The Ensign Group, Inc. (ENSG) 10-Q 31 Oct 18 2018 Q3 Quarterly report Financial data

DEI Info Cover Page Document

DEI Info Cover Page Document - shares	9 Months Ended
	Sep. 30, 2018	Oct. 30, 2018
Entity Information [Abstract]
Entity Registrant Name	ENSIGN GROUP, INC
Entity Central Index Key	1,125,376
Current Fiscal Year End Date	--12-31
Entity Filer Category	Large Accelerated Filer
Document Type	10-Q
Document Period End Date	Sep. 30, 2018
Document Fiscal Year Focus	2,018
Document Fiscal Period Focus	Q3
Amendment Flag	false
Entity Emerging Growth Company	false
Entity Small Business	false
Entity Common Stock, Shares Outstanding		52,319,166

Consolidated Balance Sheets

Consolidated Balance Sheets - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Current assets:
Cash and cash equivalents	$ 45,657	$ 42,337
Accounts receivable—less allowance for doubtful accounts of $2,484 and $43,961 at September 30, 2018 and December 31, 2017, respectively (Note 3)	261,454	265,068
Investments—current	9,688	13,092
Prepaid income taxes	6,509	19,447
Prepaid expenses and other current assets	25,105	28,132
Total current assets	348,413	368,076
Property and equipment, net	593,088	537,084
Insurance subsidiary deposits and investments	32,487	28,685
Escrow deposits	660	228
Deferred tax assets	12,035	12,745
Restricted and other assets	20,459	16,501
Intangible assets, net	31,620	32,803
Goodwill	78,612	81,062
Other indefinite-lived intangibles	26,201	25,249
Total assets	1,143,575	1,102,433
Current liabilities:
Accounts payable	41,323	39,043
Accrued wages and related liabilities	99,047	90,508
Accrued self-insurance liabilities—current	23,113	22,516
Other accrued liabilities	74,297	63,815
Current maturities of long-term debt	10,080	9,939
Total current liabilities	247,860	225,821
Long-term debt—less current maturities	245,604	302,990
Accrued self-insurance liabilities—less current portion	54,704	50,220
Deferred rent and other long-term liabilities	11,450	11,268
Deferred gain related to sale-leaseback (Note 16)	11,581	12,075
Total liabilities	571,199	602,374
Commitments and contingencies (Notes 14, 16 and 17)
Equity:
Common stock; $0.001 par value; 75,000 shares authorized; 54,740 and 52,248 shares issued and outstanding at September 30, 2018, respectively, and 53,675 and 51,360 shares issued and outstanding at December 31, 2017, respectively (Note 18)	54	53
Additional paid-in capital	278,802	266,058
Retained earnings	321,448	264,691
Common stock in treasury, at cost, 1,932 shares at September 30, 2018 and December 31, 2017, respectively	(38,405)	(38,405)
Total Ensign Group, Inc. stockholders' equity	561,899	492,397
Non-controlling interest	10,477	7,662
Total equity	572,376	500,059
Total liabilities and equity	$ 1,143,575	$ 1,102,433

Consolidated Balance Sheets Bal

Consolidated Balance Sheets Balance Sheet (Paranthetical) - USD ($) shares in Thousands, $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Current assets:
Allowance for doubtful accounts	$ 2,484	$ 43,961
Equity:
Common stock, par value	$ 0.001	$ 0.001
Common stock, shares authorized	75,000	75,000
Common stock, shares issued	54,740	53,675
Common stock, shares outstanding	52,248	51,360
Common stock in treasury, at cost	1,932	1,932

Consolidated Statements of Inco

Consolidated Statements of Income - USD ($) shares in Thousands, $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Revenue
Total revenue	$ 514,364	$ 471,594	$ 1,502,884	$ 1,361,612
Expense
Cost of services	413,723	381,544	1,200,098	1,103,976
(Return of unclaimed class action settlement)/charges related to class action lawsuit (Note 17)	0	0	(1,664)	11,000
Losses related to divestitures (Note 6 and 16)	0	0	0	2,731
Rent—cost of services (Note 16)	34,851	33,782	103,173	98,267
General and administrative expense	24,601	19,261	72,091	57,784
Depreciation and amortization	11,902	11,448	35,145	32,712
Total expenses	485,077	446,035	1,408,843	1,306,470
Income from operations	29,287	25,559	94,041	55,142
Other income (expense):
Interest expense	(3,989)	(3,519)	(11,471)	(10,017)
Interest income	467	395	1,477	973
Other expense, net	(3,522)	(3,124)	(9,994)	(9,044)
Income before provision for income taxes	25,765	22,435	84,047	46,098
Provision for income taxes	5,415	8,160	18,078	16,487
Net income	20,350	14,275	65,969	29,611
Less: net (loss)/income attributable to noncontrolling interests	(511)	63	(35)	342
Net income attributable to The Ensign Group, Inc.	$ 20,861	$ 14,212	$ 66,004	$ 29,269
Basic:
Basic net income per common share attributable to The Ensign Group, Inc.	$ 0.40	$ 0.28	$ 1.27	$ 0.58
Diluted:
Diluted net income per common share attributable to The Ensign Group, Inc.	$ 0.38	$ 0.27	$ 1.22	$ 0.56
Weighted average common shares outstanding:
Basic	52,139	50,911	51,870	50,795
Diluted	54,632	52,828	54,176	52,674
Dividends per share	$ 0.0450	$ 0.0425	$ 0.1350	$ 0.1275
Health Care, Patient Service [Member]
Revenue
Total revenue	$ 476,306	$ 436,139	$ 1,391,549	$ 1,260,802
Health Care, Resident Service [Member]
Revenue
Total revenue	$ 38,058	$ 35,455	$ 111,335	$ 100,810

Consolidated Statements of Cash

Consolidated Statements of Cash Flows - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017
Cash flows from operating activities:
Net income	$ 65,969	$ 29,611
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation and amortization	35,145	32,712
Goodwill and intangible asset impairment	3,653	0
Amortization of deferred financing fees	882	767
Amortization of deferred gain on sale-leaseback (Note 16)	(493)	(256)
Impairment of long-lived assets	860	111
Deferred income taxes	710	575
Provision for doubtful accounts (Note 3)	2,101	21,934
Share-based compensation	7,639	6,755
Cash received from insurance proceeds related to replacement properties and business interruptions	1,783	0
Gain on insurance claims and disposal of assets	(1,097)	(71)
Income tax refund	11,000	0
Change in operating assets and liabilities
Accounts receivable (Note 3)	3,479	(33,098)
Prepaid income taxes	1,938	(13,820)
Prepaid expenses and other assets	238	(2,797)
Insurance subsidiary deposits and investments	(399)	(169)
Charge related to class action lawsuit (Note 17)	0	11,000
Liabilities related to operational closures (Note 6 and 16)	0	2,620
Accounts payable	2,031	2,499
Accrued wages and related liabilities	8,540	(8,717)
Income taxes payable	0	(1,182)
Other accrued liabilities	9,092	8,668
Accrued self-insurance liabilities	4,025	5,456
Deferred rent liability	181	651
Net cash provided by operating activities	157,277	63,249
Cash flows from investing activities:
Purchase of property and equipment	(37,632)	(39,775)
Cash payments for business acquisitions (Note 7)	(1,625)	(83,945)
Cash payments for asset acquisitions (Note 7)	(57,859)	(310)
Escrow deposits	(660)	(849)
Escrow deposits used to fund acquisitions	228	1,582
Cash proceeds from sale-leaseback (Note 16)	0	38,000
Cash proceeds from the sale of assets and insurance proceeds related to damaged properties	2,971	2,546
Restricted and other assets	(692)	(315)
Net cash used in investing activities	(95,269)	(83,066)
Cash flows from financing activities:
Proceeds from revolving credit facility and other debt (Note 14)	600,000	680,000
Payments on revolving credit facility and other debt (Note 14)	(657,427)	(668,089)
Issuance of common stock upon exercise of options	6,135	4,212
Proceeds from sale of subsidiary shares (Note 15)	1,972	0
Repurchase of shares of common stock and subsidiary shares (Note 15 and Note 18)	(1,972)	(7,288)
Dividends paid	(7,042)	(6,528)
Non-controlling interest distribution	(336)	0
Purchase of non-controlling interest	0	(83)
Payments of deferred financing costs	(18)	(58)
Net cash (used in)/provided by financing activities	(58,688)	2,166
Net increase (decrease) in cash and cash equivalents	3,320	(17,651)
Cash and cash equivalents beginning of period	42,337	57,706
Cash and cash equivalents end of period	45,657	40,055
Cash paid during the period for:
Interest	11,625	10,014
Income taxes	15,563	30,780
Non-cash financing and investing activity:
Accrued capital expenditures	3,800	4,780
Note receivable from sale of ancillary business and asset acquisition	$ 129	$ 0

