by breaking them into bite-sized pieces, transitioning in the traditional Ensign way, but with a local cluster-driven plan that gives each operation the time and attention they deserve. The performance of our newly acquired operations, particularly in the last few years, shows that our building-by-building approach to transitions works for single operations, small portfolios, and larger portfolios, particularly when the larger deals span several markets and geographies. While we will certainly continue to evaluate and consider any deal that's out there, we are also very comfortable growing the way we've grown over the last few quarters, with lots of transactions across many states, including small deals to larger portfolios and where it makes sense, higher priced strategic assets.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

As we look at the current pipeline, we continue to see opportunities that include everything from larger portfolios, landlords looking to replace current tenants, nonprofits looking to divest of their post-acute assets, and a steady flow of traditional onesie-twosies. We have several new additions lining up for Q2 and Q3 of 2026 as our local leadership teams and their partners at the service center work together to source, underwrite, and carefully select the right opportunities. We continue to have a lot of success in closing deals with sellers who are not just interested in receiving top dollar, but care deeply about the quality and reputation of the company they select to inherit their legacy, and they choose us because they believe in our mission to dignify post-acute care.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

During the quarter, we were pleased to complete the construction of a replacement facility of one of our high-performing skilled nursing operations in San Diego County. Grossmont Post Acute Care in La Mesa, California, which is located next to Sharp Grossmont Hospital, which was housed in an aging building that the landlord decided to replace with a new medical office space. After several years and lots of hard work, we successfully completed the construction and have moved all the patients and staff to a brand-new state-of-the-art building while also adding 15 beds to the original license for a total of 105 beds. In just a few months of operation, Grossmont has increased daily census of skilled patients from around 72 to 95.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

We will continue to look for opportunities to add beds to successful operations and where appropriate, to invest in newer construction in markets we know well. Our local leaders continue to recruit future CEOs for Ensign affiliated operations, and we have a deep bench of CEOs in training that are eagerly preparing for their opportunity to lead. This high-quality influx of leadership talent, combined with our decentralized transition model, allows us to grow without being limited by typical corporate bottlenecks. We also continue to store enough dry powder on our balance sheet to fund a significant amount of growth, including adding even more real estate assets to our portfolio. Our unique acquisition and transition strategy puts us in an excellent position to continue growing in a healthy and sustainable way.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

We are also pleased with the continued growth of Standard Bearer, which added 21 new assets during the quarter and since. Standard Bearer is now comprised of 173 owned properties, of which 137 are leased to an Ensign affiliated operator and 37 are leased to third-party operators. We are excited to add to our growing list of relationships with unaffiliated operators, which further diversifies our tenant base and helps our organization as a whole continue to advance our mission by working closely with like-minded operators that want to make a difference in the industry. Going forward, Standard Bearer will work together with our existing operating partners and new relationships we are developing in order to acquire portfolios comprised of operations that Ensign would operate and facilities that high-quality third parties are interested in operating under a lease.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

Collectively, Standard Bearer generated rental revenue of $36.1 million for the quarter, of which $30 million was derived from Ensign affiliated operations. For the quarter, Standard Bearer reported $21.6 million in FFO, and as of the end of the quarter, had an EBITDA to rent coverage ratio of 2.7 times. With that, I will turn the call over to Spencer, our COO, to add more color around operations. Spencer?

[Spencer Burton, President and COO at The Ensign Group]

Thanks, Chad, and hello, everyone. I wanted to share two outstanding operations that have achieved exceptional growth through clinical excellence, strong relationships with managed care organizations, and proactive leadership development. The first operation is Sunwest Choice Healthcare & Rehab, a 140-bed skilled nursing facility located in the metro Phoenix area. Sunwest illustrates the ongoing improvements that a strong same-store operation can achieve by recognizing its community niche and delivering high-quality outcomes with consistent customer service. When this operation was acquired in 2018, it faced serious clinical and staffing challenges, as well as a poor reputation in its healthcare community. The Sunwest team, led by CEO Doug Bowen and COO Michelle Norton, have methodically transformed their operation into a CMS five-star facility of choice.

[Spencer Burton, President and COO at The Ensign Group]

Like many of our most mature operations, Sunwest consistently remains essentially full, with occupancy increasing only slightly from 95% in the first quarter of 2025 to 96% this quarter. Revenues grew 10% over prior-year quarter, driven by improved acuity-based reimbursement and a higher skilled mix. During the same period, skilled mix days increased 21%, fueled in large part by 37% growth in managed care. The Phoenix healthcare market is heavily penetrated by managed care plans, all of which emphasize strong outcomes, shorter length of stay, and reduced hospitalizations. In this environment, Sunwest has focused on differentiating itself by building consistency in staffing with care staff turnover rates far better than the CMS average for Arizona.

[Spencer Burton, President and COO at The Ensign Group]

These managed care relationships, combined with sustained excellence in outcomes, particularly for high acuity patients, have allowed Sunwest to develop specialty units for underserved and hard-to-place patient populations, including patients with severe dementia and behavioral needs. Today, these special units run at high occupancy and have strengthened the facility's clinical reputation, which in turn contributed to Sunwest's 43% EBIT growth over prior year quarter. Our second facility highlight, Mystic Park Rehabilitation and Healthcare in San Antonio, Texas, has made significant progress since acquisition in late 2022. At the time of transition, the facility was facing serious clinical challenges and scrutiny from state regulators. Under the leadership of CEO Osiris White and COO Selena Cervantes, the operation has been fundamentally transformed.

[Spencer Burton, President and COO at The Ensign Group]

It now achieves a 5-star rating in CMS quality measures, with survey points scoring 70% better than the state average. Recently published CMS data places Mystic Park in the top 10% for expected discharge function scores from CMS, reflecting significantly stronger than industry patient outcomes in skilled rehabilitation. Also, nursing staff turnover has declined to well below the state and national averages. Operational performance has followed these clinical gains. In Q1, skilled mix days increased 61% over prior year quarter, driving 19% revenue growth and a 163% increase in earnings during the same time frame. In addition to being an exceptional turnaround story, Mystic Park also illustrates how facility-level excellence enables broader growth across our organization. For example, the leadership pipeline developed at the facility has supported the recently announced growth in Texas.

[Spencer Burton, President and COO at The Ensign Group]

Because of the stable team and strong systems at Mystic Park, Osiris, the CEO, was able to transfer to lead the newly formed North Houston market, which includes four of the 17 facilities acquired on May 1. Selena and the remaining Mystic team have selected a San Antonio-based AIT to be the next leader. Because he completed his training in the San Antonio market, he's well prepared to lead the facility's continued progress while benefiting from the team's strong experience and established systems. This model, stabilize, improve quality, develop leaders, and scale, remains central to our ability to grow while maintaining cultural and clinical standards. With that, I'll turn the time over to Suzanne to provide more detail on the company's financial performance and our guidance.

[Suzanne Snapper, CFO at The Ensign Group]

Thank you, Spencer, and good morning, everyone. Detailed financials for the quarter are contained in our 10-Q and press release filed yesterday. Some additional highlights for the quarter compared to the prior year quarter include the following: GAAP diluted earnings per share was $1.67, an increase of 21.9%. Adjusted diluted earnings per share was $1.85, an increase of 21.7%. Consolidated GAAP revenue and adjusted revenues were both $1.4 billion, an increase of 18.4%. GAAP net income was $99.7 million, an increase of 24.2%, and adjusted net income was $110.2 million, an increase of 23.9%. Other key metrics as of March 31st, 2026 include cash and cash equivalents of $539.5 million and cash flow from operations of $100.2 million. During the first three months of 2026, we spent more than $60 million to execute on our strategic growth plan.