Description of Business

Description of Business	9 Months Ended
	Sep. 30, 2018
DESCRIPTION OF BUSINESS [Abstract]
Organization, Consolidation and Presentation of Financial Statements Disclosure [Text Block]	DESCRIPTION OF BUSINESS The Company - The Ensign Group, Inc. (collectively, Ensign or the Company), is a holding company with no direct operating assets, employees or revenue. The Company, through its operating subsidiaries, is a provider of health care services across the post-acute care continuum, as well as other ancillary businesses. As of September 30, 2018 , the Company operated 236 facilities, 49 home health, hospice and home care agencies and other ancillary operations located in Arizona, California, Colorado, Idaho, Iowa, Kansas, Nebraska, Nevada, Oklahoma, Oregon, South Carolina, Texas, Utah, Washington, Wisconsin and Wyoming. The Company's operating subsidiaries, each of which strives to be the operation of choice in the community it serves, provide a broad spectrum of skilled nursing, assisted living, home health, home care, hospice and other ancillary services. The Company's operating subsidiaries have a collective capacity of approximately 19,300 operational skilled nursing beds and 5,200 assisted living and independent living units. As of September 30, 2018 , the Company owned 68 of its 236 affiliated facilities and leased an additional 168 facilities through long-term lease arrangements and had options to purchase twelve of those 168 facilities. As of December 31, 2017 , the Company owned 63 of its 230 affiliated facilities and leased an additional 167 facilities through long-term lease arrangements and had options to purchase eleven of those 167 facilities. Certain of the Company’s wholly-owned independent subsidiaries, collectively referred to as the Service Center, provide certain accounting, payroll, human resources, information technology, legal, risk management and other centralized services to the other operating subsidiaries through contractual relationships with such subsidiaries. The Company also has a wholly-owned captive insurance subsidiary (the Captive) that provides some claims-made coverage to the Company’s operating subsidiaries for general and professional liability, as well as coverage for certain workers’ compensation insurance liabilities. Each of the Company's affiliated operations are operated by separate, wholly-owned, independent subsidiaries that have their own management, employees and assets. References herein to the consolidated “Company” and “its” assets and activities in this 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 September 30, 2018 and for the three and nine months ended September 30, 2018 and 2017 (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, 2017 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.

Significant Accounting Policies

Significant Accounting Policies	9 Months Ended
	Sep. 30, 2018
Accounting Policies [Abstract]
Basis of Presentation and Significant Accounting Policies [Text Block]	SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Basis of Presentation — The accompanying Interim Financial Statements have been prepared in accordance with accounting principles generally accepted in the United States (GAAP). The Company is the sole member or shareholder of various consolidated limited liability companies and corporations established to operate various acquired skilled nursing and assisted living operations, home health, hospice and home care operations, and related ancillary services. All intercompany transactions and balances have been eliminated in consolidation. The condensed consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest. The Company presents noncontrolling interest within the equity section of its condensed consolidated balance sheets. The Company presents the amount of consolidated net income that is attributable to The Ensign Group, Inc. and the noncontrolling interest in its condensed consolidated statements of income. Estimates and Assumptions — The preparation of Interim Financial Statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the Interim Financial Statements and the reported amounts of revenue and expenses during the reporting periods. The most significant estimates in the Company’s Interim Financial Statements relate to revenue, intangible assets and goodwill, impairment of long-lived assets, general and professional liability, workers' compensation and healthcare claims included in accrued self-insurance liabilities, and income taxes. Actual results could differ from those estimates. Fair Value of Financial Instruments — The Company’s financial instruments consist principally of cash and cash equivalents, debt security investments, accounts receivable, insurance subsidiary deposits, accounts payable and borrowings. The Company believes all of the financial instruments’ recorded values approximate fair values because of their nature or respective short durations. Revenue Recognition — On January 1, 2018, the Company adopted Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (ASC 606) applying the modified retrospective method. Results for reporting periods beginning January 1, 2018 are presented under ASC 606, while prior period amounts are not adjusted and continue to be reported under the accounting standards in effect for the prior period. The adoption of ASC 606 did not have a material impact on the measurement nor on the recognition of revenue of contracts, for which all revenue had not been recognized, as of January 1, 2018, therefore no cumulative adjustment has been made to the opening balance of retained earnings at the beginning of 2018. See Note 3, Revenue and Accounts Receivable . Accounts Receivable and Allowance for Doubtful Accounts — Accounts receivable consist primarily of amounts due from Medicare and Medicaid programs, other government programs, managed care health plans and private payor sources, net of estimates for variable consideration. The allowance for doubtful accounts reflects the Company’s best estimate of probable losses inherent in the accounts receivable balance. The Company determines the allowance based on known troubled accounts and other currently available evidence. See Note 3, Revenue and Accounts Receivable . Property and Equipment — Property and equipment are initially recorded at their historical cost. Repairs and maintenance are expensed as incurred. Depreciation is computed using the straight-line method over the estimated useful lives of the depreciable assets (ranging from three to 59 years ). Leasehold improvements are amortized on a straight-line basis over the shorter of their estimated useful lives or the remaining lease term. Impairment of Long-Lived Assets — The Company reviews the carrying value of long-lived assets that are held and used in the Company’s operating subsidiaries for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of these assets is determined based upon expected undiscounted future net cash flows from the operating subsidiaries to which the assets relate, utilizing management’s best estimate, appropriate assumptions, and projections at the time. If the carrying value is determined to be unrecoverable from future operating cash flows, the asset is deemed impaired and an impairment loss would be recognized to the extent the carrying value exceeded the estimated fair value of the asset. The Company estimates the fair value of assets based on the estimated future discounted cash flows of the asset. Management has evaluated its long-lived assets and recorded an impairment charge of $860 and $111 during the nine months ended September 30, 2018 and 2017 , respectively. The Company did not identify any asset impairment during the three months ended September 30, 2018 and 2017 . Leases and Leasehold Improvements - At the inception of each lease, the Company performs an evaluation to determine whether the lease should be classified as an operating or capital lease. The Company records rent expense for operating leases that contain scheduled rent increases on a straight-line basis over the term of the lease. The lease term used for straight-line rent expense is calculated from the date the Company is given control of the leased premises through the end of the lease term. The lease term used for this evaluation also provides the basis for establishing depreciable lives for buildings subject to lease and leasehold improvements, as well as the period over which the Company records straight-line rent expense. Intangible Assets and Goodwill — Definite-lived intangible assets consist primarily of favorable leases, lease acquisition costs, patient base, facility trade names and customer relationships. Favorable leases and lease acquisition costs are amortized over the life of the lease of the facility. Patient base is amortized over a period of four to eight months, depending on the classification of the patients and the level of occupancy in a new acquisition on the acquisition date. Trade names at affiliated facilities are amortized over 30 years and customer relationships are amortized over a period of up to 20 years . The Company's indefinite-lived intangible assets consist of trade names, and Medicare and Medicaid licenses. The Company tests indefinite-lived intangible assets for impairment on an annual basis or more frequently if events or changes in circumstances indicate that the carrying amount of the intangible asset may not be recoverable. Goodwill represents the excess of the purchase price over the fair value of identifiable net assets acquired in business combinations. Goodwill is subject to annual testing for impairment. In addition, goodwill is tested for impairment if events occur or circumstances change that would reduce the fair value of a reporting unit below its carrying amount. The Company performs its annual test for impairment during the fourth quarter of each year. Management evaluated its goodwill and intangible assets during the third quarter, due to changes in circumstances and the Company recorded an impairment charge of $3,653 to goodwill and intangible assets during the three and nine months ended September 30, 2018 . The Company did not identify any goodwill and intangible assets impairment during the three and nine months ended September 30, 2017 . See further discussion at Note 10, Goodwill and Other Indefinite-Lived Intangible Assets . Self-Insurance — The Company is partially self-insured for general and professional liability up to a base amount per claim (the self-insured retention) with an aggregate, one-time deductible above this limit. Losses beyond these amounts are insured through third-party policies with coverage limits per claim, per location and on an aggregate basis for the Company. The combined self-insured retention is $500 per claim, subject to an additional one-time deductible of $750 for California affiliated operations and a separate, one-time, deductible of $1,000 for non-California operations. For all affiliated operations, except those located in Colorado, the third-party coverage above these limits is $1,000 per claim, $3,000 per operation, with a $5,000 blanket aggregate limit and an additional state-specific aggregate where required by state law. In Colorado, the third-party coverage above these limits is $1,000 per claim and $3,000 per operation, which is independent of the aforementioned blanket aggregate limits that apply outside of Colorado. The self-insured retention and deductible limits for general and professional liability and workers' compensation for all states (except Texas and Washington for workers' compensation) are self-insured through the Captive, the related assets and liabilities of which are included in the accompanying condensed consolidated balance sheets. The Captive is subject to certain statutory requirements as an insurance provider. These requirements include, but are not limited to, maintaining statutory capital. The Company’s policy is to accrue amounts equal to the actuarially estimated costs to settle open claims of insureds, as well as an estimate of the cost of insured claims that have been incurred but not reported. The Company develops information about the size of the ultimate claims based on historical experience, current industry information and actuarial analysis, and evaluates the estimates for claim loss exposure on a quarterly basis. Accrued general liability and professional malpractice liabilities on an undiscounted basis, net of anticipated insurance recoveries, were $41,280 and $38,998 as of September 30, 2018 and December 31, 2017 , respectively. The Company’s operating subsidiaries are self-insured for workers’ compensation in California. To protect itself against loss exposure in California with this policy, the Company has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington, are under a loss sensitive plan that insures individual claims that exceed $350 per occurrence. In Washington, the operating subsidiaries' coverage is financed through premiums paid by the employers and employees. The claims and pay benefits are managed through a state insurance pool. Outside of California, Texas and Washington, the Company has purchased insurance coverage that insures individual claims that exceed $350 per accident. In all states except Washington, the Company accrues amounts equal to the estimated costs to settle open claims, as well as an estimate of the cost of claims that have been incurred but not reported. The Company uses actuarial valuations to estimate the liability based on historical experience and industry information. Accrued workers’ compensation liabilities are recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets and were $24,427 and $23,621 as of September 30, 2018 and December 31, 2017 , respectively. In addition, the Company has recorded an asset and equal liability of $6,451 and $5,394 at September 30, 2018 and December 31, 2017 , respectively, in order to present the ultimate costs of malpractice and workers' compensation claims and the anticipated insurance recoveries on a gross basis. See Note 11 Restricted and Other Assets. The Company self-funds medical (including prescription drugs) and dental healthcare benefits to the majority of its employees. The Company is fully liable for all financial and legal aspects of these benefit plans. To protect itself against loss exposure with this policy, the Company has purchased individual stop-loss insurance coverage that insures individual claims that exceed $300 for each covered person with an additional one-time aggregate individual stop loss deductible of $75 . Beginning 2016, the Company's policy does not include the additional one-time aggregate individual stop loss deductible of $75 . The Company’s accrued liability under these plans recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets was $5,659 and $4,723 as of September 30, 2018 and December 31, 2017 , respectively. The Company believes that adequate provision has been made in the Interim Financial Statements for liabilities that may arise out of patient care, workers’ compensation, healthcare benefits and related services provided to date. The amount of the Company’s reserves was determined based on an estimation process that uses information obtained from both company-specific and industry data. This estimation process requires the Company to continuously monitor and evaluate the life cycle of the claims. Using data obtained from this monitoring and the Company’s assumptions about emerging trends, the Company, with the assistance of an independent actuary, develops information about the size of ultimate claims based on the Company’s historical experience and other available industry information. The most significant assumptions used in the estimation process include determining the trend in costs, the expected cost of claims incurred but not reported and the expected costs to settle or pay damage awards with respect to unpaid claims. The self-insured liabilities