[Suzanne Snapper, CFO at The Ensign Group]

We made these investments from a position of strength, as shown by our lease-adjusted net debt to EBITDA ratio of 1.73 times after taking these investments into consideration. Our continued ability to maintain low leverage, even during periods of significant acquisition, is particularly noteworthy and demonstrates our commitment to disciplined growth, as well as our belief that we can continue to achieve sustainable growth in the long run. In early April, CMS released the proposed 2027 skilled nursing facility payment rule, which includes a net market basket increase of 2.4%. This increase provides reimbursement stability and is consistent with the expectations included in our guidance. In addition, we currently have more than $592 million of available capacity under our line of credit.

[Suzanne Snapper, CFO at The Ensign Group]

Which when combined with the cash on our balance sheet, gives us over $1 billion in dry powder for future investments. We also own 179 assets, 155 of which are owned completely debt free. They continue to gain significant value over time, adding even more liquidity to help with future growth. The company paid quarterly cash dividends of $0.065 per share. We have a long history of paying dividends, as I increased the annual dividends for 23 consecutive years. As Barry mentioned, we are increasing our annual 2026 earning guidance to between $7.48 and $7.62 per diluted share, and our annual revenue guidance between $5.81 billion and $5.86 billion.

[Suzanne Snapper, CFO at The Ensign Group]

We have evaluated multiple scenarios and based upon the strength in our performance and positive momentum between occupancy and skilled mix as well as continued progress on labor, agency management, and other operational initiatives, we have confidence that we can achieve these results. Our 2026 guidance is based on diluted weighted average common shares outstanding of approximately 60 million, a tax rate of 25%, the inclusion of acquisitions closed and expected to be closed through the second quarter of 2026, the inclusion of management's expectations for reimbursement rates, with the primary exclusion coming from stock-based compensation and system implementation costs.

[Suzanne Snapper, CFO at The Ensign Group]

Other factors that could impact quarterly performance include variation in reimbursement systems, delays and changes in state budgets, seasonality and occupancy and skilled mix, the influence of the general economy, census, and staffing, the short-term impact of our acquisition activities, variations in insurance controls, and other factors. Now I'll turn it back over to Barry. Barry?

[Barry Port, CEO at The Ensign Group]

Thanks, Suzanne. As we wrap up, I want to again express how honored and grateful we are to work alongside the incredible leaders, caregivers, and support teams across our organization who make these results possible. What they do every day goes far beyond metrics. It changes lives. As we see in very personal ways, I want to share a quick example. Recently, our CFO's father, Joe, underwent a complex bypass procedure that required extended recovery at our very own Victoria Healthcare & Rehabilitation Center. The caregivers and therapists there didn't just provide excellent care. They surrounded him with the kind of coordinated, compassionate support that helped him regain his strength, walk again, and ultimately return home strong and safe. That team represents the very best of what we do, what they do is not unique.

[Barry Port, CEO at The Ensign Group]

Stories like Joe's are playing out every day for thousands of patients at hundreds of our affiliated campuses all over the country every single day. Patients like Joe may not choose to be in our care, but they absolutely need to be, and increasingly so as acuity rises and recovery becomes more complex. The role of high-quality skilled nursing has never been more essential. The demand is real, it is growing, and it's happening in every market we serve. That's what gives us so much confidence in our future. Our performance this quarter is not the result of short-term dynamics or simple luck. It's the result of a model built on clinical excellence, local leadership, and a culture that puts patients first.

[Barry Port, CEO at The Ensign Group]

When you combine that with the demographic tailwinds ahead of us and the continued trust that we are earning in our communities, we believe the opportunity in front of us is as strong as it's ever been. Thank you again for your continued interest and support. With that, we'll now turn to the Q&A portion of our call. Operator, can you please provide instructions for the Q&A?

[Operator]

Your first question comes from the line of Ben Hendrix with RBC Capital Markets. Your line is open. Please go ahead.