are based upon estimates, and while management believes that the estimates of loss are reasonable, the ultimate liability may be in excess of or less than the recorded amounts. Due to the inherent volatility of actuarially determined loss estimates, it is reasonably possible that the Company could experience changes in estimated losses that could be material to net income. If the Company’s actual liability exceeds its estimates of loss, its future earnings, cash flows and financial condition would be adversely affected. Income Taxes — Deferred tax assets and liabilities are established for temporary differences between the financial reporting basis and the tax basis of the Company’s assets and liabilities at tax rates in effect when such temporary differences are expected to reverse. The Company generally expects to fully utilize its deferred tax assets; however, when necessary, the Company records a valuation allowance to reduce its net deferred tax assets to the amount that is more likely than not to be realized. In determining the need for a valuation allowance or the need for and magnitude of liabilities for uncertain tax positions, the Company makes certain estimates and assumptions. These estimates and assumptions are based on, among other things, knowledge of operations, markets, historical trends and likely future changes and, when appropriate, the opinions of advisors with knowledge and expertise in certain fields. Due to certain risks associated with the Company’s estimates and assumptions, actual results could differ. The Tax Cuts and Jobs Act (the Tax Act), which was enacted in December 2017, decreased the corporate income tax rate from 35.0% to 21.0% beginning on January 1, 2018. The Company’s actual effective tax rate for fiscal 2018 may differ from management’s estimate due to changes in interpretations and assumptions, and the excess tax benefits impact of share-based payment awards. See Note 13, Income Taxes for further detail. Noncontrolling Interest — The noncontrolling interest in a subsidiary is initially recognized at estimated fair value on the acquisition date and is presented within total equity in the Company's condensed consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to The Ensign Group, Inc. in its condensed consolidated statements of income and net income per share is calculated based on net income attributable to The Ensign Group, Inc.'s stockholders. The carrying amount of the noncontrolling interest is adjusted based on an allocation of subsidiary earnings based on ownership interest. Share-Based Compensation — The Company measures and recognizes compensation expense for all share-based payment awards made to employees and directors including employee stock options based on estimated fair values, ratably over the requisite service period of the award. Net income has been reduced as a result of the recognition of the fair value of all stock options and restricted stock awards issued, the amount of which is contingent upon the number of future grants and other variables. Recent Accounting Pronouncements — Except for rules and interpretive releases of the Securities and Exchange Commission (SEC) under authority of federal securities laws and a limited number of grandfathered standards, the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) is the sole source of authoritative GAAP literature recognized by the FASB and applicable to the Company. For any new pronouncements announced, the Company considers whether the new pronouncements could alter previous generally accepted accounting principles and determines whether any new or modified principles will have a material impact on the Company's reported financial position or operations in the near term. The applicability of any standard is subject to the formal review of the Company's financial management and certain standards are under consideration. Recent Accounting Standards Adopted by the Company In 2014, the FASB and International Accounting Standards Board issued their final standard on revenue from contracts with customers that outlines a single comprehensive model for entities to use in accounting for revenue arising from contracts with customers. Under this new standard and subsequently issued amendments, revenue is recognized at the time a good or service is transferred to a customer for the amount of consideration received. Entities may apply the new standard either retrospectively to each period presented (full retrospective method) or retrospectively with the cumulative effect recognized in beginning retained earnings as of the date of adoption (modified retrospective method). The Company adopted the new revenue standard as of January 1, 2018 using the modified retrospective transition method. The adoption of ASC 606 did not have a material impact on the measurement, nor on the recognition of revenue of contracts, for which all revenue had not been recognized as of January 1, 2018. Therefore, no cumulative adjustment has been made to the opening balance of retained earnings at the beginning of 2018. The comparative information has not been restated and continues to be reported under the accounting standards in effect for the period presented. In May 2017, the FASB issued amended authoritative guidance to provide guidance on types of changes to the terms or conditions of share-based payment awards to which an entity would be required to apply modification accounting under ASC 718. The new guidance was effective for the Company in the first quarter of fiscal year 2018. The adoption of this standard did not have a material impact on the Company's consolidated financial statements. In January 2017, the FASB issued amended authoritative guidance to clarify the definition of a business and reduce diversity in practice related to the evaluation of whether transactions should be accounted for as acquisitions (or disposals) of assets or businesses. The new provisions provide the requirements needed for an integrated set of assets and activities (the set) to be a business and also establish a practical way to determine when a set is not a business. The accounting standards update (ASU) provides a screen to determine when an integrated set of assets and activities is not a business. The more robust framework helps entities to narrow the definition of outputs created by the set and align it with how outputs are described in the new revenue standard. The new guidance was effective for the Company in the first quarter of fiscal year 2018. The fair value of assets for nine of the Company's acquisitions during the nine months ended September 30, 2018 was concentrated in property and equipment and as such, these transactions were classified as asset acquisitions in accordance with ASC 805. The fair value of assets for the remaining two acquisitions during the nine months ended September 30, 2018 was concentrated in goodwill and as such, these transactions were classified as business acquisitions in accordance with ASC 805. Some of these acquisitions would have been classified as business combinations prior to the adoption of the ASU. The Company anticipates that future acquisitions will be classified as a mixture of business and asset acquisitions under the new guidance. In March 2018, we adopted ASU 2018-05, Income Taxes (Topic 740): Amendments to the SEC Paragraphs Pursuant to SEC Staff Accounting Bulletin No. 118, which updates the income tax accounting in U.S. GAAP to reflect the Securities and Exchange Commission (SEC) interpretive guidance released in December 2017, when the Tax Act was signed into law. Additional information regarding the adoption of this standard is contained in Note 13, Income Taxes. In October 2016, the FASB issued amended authoritative guidance to require companies to recognize the income tax consequences of an intra-entity transfer of an asset, other than inventory, when the transfer occurs. The new guidance is required to be applied on a modified retrospective basis through a cumulative-effect adjustment directly to retained earnings as of the beginning of the period of adoption. The new guidance was effective for the Company in the first quarter of fiscal year 2018. The adoption of this standard did not have a material impact on the Company's consolidated financial statements. In August 2016, the FASB issued amended authoritative guidance to reduce the diversity in practice related to the presentation and classification of certain cash receipts and cash payments in the statement of cash flows. The new provisions target cash flow issues related to (i) debt prepayment or debt extinguishment costs, (ii) settlement of debt instruments with coupon rates that are insignificant relative to effective interest rates, (iii) contingent consideration payments made after a business combination, (iv) proceeds from settlement of insurance claims, (v) proceeds from the settlement of corporate-owned life insurance and bank-owned life insurance policies, (vi) distributions received from equity method investees, (vii) beneficial interests in securitization transactions and (viii) separately identifiable cash flows and application of the predominance principle. The new guidance was effective for the Company in the first quarter of fiscal year 2018. The adoption of this standard did not have a material impact on the Company's consolidated financial statements. Accounting Standards Recently Issued But Not Yet Adopted by the Company In August 2018, the FASB issued amended guidance to simplify fair value measurement disclosure requirements. The new provisions eliminate the requirements to disclose (1) transfers between Level 1 and Level 2 of the fair value hierarchy, (2) policies related to valuation processes and the timing of transfers between levels of the fair value hierarchy, and (3) net asset value disclosure of estimates of timing of future liquidity events. The FASB also modified disclosure requirements of Level 3 fair value measurements. This guidance is effective for annual periods beginning after December 15, 2019, which will be the Company's fiscal year 2020, with early adoption permitted. The adoption of this standard is not expected to have a material impact on the Company's consolidated financial statements. In January 2017, the FASB issued amended authoritative guidance to simplify and reduce the cost and complexity of the goodwill impairment test. The new provisions eliminate step 2 from the goodwill impairment test and shifts the concept of impairment from a measure of loss when comparing the implied fair value of goodwill to its carrying amount to comparing the fair value of a reporting unit with its carrying amount. The FASB also eliminated the requirements for any reporting unit with a zero or negative carrying amount to perform a qualitative assessment or step 2 of the goodwill impairment test. The new guidance does not amend the optional qualitative assessment of goodwill impairment. This guidance is effective for annual periods beginning after December 15, 2019, which will be the Company's fiscal year 2020, with early adoption permitted. The adoption of this standard is not expected to have a material impact on the Company's consolidated financial statements. In February 2016, the FASB issued amended authoritative guidance on accounting for leases. The new provisions require that a lessee of operating leases recognize, in the statement of financial position, a liability to make lease payments (the lease liability) and a right-of-use asset representing its right to use the underlying asset for the lease term. The lease liability will be equal to the present value of lease payments, with the right-of-use asset based upon the lease liability. The classification criteria for distinguishing between finance (or capital) leases and operating leases are substantially similar to the previous lease guidance, but with no explicit bright lines. As such, operating leases will result in straight-line rent expense similar to current practice. For short term leases (term of 12 months or less), a lessee is permitted to make an accounting election not to recognize lease assets and lease liabilities, which would generally result in lease expense being recognized on a straight-line basis over the lease term. This guidance applies to all entities and is effective for annual periods beginning after December 15, 2018, which will be the Company's fiscal year 2019, with early adoption permitted. The Company is currently evaluating the impact this guidance will have on its consolidated financial statements and disclosures and expects that this adoption will result in a material increase in the assets and liabilities on its consolidated balance sheets, primarily related to leases of facilities. The Company is in the process of cataloging its existing lease contracts and implementing changes to the systems, related processes and controls. The Company is planning to elect the several practical expedients upon transition, including retaining the lease classification for any leases that existed prior to adoption of the standard and the application date to be the beginning of the adoption period, which is January 1, 2019.