[Ben Hendrix, VP of Equity Research at RBC Capital Markets]

Great. Thank you very much. Very glad to hear that Joe is making a strong recovery. Just wanted to touch on some of the clinical review commentary. I really appreciate all the commentary and definitely appreciate and understand the ebb and flow of skilled intensity and, you know, that clinical review is nothing new. Just wanted to get your comments on any broad trends you might be seeing in clinical review intensity, just given that so much of the Medicare Advantage population is in plans that are focused on retaining margin and rebuilding margin this year. And like on a related note, when managed care plans kind of see facilities like Sunwest see such massive increases in skilled mix and managed care mix, does that ever trigger higher clinical review? Any comments you have there? Thanks.

[Barry Port, CEO at The Ensign Group]

I just think the comments around clinical review are being a bit overblown. It's really not a new phenomenon. It's something that's been embedded and in place for a long time, especially when, to your point, Ben, acuity is high. We're used to dealing with clinical review. We have an entire team that is dedicated to providing analysis and documentation to support the care that we're providing both proactively and then also in response to any general inquiries. That team's been in place for many years. You know, we're just not seeing certainly any of that, any, at least of the recent comments translate into our business. We saw a growth in our United business.

[Barry Port, CEO at The Ensign Group]

We saw significant growth in several other payers. In the quarter and across the year, our occupancy reached record levels this quarter, and our managed care and Medicare census both increased sequentially from Q4 to Q1. What we think is happening is that some of the hospital softness, not related to the managed care piece that you asked about, was episodic, respiratory weather-related. That tends to normalize by the time patients move through the system. On the Optum side, we view this less as demand going away, more as demand being refined. The higher acuity patients who truly need skilled nursing are still coming, and in many cases, we're capturing a larger share of those patients.

[Ben Hendrix, VP of Equity Research at RBC Capital Markets]

Thank you very much. Just a quick follow-up on the EPS guidance. We're getting some questions around the guidance raised, specifically against that sizable M&A activity that you've recently announced. Just wondering if you could help us bridge to the guidance revision, specifically how much is driven by organic growth versus M&A. I believe some concern that maybe if M&A is contributing to the growth, is there an implication that maybe the organic is getting a little softer, or is it just some conservatism in the number? Any comments there? Thanks.

[Suzanne Snapper, CFO at The Ensign Group]

Yeah. I think it's a great question. I think, you know, when we look at this acquisition that we closed today, our commentary on it has been that the physical plants are really, really good shape. Chad can add more color on that. Really, the type of acquisition that we're taking is a turnaround acquisition. When we kind of embed turnaround acquisitions into our guidance, like we have for years, is that really you see that bump in revenue at a disproportional rate to the bump in EPS. That's exactly what we would expect. We're super excited about this acquisition, but we would expect most of it just to hit the revenue line, not really to contribute to earnings at the same rate as our existing operations.

[Suzanne Snapper, CFO at The Ensign Group]

That's very consistent with what we've always seen when we're taking a turnaround operation.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

I mean, that's a comment in this release that, you know, over the next several months, right? I think obviously, long term, we expect them to be very successful and accretive, like she said, like we've done for years.

[Suzanne Snapper, CFO at The Ensign Group]

We're really excited about the guidance. The guidance raised, obviously reflects a huge strong Q1, but also that continued execution. Some seasonality in therefore Q2 and Q3, because that's through the summer months. You know, we also usually have not as high a skilled mixture in those months, and then costs rise as a relative to the revenue that we do bring in because the activity tends to slow down a little bit.

[Barry Port, CEO at The Ensign Group]

We base our guidance on what we expect these to do. You know, I think you can also look backwards and listen to our commentary about how other recent acquisitions have contributed ahead of schedule. I wouldn't be surprised if that happened. If it does, we'll revise again. It's not necessarily conservatism. We try to reflect an accurate picture of where we think these will contribute. Obviously, we've had to update and revise as time has gone on when things have gone faster than we're scheduled to.

[Ben Hendrix, VP of Equity Research at RBC Capital Markets]

Great. Thank you very much.

[Operator]

Our next question comes from the line of David MacDonald with Truist. Your line is open. Please go ahead.

[David MacDonald, Analyst at Truist Securities]

Yeah, good afternoon, everyone. Guys, just two questions. One, can you pull the deal pipeline apart for us a little bit? I mean, if we look, you know, the average deal size feels like it's getting a bit bigger. Can you guys just make some, you know, just give us some sense of when you look at the pipeline of deals, has the average deal size relative to a handful of years ago gotten bigger? Secondly, you know, are you seeing opportunities to buy the real estate in more of those deals that are within the pipeline?

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

Yeah, thanks for the question. I think there definitely is a trend of more and more, call it mid-size, you know, regional portfolios are coming to market for sure. That's, you know, I would say there's more supply of that type of deal. The other thing, I mean, it's not that we haven't had those in the past. I would say, you know, we have, I guess emphasized this a little bit in our calls over the last several quarters too, but, you know, we have approached these larger portfolios a little bit differently. If you go way back to, you know, 2016 or so, we did a larger portfolio in Texas called the Legend deal.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

It was, you know, at the time, the biggest deal we'd done, and we tried to kind of do it like a merger and just sort of, you know, fold into our organization and left a lot of their structure in place and those types of things. That took us years to kind of, you know, unwind. Since then, we've been successful in several larger deals and doing what I kind of described in our prepared remarks by breaking it into bite-sized pieces and using our cluster model and that local leadership structure to take a larger deal and make it, you know, three or four buildings per cluster or market and not, you know, 20. That's been something that I think has increased our appetite, I would say, for larger acquisitions.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

It's both things. We've seen more of those come to market and I think we're more and more confident that we can do those successfully in our Ensign way. On the real estate question. You know, I would say, it's probably not necessarily a trend that we're seeing more real estate opportunities. You know, it wouldn't surprise me if we have a big, big acquisition here or, you know, in the near or near future or in the sort of midterm future that would include a lot of leased buildings too. You know, because I think our priorities remain the same. We'd You know, our first priority would be to own it and operate it if we can. Second would be to do really attractive long-term leases.

[Chad Keetch, CIO, EVP, and Secretary at The Ensign Group]

We have a lot of great real estate partners that, you know, we love to work with and including our REIT partners and others that are, you know, private real estate holders. We're actively looking at doing those deals too. Then, you know, the third priority would be to own it and lease to third party like we did in the Wisconsin senior living deal. Hopefully, that helps.

[David MacDonald, Analyst at Truist Securities]

Okay. Just one quick follow-up. You know, on some of the labor, a two-part question. One, can you guys just spend a minute on, you know, what you guys are doing on recruiting and retention that's, you know, driving such success on the labor side? If I could sneak one more in, just on the ERP system implementation, is there, you know, one or two areas that you would call out where, you know, that has made your life meaningfully easier or improved efficiencies meaningfully?

[Spencer Burton, President and COO at The Ensign Group]

On the labor question, I'll start with that one. Thanks for the question on it. It's a focus for us as an organization, but really how it works is you've got more and more visibility. Our data systems give us more real time and more consistent ways to measure ourselves on labor metrics. You combine that with our model, which is, you know, CEO, COO caliber leaders in every operation that are then clustered into groups where there's consistent sharing of best practices and peer accountability. Those are folded into markets where, you know, data is and practices are shared more widely.

[Spencer Burton, President and COO at The Ensign Group]

We've really seen, for example, in our overtime management, our labor management, we've seen a really nice kind of synchronization of local efforts, improved data visibility, best practice sharing, and then service center, you know, providing more kind of macro tools that allow people to do it more effectively on a local level. It's been really fun to see, you know, overtime improve, agency spending improve, turnover improve, and yeah, it continues to be a major focus for us. We're not satisfied with where we are yet, but we're really grateful for the improvements.