Revenue and Accounts Receivable

Revenue and Accounts Receivable	9 Months Ended
	Sep. 30, 2018
REVENUE AND ACCOUNTS RECEIVABLE [Abstract]
Revenue and Accounts receivable [Text Block]	REVENUE AND ACCOUNTS RECEIVABLE The Company's revenue is derived primarily from providing healthcare services to its patients. Revenues are recognized when services are provided to the patients at the amount that reflects the consideration to which the Company expects to be entitled from patients and third-party payors, including Medicaid, Medicare and insurers (private and Medicare replacement plans), in exchange for providing patient care. The healthcare services in transitional and skilled, home health and hospice patient contracts include routine services in exchange for a contractual agreed-upon amount or rate. Routine services are treated as a single performance obligation satisfied over time as services are rendered. As such, patient care services represent a bundle of services that are not capable of being distinct. Additionally, there may be ancillary services which are not included in the daily rates for routine services, but instead are treated as separate performance obligations satisfied at a point in time, if and when, those services are rendered. Revenue recognized from healthcare services are adjusted for estimates of variable consideration to arrive at the transaction price. The Company determines the transaction price based on contractually agreed-upon amounts or rate, adjusted for estimates of variable consideration. The Company uses the expected value method in determining the variable component that should be used to arrive at the transaction price, using contractual agreements and historical reimbursement experience within each payor type. The amount of variable consideration which is included in the transaction price may be constrained, and is included in the net revenue only to the extent that it is probable that a significant reversal in the amount of the cumulative revenue recognized will not occur in a future period. If actual amounts of consideration ultimately received differ from the Company’s estimates, the Company adjusts these estimates, which would affect net service revenue in the period such variances become known. Revenue from the Medicare and Medicaid programs accounted for 68.6% and 68.2% of the Company's revenue for the three and nine months ended September 30, 2018 , respectively, and 68.8% and 68.4% for the three and nine months ended September 30, 2017 . Settlement with Medicare and Medicaid payors for retroactive adjustments due to audits and reviews are considered variable consideration and are included in the determination of the estimated transaction price. These settlements are estimated based on the terms of the payment agreement with the payor, correspondence from the payor and the Company’s historical settlement activity. Consistent with healthcare industry practices, any changes to these revenue estimates are recorded in the period the change or adjustment becomes known based on final settlement. The Company recorded adjustments to revenue which were not material to the Company's consolidated revenue or Interim Financial Statements for the three and nine months ended September 30, 2018 and 2017 . Disaggregation of Revenue The Company disaggregates revenue from contracts with its patients by reportable operating segments and payors. The Company determines that disaggregating revenue into these categories achieves the disclosure objectives to depict how the nature, amount, timing and uncertainty of revenue and cash flows are affected by economic factors. A reconciliation of disaggregated revenue to segment revenue as well as revenue by payor is provided in Note 6, Business Segments . The Company’s service specific revenue recognition policies are as follows: Transitional and Skilled Nursing Revenue The Company’s revenue is derived primarily from providing long-term healthcare services to patients and is recognized on the date services are provided at amounts billable to individual patients, adjusted for estimates for variable consideration. For patients under reimbursement arrangements with third-party payors, including Medicaid, Medicare and private insurers, revenue is recorded based on contractually agreed-upon amounts or rate, adjusted for estimates for variable consideration, on a per patient, daily basis or as services are performed. Assisted and Independent Living Revenue The Company's assisted and independent living revenue consists of fees for basic housing and assisted living care. Accordingly, we record revenue when services are rendered on the date services are provided at amounts billable to individual residents. Residency agreements are generally for a term of 30 days, with resident fees billed monthly in advance. For patients under reimbursement arrangements with Medicaid, revenue is recorded based on contractually agreed-upon amounts or rates on a per resident, daily basis or as services are rendered. Home Health Revenue Medicare Revenue Net service revenue is recorded under the Medicare prospective payment system based on a 60-day episode payment rate that is subject to adjustment based on certain variables including, but not limited to: (a) an outlier payment if patient care was unusually costly; (b) a low utilization payment adjustment if the number of visits was fewer than five; (c) a partial payment if the patient transferred to another provider or the Company received a patient from another provider before completing the episode; (d) a payment adjustment based upon the level of therapy services required; (e) the number of episodes of care provided to a patient, regardless of whether the same home health provider provided care for the entire series of episodes; (f) changes in the base episode payments established by the Medicare program; (g) adjustments to the base episode payments for case mix and geographic wages; and (h) recoveries of overpayments. The Company makes adjustments to Medicare revenue on completed episodes to reflect differences between estimated and actual payment amounts, an inability to obtain appropriate billing documentation or authorizations acceptable to the payor and other reasons unrelated to credit risk. Revenue is also adjusted for estimates for variable consideration. Therefore, the Company believes that its reported net service revenue and patient accounts receivable will be the net amounts to be realized from Medicare for services rendered. In addition to revenue recognized on completed episodes, the Company also recognizes a portion of revenue associated with episodes in progress. Episodes in progress are 60-day episodes of care that begin during the reporting period, but were not completed as of the end of the period. As such, the Company estimates revenue and recognizes it on a daily basis. The primary factors underlying this estimate are the number of episodes in progress at the end of the reporting period, expected Medicare revenue per episode and its estimate of the average percentage complete based on visits performed. Non-Medicare Revenue Episodic Based Revenue - The Company recognizes revenue in a similar manner as it recognizes Medicare revenue for episodic-based rates that are paid by other insurance carriers, including Medicare Advantage programs; however, these rates can vary based upon the negotiated terms. Non-episodic Based Revenue - Revenue is recorded on an accrual basis based upon the date of service at amounts equal to its established or estimated per-visit rates, and adjusted for estimates for variable consideration, as applicable. Hospice Revenue Revenue is recorded on an accrual basis based upon the date of service at amounts equal to the estimated payment rates, net of estimates for variable consideration. The estimated payment rates are daily rates for each of the levels of care the Company delivers. The Company makes adjustments to revenue for an inability to obtain appropriate billing documentation or authorizations acceptable to the payor and other reasons, including credit risk. Additionally, as Medicare hospice revenue is subject to an inpatient cap limit and an overall payment cap, the Company monitors its provider numbers and estimates amounts due back to Medicare if a cap has been exceeded. The Company records these adjustments as a reduction to revenue and increases to other accrued liabilities. Impact of New Revenue Guidance on Financial Statement Line Items The following tables summarize the impact of adopting ASC 606 on the Company’s condensed consolidated statements of income for the three and nine months ended September 30, 2018 . There was no impact to the condensed consolidated balance sheet as of September 30, 2018 or condensed consolidated statements of cash flows for the nine months ended September 30, 2018 , as such, no pro forma information is provided in the Interim Financial Statements. Three Months Ended September 30, Nine Months Ended September 30, 2018 2017 2018 2017 Total revenue As Reported $ 514,364 $ 471,594 $ 1,502,884 $ 1,361,612 Adjustments 7,854 — 25,736 — Pro forma as if the previous accounting guidance was in effect $ 522,218 $ 471,594 $ 1,528,620 $ 1,361,612 Cost of Services: As Reported $ 413,723 $ 381,544 $ 1,200,098 $ 1,103,976 Adjustments 7,854 — 25,736 — Pro forma as if the previous accounting guidance was in effect $ 421,577 $ 381,544 $ 1,225,834 $ 1,103,976 Total Expense: As Reported $ 485,077 $ 446,035 $ 1,408,843 $ 1,306,470 Adjustments 7,854 — 25,736 — Pro forma as if the previous accounting guidance was in effect $ 492,931 $ 446,035 $ 1,434,579 $ 1,306,470 The majority of what was previously presented as bad debt expense under operating expenses has been incorporated as an implicit price concession factored into the calculation of net revenues, as shown in the "Adjustments" line in the table above. Subsequent material events that alter the payor's ability to pay are recorded as bad debt expense. The Company's bad debt expense and bad debt as a percent of total revenue was $1,128 and 0.2% , and $2,101 and 0.1% for the three and nine months ended September 30, 2018 , respectively, and $7,288 and 1.5% , and $21,934 and 1.6% , for the three and nine months ended September 30, 2017 , respectively. Prior period results reflect reclassifications, for comparative purposes, related to the adoption of ASC 606, for the presentation of the Company’s assisted and independent living revenue. Historically, the Company only presented total revenue for all revenue services. This reclassification had no effect on the reported results of operations. Revenue for the three and nine months ended September 30, 2018 and 2017 is summarized in the following tables: Three Months Ended September 30, 2018 2018 Pro Forma (2) 2017 Revenue % of Revenue Revenue % of Revenue Revenue % of Revenue Medicaid $ 188,486 36.6 % $ 190,892 36.6 % $ 169,100 35.9 % Medicare 133,554 26.0 134,670 25.8 127,348 27.0 Medicaid — skilled 30,684 6.0 31,121 6.0 27,737 5.9 Total Medicaid and Medicare 352,724 68.6 356,683 68.4 324,185 68.8 Managed care 80,196 15.6 82,081 15.6 74,723 15.8 Private and other payors (1) 81,444 15.8 83,454 16.0 72,686 15.4 Revenue $ 514,364 100.0 % $ 522,218 100.0 % $ 471,594 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended September 30, 2018 and 2017. (2) The 2018 pro forma results reflect balances assuming previous accounting guidance was still in effect. Nine Months Ended September 30, 2018 2018 Pro Forma (2) 2017 Revenue % of Revenue Revenue % of Revenue Revenue % of Revenue Medicaid $ 529,280 35.2 % $ 537,890 35.2 % $ 470,008 34.5 % Medicare 409,681 27.3 413,078 27.0 385,419 28.3 Medicaid — skilled 86,024 5.7 87,594 5.7 75,667 5.6 Total Medicaid and Medicare 1,024,985 68.2 1,038,562 67.9 931,094 68.4 Managed care 244,062 16.2 249,712 16.3 225,210 16.5 Private and other payors (1) 233,837 15.6 240,346 15.8 205,308 15.1 Revenue $ 1,502,884 100.0 % $ 1,528,620 100.0 % $ 1,361,612 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2018 and 2017. (2) The 2018 pro forma results reflect balances assuming previous accounting guidance was still in effect. Balance Sheet Impact Included in the Company’s condensed consolidated balance sheet are contract assets, comprised of billed accounts receivable and unbilled receivables, which are the result of the timing of revenue recognition, billings and cash collections, as well as, contract liabilities, which primarily represent payments the Company receives in advance of services provided. The Company had no material contract liabilities, or activity as of and for the three and nine months ended September 30, 2018 , related to its transitional and skilled services, and home health and hospice services segments. Accounts receivable as of September 30, 2018 and December 31, 2017 is summarized in the following table: September 30, December 31, 2018 2018 Pro Forma (1) 2017 Medicaid $ 101,310 $ 117,227 $ 119,441 Managed care 53,825 67,150 68,930 Medicare 47,367 54,428 55,667 Private and other payors 61,436 72,516 64,991 263,938 311,321 309,029 Less: allowance for doubtful accounts (2,484 ) (49,867 ) (43,961 ) Accounts receivable, net $ 261,454 $ 261,454 $ 265,068 (1) The 2018 pro forma results reflect balances assuming previous accounting guidance was still in effect. Practical Expedients and Exemptions As the Company’s contracts with its patients have an original duration of one year or less, the Company uses the practical expedient applicable to its contracts and does not consider the time value of money. Further, because of the short duration of these contracts, the Company has not disclosed the transaction price for the remaining performance obligations as of the end of each reporting period or when the Company expects to recognize this revenue. In addition, the Company has applied the practical expedient provided by ASC 340, Other Assets and Deferred Costs , and all incremental customer contract acquisition costs are expensed as they are incurred because the amortization period would have been one year or less.

Computation of Net Income Per C

Computation of Net Income Per Common Share	9 Months Ended
	Sep. 30, 2018
COMPUTATION OF NET INCOME PER COMMON SHARE [Abstract]
Earnings Per Share [Text Block]	COMPUTATION OF NET INCOME PER COMMON SHARE Basic net income per share is computed by dividing income from continuing operations attributable to The Ensign Group, Inc. stockholders by the weighted average number of outstanding common shares for the period. The computation of diluted net income per share is similar to the computation of basic net income per share except that the denominator is increased to include the number of additional common shares that would have been outstanding if the dilutive potential common shares had been issued. A reconciliation of the numerator and denominator used in the calculation of basic net income per common share follows: Three Months Ended September 30, Nine Months Ended September 30, 2018 2017 2018 2017 Numerator: Net income $ 20,350 $ 14,275 $ 65,969 $ 29,611 Less: net (loss)/income attributable to noncontrolling interests (511 ) 63 (35 ) 342 Net income attributable to The Ensign Group, Inc. $ 20,861 $ 14,212 $ 66,004 $ 29,269 Denominator: Weighted average shares outstanding for basic net income per share 52,139 50,911 51,870 50,795 Basic net income per common share attributable to The Ensign Group, Inc. $ 0.40 $ 0.28 $ 1.27 $ 0.58 A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows: Three Months Ended September 30, Nine Months Ended September 30, 2018 2017 2018 2017 Numerator: Net income $ 20,350 $ 14,275 $ 65,969 $ 29,611 Less: net (loss)/income attributable to noncontrolling interests (511 ) 63 (35 ) 342 Net income attributable to The Ensign Group, Inc. $ 20,861 $ 14,212 $ 66,004 $ 29,269 Denominator: Weighted average common shares outstanding 52,139 50,911 51,870 50,795 Plus: incremental shares from assumed conversion (1) 2,493 1,917 2,306 1,879 Adjusted weighted average common shares outstanding 54,632 52,828 54,176 52,674 Diluted net income per common share attributable to The Ensign Group, Inc. $ 0.38 $ 0.27 $ 1.22 $ 0.56 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 244 and 163 for the three and nine months ended September 30, 2018 , respectively and 1,352 and 1,326 for the three and nine months ended September 30, 2017 , respectively.

Fair Value Measurements

Fair Value Measurements	9 Months Ended
	Sep. 30, 2018
Fair Value Disclosures [Abstract]
Fair Value Disclosures [Text Block]	FAIR VALUE MEASUREMENTS Fair value measurements are based on a three-tier hierarchy that prioritizes the inputs used to measure fair value. These tiers include: Level 1, defined as observable inputs such as quoted market prices in active markets; Level 2, defined as inputs other than quoted prices included within Level 1 that are observable for the asset or liability, either directly or indirectly; and Level 3, defined as unobservable inputs for which little or no market data exists, therefore requiring an entity to develop its own assumptions. The following table summarizes the financial assets and liabilities measured at fair value on a recurring basis as of September 30, 2018 and December 31, 2017 : September 30, 2018 December 31, 2017 Level 1 Level 2 Level 3 Level 1 Level 2 Level 3 Cash and cash equivalents $ 45,657 $ — $ — $ 42,337 $ — $ — The Company's non-financial assets, which include long-lived assets, including goodwill, intangible assets and property and equipment, are not required to be measured at fair value on a recurring basis. However, on a periodic basis, or whenever events or changes in circumstances indicate that their carrying value may not be recoverable, the Company assesses its long-lived assets for impairment. When impairment has occurred, such long-lived assets are written down to fair value. See Note 2, Summary of Significant Accounting Policies for further discussion of the Company's significant accounting policies. Debt Security Investments - Held to Maturity At September 30, 2018 and December 31, 2017 , the Company had approximately $42,175 and $41,777 , respectively, in debt security investments which were classified as held to maturity and carried at amortized cost. The carrying value of the debt securities approximates fair value based on Level 1. The Company has the intent and ability to hold these debt securities to maturity. Further, as of September 30, 2018 , the debt security investments were held in AA, A and BBB rated debt securities.