[Suzanne Snapper, CFO at The Ensign Group]

On the second question, we actually just implemented our ERP system on January first. We're in that stage of, you know, working through the very first quarter and very first month of closing everything out. We're not to that efficiency stage, obviously the entire purpose of doing ERP system is to have more efficiency, have better data, have more information that we can actually, like Spencer just mentioned, pass to the field in a quicker, faster, and more effective way at a more granular level. We're really excited about the implementation.

[Suzanne Snapper, CFO at The Ensign Group]

We know that right now we're at the beginning phases, and it might feel like a little bit more work than less work, but the opportunity that we can have from what we'll have in the long run from a system implementation like we just went through will really be something that we'll be able to use for years and years to come and really have an opportunity to make information easier, more accessible, and just change the entire process that we do on the back end.

[David MacDonald, Analyst at Truist Securities]

Okay. Thank you very much.

[Operator]

Our next question comes from the line of Raj Kumar with Stephens. Your line is open. Please go ahead.

[Raj Kumar, Analyst at Stephens]

Hey. Just maybe kind of thinking about the kind of overall philosophy and maybe the kind of evolution of the model, you know, when we think outside of SNFs, senior living and kind of all the other, you know, stuff that Ensign does within the post-acute continuum. I guess, you know, when we think about, you know, certain areas of interest, does kind of I-SNP come to mind? I know you guys partner, you know, with plans, but, you know, in terms of kind of expanding the quality of care and the control around that, has there ever been kind of an area of interest for you? Just kind of curious on your, on your thoughts on that, just given kind of your footprint in the post-acute spectrum.

[Barry Port, CEO at The Ensign Group]

The short answer.

[Suzanne Snapper, CFO at The Ensign Group]

Yeah. That's a great question. Go ahead, Barry.

[Barry Port, CEO at The Ensign Group]

Sorry. I'll start. Suzanne's much more knowledgeable about this, but the short answer is yes. Yes. It's something we're always looking at. It's obviously something we participate in in several markets. It's something we watch closely. There are some pros and cons to the model. You know, we could get into that at another time. You know, we tend to, as you can tell, stick to what we know we are good at and then partner closely with our managed care providers who are, you know, probably more focused on this area than a pure play operator could be. That said, there are obvious opportunities there to kind of control certain aspects of payment and to kind of be more of a quasi-payer and convener when it comes to that model. Suzanne, anything you wanna add to that?

[Suzanne Snapper, CFO at The Ensign Group]

I was just gonna add exactly that. You know, there's always we're always doing what we call pilot programs in different markets, in different places. They all look a little bit different. None of them are a large portion of our total operations, but I think that that's what keeps us nimble and keeps us quick and looking to see if we do wanna do something at a larger scale one time, we'll have already tested out in a pilot and have a proven concept for them to kind of expand upon that. Definitely lots of versions of I-SNP or quality improvement programs and a whole bunch of different specialty programs that we have or capitation programs that we have here. We have a lot of those going on throughout the organization.

[Suzanne Snapper, CFO at The Ensign Group]

I would characterize them as all model pilot programs that we continue to learn from and then, you know, as one really pops, we start to expand it. It's, again, it's not us expanding it's educating that how this program works, and then the operations partners that we have in the field really latching onto that because they can see the value that it creates service, that it delivers to the patient.

[Raj Kumar, Analyst at Stephens]

Great. Yeah, appreciate the color there. Maybe just from a modeling perspective, you know, kind of integrating these, you know, large portfolio of assets. As you kind of think about seasonality, you know, from a skill mix and occupancy perspective, and then kind of the impact of the onboarded portfolio to the kind of consolidated metrics, how should we kind of be thinking about that as we think about the remainder of the year?

[Suzanne Snapper, CFO at The Ensign Group]

I would say that our pattern would be typical for our normal pattern, right? That we've seen outside of the COVID years, where you really typically see a Q2, Q3 more seasonally light for a skilled mix and then really a stronger Q4. Barry or Spencer, do you have any other color?