Business Segments

Business Segments	9 Months Ended
	Sep. 30, 2018
Segment Reporting [Abstract]
Segment Reporting Disclosure [Text Block]	BUSINESS SEGMENTS The Company has three reportable operating segments: (1) transitional and skilled services, which includes the operation of skilled nursing facilities; (2) assisted and independent living services, which includes the operation of assisted and independent living facilities; and (3) home health and hospice services, which includes the Company's home health, home care and hospice businesses. The Company's Chief Executive Officer, who is its chief operating decision maker, or CODM, reviews financial information at the operating segment level. The Company also reports an “all other” category that includes results from its mobile diagnostics and other ancillary operations. These operations are neither significant individually nor in aggregate, and therefore do not constitute a reportable segment. The reporting segments are business units that offer different services and are managed separately to provide greater visibility into those operations. As of September 30, 2018 , transitional and skilled services included 163 wholly-owned affiliated skilled nursing operations and 22 campuses that provide skilled nursing and rehabilitative care services and assisted and independent living services. The Company provided room and board and social services through 51 wholly-owned affiliated assisted and independent living operations and 22 campuses as mentioned above. Home health, home care and hospice services were provided to patients through 49 affiliated agencies. As of September 30, 2018 , the Company held majority membership interests in other ancillary operations, which operating results are included in the "all other" category. The Company evaluates performance and allocates capital resources to each segment based on an operating model that is designed to maximize the quality of care provided and profitability. General and administrative expenses are not allocated to any segment for purposes of determining segment profit or loss, and are included in the "all other" category in the selected segment financial data that follows. The accounting policies of the reporting segments are the same as those described in Note 2 , Summary of Significant Accounting Policies. The Company's CODM does not review assets by segment in his resource allocation and therefore assets by segment are not disclosed below. Segment revenues by major payor source were as follows: Three Months Ended September 30, 2018 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 176,009 $ 9,284 $ 3,193 $ — $ 188,486 36.6 % Medicare 103,506 — 30,048 — 133,554 26.0 Medicaid-skilled 30,684 — — — 30,684 6.0 Subtotal 310,199 9,284 33,241 — 352,724 68.6 Managed care 73,897 — 6,299 — 80,196 15.6 Private and other 37,668 28,774 4,297 10,705 (1) 81,444 15.8 Total revenue $ 421,764 $ 38,058 $ 43,837 $ 10,705 $ 514,364 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended September 30, 2018. The following pro forma table demonstrates the impact of adopting ASC 606 on the Company's segment revenues by major payor source for the three months ended September 30, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Three Months Ended September 30, 2018 (Pro forma) Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 178,323 $ 9,284 $ 3,285 $ — $ 190,892 36.6 % Medicare 104,392 — 30,278 — 134,670 25.8 Medicaid-skilled 31,121 — — — 31,121 6.0 Subtotal 313,836 9,284 33,563 — 356,683 68.4 Managed care 75,677 — 6,404 — 82,081 15.6 Private and other 39,675 28,774 4,300 10,705 (1) 83,454 16.0 Total revenue $ 429,188 $ 38,058 $ 44,267 $ 10,705 $ 522,218 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended September 30, 2018. Three Months Ended September 30, 2017 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 158,099 $ 8,083 $ 2,918 $ — $ 169,100 35.9 % Medicare 102,449 — 24,899 — 127,348 27.0 Medicaid-skilled 27,737 — — — 27,737 5.9 Subtotal 288,285 8,083 27,817 — 324,185 68.8 Managed care 69,335 — 5,388 — 74,723 15.8 Private and other 36,501 27,372 2,760 6,053 (1) 72,686 15.4 Total revenue $ 394,121 $ 35,455 $ 35,965 $ 6,053 $ 471,594 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended September 30, 2017. Nine Months Ended September 30, 2018 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 494,104 $ 26,225 $ 8,951 $ — $ 529,280 35.2 % Medicare 323,696 — 85,985 — 409,681 27.3 Medicaid-skilled 86,024 — — — 86,024 5.7 Subtotal 903,824 26,225 94,936 — 1,024,985 68.2 Managed care 225,865 — 18,197 — 244,062 16.2 Private and other 107,609 85,110 11,711 29,407 (1) 233,837 15.6 Total revenue $ 1,237,298 $ 111,335 $ 124,844 $ 29,407 $ 1,502,884 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2018. The following pro forma table demonstrates the impact of adopting ASC 606 on the Company's segment revenues by major payor source for the nine months ended September 30, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Nine Months Ended September 30, 2018 (Pro forma) Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 502,415 $ 26,225 $ 9,250 $ — $ 537,890 35.2 % Medicare 326,389 — 86,689 — 413,078 27.0 Medicaid-skilled 87,594 — — — 87,594 5.7 Subtotal 916,398 26,225 95,939 — 1,038,562 67.9 Managed care 231,025 — 18,687 — 249,712 16.3 Private and other 114,047 85,110 11,782 29,407 (1) 240,346 15.8 Total revenue $ 1,261,470 $ 111,335 $ 126,408 $ 29,407 $ 1,528,620 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2018. Nine Months Ended September 30, 2017 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 439,757 $ 22,322 $ 7,929 $ — $ 470,008 34.5 % Medicare 314,827 — 70,592 — 385,419 28.3 Medicaid-skilled 75,667 — — — 75,667 5.6 Subtotal 830,251 22,322 78,521 — 931,094 68.4 Managed care 208,957 — 16,253 — 225,210 16.5 Private and other 102,469 78,488 7,945 16,406 (1) 205,308 15.1 Total revenue $ 1,141,677 $ 100,810 $ 102,719 $ 16,406 $ 1,361,612 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2017. The following table sets forth selected financial data consolidated by business segment: Three Months Ended September 30, 2018 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 421,764 $ — $ 43,837 $ 10,705 $ — $ 476,306 Assisted and independent living revenue — 38,058 — — — 38,058 Revenue from external customers $ 421,764 $ 38,058 $ 43,837 $ 10,705 $ — $ 514,364 Intersegment revenue (1) 857 — — 851 (1,708 ) — Total revenue $ 422,621 $ 38,058 $ 43,837 $ 11,556 $ (1,708 ) $ 514,364 Segment income (loss) (2) $ 46,350 $ 4,733 $ 7,297 $ (29,093 ) $ — $ 29,287 Interest expense, net of interest income $ (3,522 ) Income before provision for income taxes $ 25,765 Depreciation and amortization $ 8,061 $ 1,902 $ 263 $ 1,676 $ — $ 11,902 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense and goodwill and intangible assets impairment for the three months ended September 30, 2018 are included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. The following pro forma table demonstrates the impact of adopting ASC 606 on the Company's selected financial data consolidated by business segment for the three months ended September 30, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Three Months Ended September 30, 2018 (Pro forma) Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 429,188 $ — $ 44,267 $ 10,705 $ — $ 484,160 Assisted and independent living revenue — 38,058 — — — 38,058 Revenue from external customers $ 429,188 $ 38,058 $ 44,267 $ 10,705 $ — $ 522,218 Intersegment revenue (1) 857 — — 851 (1,708 ) — Total revenue $ 430,045 $ 38,058 $ 44,267 $ 11,556 $ (1,708 ) $ 522,218 Segment income (loss) (2) $ 46,350 $ 4,733 $ 7,297 $ (29,093 ) $ — $ 29,287 Interest expense, net of interest income $ (3,522 ) Income before provision for income taxes $ 25,765 Depreciation and amortization $ 8,061 $ 1,902 $ 263 $ 1,676 $ — $ 11,902 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense and goodwill and intangible assets impairment for the three months ended September 30, 2018 are included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. Three Months Ended September 30, 2017 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 394,121 $ — $ 35,965 $ 6,053 $ — $ 436,139 Assisted and independent living revenue — $ 35,455 $ — $ — — 35,455 Revenue from external customers $ 394,121 $ 35,455 $ 35,965 $ 6,053 $ — $ 471,594 Intersegment revenue (1) 739 — — 583 (1,322 ) — Total revenue $ 394,860 $ 35,455 $ 35,965 $ 6,636 $ (1,322 ) $ 471,594 Segment income (loss) (2) $ 36,868 $ 4,342 $ 4,695 $ (20,346 ) $ — $ 25,559 Interest expense, net of interest income $ (3,124 ) Income before provision for income taxes $ 22,435 Depreciation and amortization $ 7,881 $ 1,572 $ 235 $ 1,760 $ — $ 11,448 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense during the three months ended September 30, 2017 is included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. Nine Months Ended September 30, 2018 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,237,298 $ — $ 124,844 $ 29,407 $ — $ 1,391,549 Assisted and independent living revenue — $ 111,335 $ — $ — — 111,335 Revenue from external customers $ 1,237,298 $ 111,335 $ 124,844 $ 29,407 $ — $ 1,502,884 Intersegment revenue (1) 2,191 — — 3,045 (5,236 ) — Total revenue $ 1,239,489 $ 111,335 $ 124,844 $ 32,452 $ (5,236 ) $ 1,502,884 Segment income (loss) (2) $ 135,755 $ 14,361 $ 19,623 $ (75,698 ) $ — $ 94,041 Interest expense, net of interest income $ (9,994 ) Income before provision for income taxes $ 84,047 Depreciation and amortization $ 23,571 $ 5,362 $ 789 $ 5,423 $ — $ 35,145 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense, the return of unclaimed class action settlement and goodwill and intangible assets impairment for the nine months ended September 30, 2018, are included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. The following pro forma table demonstrates the impact of adopting ASC 606 on the Company's selected financial data consolidated by business segment for the nine months ended September 30, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Nine Months Ended September 30, 2018 (Pro forma) Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,261,470 $ — $ 126,408 $ 29,407 $ — $ 1,417,285 Assisted and independent living revenue — 111,335 — — — 111,335 Revenue from external customers $ 1,261,470 $ 111,335 $ 126,408 $ 29,407 $ — $ 1,528,620 Intersegment revenue (1) 2,191 — — 3,045 (5,236 ) — Total revenue $ 1,263,661 $ 111,335 $ 126,408 $ 32,452 $ (5,236 ) $ 1,528,620 Segment income (loss) (2) $ 135,755 $ 14,361 $ 19,623 $ (75,698 ) $ — $ 94,041 Interest expense, net of interest income $ (9,994 ) Income before provision for income taxes $ 84,047 Depreciation and amortization $ 23,571 $ 5,362 $ 789 $ 5,423 $ — $ 35,145 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense, the return of unclaimed class action settlement and goodwill and intangible assets impairment for the nine months ended September 30, 2018, are included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. Nine Months Ended September 30, 2017 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,141,677 $ — $ 102,719 $ 16,406 $ — $ 1,260,802 Assisted and independent living revenue — $ 100,810 $ — $ — — 100,810 Revenue from external customers $ 1,141,677 $ 100,810 $ 102,719 $ 16,406 $ — $ 1,361,612 Intersegment revenue (1) 2,114 — — 2,196 (4,310 ) — Total revenue $ 1,143,791 $ 100,810 $ 102,719 $ 18,602 $ (4,310 ) $ 1,361,612 Segment income (loss) (2) $ 100,362 $ 12,438 $ 13,912 $ (71,570 ) $ — $ 55,142 Interest expense, net of interest income $ (9,044 ) Income before provision for income taxes $ 46,098 Depreciation and amortization $ 22,038 $ 4,687 $ 700 $ 5,287 $ — $ 32,712 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense, including charges related to class action lawsuit during the nine months ended September 30, 2017, is included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. The Company's transitional and skilled services segment income for the nine months ended September 30, 2017 included continued obligations under the lease related to closed operations, lease termination costs and related closing expenses of $4,017 . This amount includes the present value of future rental payments of approximately $2,715 and long-lived asset impairment of $111 . See Note 16, Leases for further detail. Also included in the nine months ended September 30, 2017 is the loss recovery of $1,286 related to a facility that was closed in the prior year.