[Spencer Burton, President and COO at The Ensign Group]

No, I think that's right.

[Raj Kumar, Analyst at Stephens]

Thank you.

[Operator]

Our next question comes from the line of A.J. Rice with UBS.

[A.J. Rice, Managing Director at UBS]

Hi, everybody. Thanks for the question. First maybe, obviously the company and the sector came through the One Big Beautiful Bill discussion pretty well. We are obviously hearing some states are a little challenged in their budgeting. Others are doing fine. Just wonder if you could maybe speak to what you're seeing in your discussions regarding Medicaid rates and the outlook. Is it sort of steady state from your perspective? Maybe just give some flavor on that.

[Suzanne Snapper, CFO at The Ensign Group]

It's, this is Suzanne. Definitely steady state right now. I think what we're seeing is, you know, people looking beyond 2026 and into 2027, where they're thinking about potentially how to navigate waters, where it might be a little bit more, the funds might be as not as fluid. I think one of the things that we're doing to make sure we're ahead of that is just being super active. We are meeting with the states, meeting with folks who are in our associations representing us and really taking an active role in where Medicaid could go for us and educating what we do for their residents and our residents and obviously the folks that are in the state.

[Suzanne Snapper, CFO at The Ensign Group]

We feel really good about where it sits today on a Medicaid front because of people recognizing the services that we deliver and the need for those services.

[A.J. Rice, Managing Director at UBS]

Okay. You talked about the I-SNP opportunity. I know another area you were looking at sort of as a demo, it sounded like a few quarters ago, was in the behavioral health area, that that's obviously a place that there's some supply-demand constraints. I wondered if you could give us any update on what you're thinking about institutional behavioral health. Sounds like there are some other demo areas that you're looking at. Is there anything else that looks particularly exciting that you would call out?

[Spencer Burton, President and COO at The Ensign Group]

On the behavioral health, there is continued innovation. As you can see this, you know, as you, as you visit different markets, there's constantly this drive from our operators to figure out what our hospital partners, what the communities, and what the plans need. We've continued to see, you know, demand for specialized behavioral health be really strong. We've continued to develop those and add those units, get, you know, contracts even with state Medicaid systems and other managed providers, where they know that they need people in a lower cost setting like ours. They know that we have the capacity to do it, and they're contracting with us or in some cases even asking us to expand to meet their needs. That continues to be a really strong area.

[Spencer Burton, President and COO at The Ensign Group]

It's very locally driven with service center support versus a service center kind of mandate or strategy. As far as, you know, non-SNF based behavioral health, we're not doing anything in that area to speak of. Just to your question about other kind of innovative areas, absolutely. There's, you know, with almost 400 operations, there's so many ideas. Really what we try and do is provide the framework to help people analyze, people understand the regulatory, you know, backdrop that they'd be operating against, understand true demand and supply and trends. We're seeing a lot of cool, as Suzanne mentioned, you know, these piloting type things that that's what allows us to grow, and that's what allows us to be so excited about the future, is it's not us coming up with one strategy.

[Spencer Burton, President and COO at The Ensign Group]

It's almost 400 operators and their teams and their clinicians coming up with what the communities need, and then we help embed them. Yes, absolutely, we expect to do more in the future.

[A.J. Rice, Managing Director at UBS]

Okay. Thanks a lot.

[Operator]

There are no further questions at this time. This concludes today's call. Thank you for attending. You may now disconnect.

Participants

Executives

• Barry Port, CEO
• Chad Keetch, CIO, EVP, and Secretary
• Spencer Burton, President and COO
• Suzanne Snapper, CFO

Analysts

• A.J. Rice, Managing Director at UBS
• Ben Hendrix, VP of Equity Research at RBC Capital Markets
• David MacDonald, Analyst at Truist Securities
• Raj Kumar, Analyst at Stephens