Acquisitions

Acquisitions	9 Months Ended
	Sep. 30, 2018
Business Combinations [Abstract]
Business Combination Disclosure [Text Block]	ACQUISITIONS The acquisition focus of the subsidiaries is to purchase or lease operations that are complementary to the current affiliated operations, accretive to the business or otherwise advance the Company's strategy. The results of all operating subsidiaries are included in the accompanying Interim Financial Statements subsequent to the date of acquisition. Acquisitions are accounted for using the acquisition method of accounting. The Company's affiliated operations also enter into long-term leases that may include options to purchase the facilities. As a result, from time to time, the affiliated operations will acquire facilities that has been operating under third-party leases. On January 1, 2018, the Company adopted Accounting Standards Codification Topic 805, Clarifying the Definition of a Business (ASC 805) prospectively, which changes the definition of a business to assist entities with evaluating when a set of transferred assets and activities is deemed to be a business. Determining whether a transferred set constitutes a business is important because the accounting for a business combination differs from that of an asset acquisition. The definition of a business also affects the accounting for dispositions. Under the new standard, when substantially all of the fair value of assets acquired is concentrated in a single asset, or a group of similar assets, the assets acquired would not represent a business and business combination accounting would not be required. The new standard may result in more transactions being accounted for as asset acquisitions rather than business combinations. The Company anticipates that future acquisitions will be classified as a mixture of business and asset acquisitions under the new guidance. During the nine months ended September 30, 2018 , the Company expanded its operations through a combination of a long-term lease and real estate purchases, with the addition of three stand-alone skilled nursing operations, two stand-alone assisted living operations, one campus operation, two home health agencies, one hospice agency and one home care agency. The Company did not acquire any material assets or assume any liabilities other than tenant's post-assumption rights and obligations under the long-term lease. The addition of these operations added 468 operational skilled nursing beds and 218 assisted living units to be operated by the Company's affiliated operating subsidiaries. In addition, with the stand-alone skilled nursing operation acquisition, the Company acquired real estate that included an adjacent long-term acute care hospital that is currently operated by a third party under a lease arrangement. The Company entered into a separate operations transfer agreement with the prior operator as part of each transaction. In addition, in June 2018, the Company acquired an office building for a purchase price of $30,959 to accommodate its growing Service Center team. The aggregate purchase price for these acquisitions during the nine months ended September 30, 2018 was $59,484 . The fair value of assets for nine of the acquisitions was concentrated in property and equipment and as such, these transactions were classified as asset acquisitions in accordance with ASC 805. The fair value of assets for the remaining two acquisitions was concentrated in goodwill and as such, these transactions were classified as business acquisitions in accordance with ASC 805. The purchase price for the two business combinations was $1,625 , mainly consisted of goodwill and indefinite-lived intangible assets of $1,609 . During the nine months ended September 30, 2017 , the Company acquired operations for an aggregate purchase price of $84,063 , consisting of land of $9,732 , building and improvements of $52,805 , equipment of $4,091 , goodwill of $10,563 , other indefinite-lived intangible assets of $5,808 , assembled occupancy of $772 and other liabilities assumed of $292 . Subsequent to September 30, 2018 , the Company acquired one stand-alone assisted living operation for a purchase price of $5,250 . The addition of these operations added 53 assisted living units to be operated by the Company's operating subsidiaries. As of the date of this report, the preliminary allocation of the purchase price for the acquisitions acquired subsequent to September 30, 2018 were not completed as necessary valuation information was not yet available. As such, the determination whether these acquisitions should be classified as business combinations or asset acquisitions under ASC 805 could change.

Property and Equipment

Property and Equipment	9 Months Ended
	Sep. 30, 2018
Property, Plant and Equipment [Abstract]
Property, Plant and Equipment Disclosure [Text Block]	PROPERTY AND EQUIPMENT— Net Property and equipment, net consist of the following: September 30, 2018 December 31, 2017 Land $ 58,579 $ 49,081 Buildings and improvements 390,529 342,641 Equipment 198,568 181,530 Furniture and fixtures 5,410 5,244 Leasehold improvements 108,821 97,221 Construction in progress 8,001 5,460 769,908 681,177 Less: accumulated depreciation (176,820 ) (144,093 ) Property and equipment, net $ 593,088 $ 537,084 See Note 7, Acquisitions for information on acquisitions during the nine months ended September 30, 2018 .

Intangible Assets - Net

Intangible Assets - Net	9 Months Ended
	Sep. 30, 2018
Intangible Assets, Net (Excluding Goodwill) [Abstract]
Intangible Assets Disclosure [Text Block]	INTANGIBLE ASSETS — Net Weighted Average Life (Years) September 30, 2018 December 31, 2017 Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Lease acquisition costs 14.5 $ 843 $ (191 ) $ 652 $ 483 $ (99 ) $ 384 Favorable leases 29.7 35,650 (8,168 ) 27,482 35,116 (6,568 ) 28,548 Assembled occupancy 0.4 2,786 (2,778 ) 8 2,659 (2,631 ) 28 Facility trade name 30.0 733 (311 ) 422 733 (293 ) 440 Customer relationships 18.2 4,670 (1,614 ) 3,056 4,933 (1,530 ) 3,403 Total $ 44,682 $ (13,062 ) $ 31,620 $ 43,924 $ (11,121 ) $ 32,803 Amortization expense was $761 and $2,067 for the three and nine months ended September 30, 2018 , respectively, and $979 and $2,280 for the three and nine months ended September 30, 2017 , respectively. Estimated amortization expense for each of the years ending December 31 is as follows: Year Amount 2018 (remainder) $ 686 2019 2,711 2020 1,616 2021 1,454 2022 1,450 2023 1,389 Thereafter 22,314 $ 31,620

Goodwill and Other Indefinite-L

Goodwill and Other Indefinite-Lived Intangible Assets	9 Months Ended
	Sep. 30, 2018
Indefinite-Lived Intangible Assets (Including Goodwill) [Abstract]
Goodwill and Other Indefinite-Lived Intangibles [Text Block]	GOODWILL AND OTHER INDEFINITE-LIVED INTANGIBLE ASSETS The Company tests goodwill during the fourth quarter of each year or more often if events or circumstances indicate there may be impairment. The Company performs its analysis for each reporting unit that constitutes a business for which discrete financial information is produced and reviewed by operating segment management and provides services that are distinct from the other components of the operating segment, in accordance with the provisions of Accounting Standards Codification topic 350, Intangibles—Goodwill and Other (ASC 350). This guidance provides the option to first assess qualitative factors to determine whether it is more likely than not that the fair value of a reporting unit is less than its carrying value, a "Step 0" analysis. If, based on a review of qualitative factors, it is more likely than not that the fair value of a reporting unit is less than its carrying value, the Company performs "Step 1" of the traditional two-step goodwill impairment test by comparing the net assets of each reporting unit to their respective fair values. The Company determines the estimated fair value of each reporting unit using a discounted cash flow analysis. In the event a unit's net assets exceed its fair value, an implied fair value of goodwill must be determined by assigning the unit's fair value to each asset and liability of the unit. The excess of the fair value of the reporting unit over the amounts assigned to its assets and liabilities is the implied fair value of goodwill. An impairment loss is measured by the difference between the goodwill carrying value and the implied fair value. The following table represents activity in goodwill by segment as of and for the nine months ended September 30, 2018 : Goodwill Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total January 1, 2018 $ 45,486 $ 3,958 $ 24,322 $ 7,296 $ 81,062 Additions — — 1,007 — 1,007 Purchase price adjustment — — 56 — 56 Impairments $ — $ — $ — (3,513 ) (3,513 ) September 30, 2018 $ 45,486 $ 3,958 $ 25,385 $ 3,783 $ 78,612 The Company recorded an impairment charge to goodwill and intangible assets of $3,653 for the three and nine months ended September 30, 2018 on one of its ancillary operations, which mainly consists of $3,513 of goodwill impairment. Management determined that the improvements in operations and related forecasted cash flows were slower than anticipated at the time of acquisition, resulting in the impairment to goodwill. The Company did not record any impairment charge to goodwill and other intangible assets during the three and nine months ended September 30, 2017 . The Company anticipates that the majority of total goodwill recognized will be fully deductible for tax purposes as of September 30, 2018 . See further discussion of goodwill acquired at Note 7, Acquisitions . During the nine months ended September 30, 2018 , the Company recorded $952 in Medicare and Medicaid licenses indefinite-lived intangible assets as part of its acquisitions. Other indefinite-lived intangible assets consists of the following: September 30, 2018 December 31, 2017 Trade name $ 1,181 $ 1,181 Medicare and Medicaid licenses 25,020 24,068 $ 26,201 $ 25,249

Restricted and Other Assets

Restricted and Other Assets	9 Months Ended
	Sep. 30, 2018
Other Assets [Abstract]
Other Assets Disclosure [Text Block]	RESTRICTED AND OTHER ASSETS Restricted and other assets consist of the following: September 30, 2018 December 31, 2017 Debt issuance costs, net $ 2,118 $ 2,799 Long-term insurance losses recoverable asset 6,451 5,394 Deposits with landlords 8,788 5,981 Capital improvement reserves with landlords and lenders 2,999 2,327 Note receivable from sale of ancillary business 103 — Restricted and other assets $ 20,459 $ 16,501 Included in restricted and other assets as of September 30, 2018 , are anticipated insurance recoveries related to the Company's workers' compensation, general and professional liability claims that are recorded on a gross rather than net basis in accordance with an Accounting Standards Update issued by the FASB.

Other Accrued Liabilities

Other Accrued Liabilities	9 Months Ended
	Sep. 30, 2018
Accrued Liabilities [Abstract]
Other Liabilities Disclosure [Text Block]	OTHER ACCRUED LIABILITIES Other accrued liabilities consist of the following: September 30, 2018 December 31, 2017 Quality assurance fee $ 5,070 $ 4,864 Refunds payable 25,347 21,661 Deferred revenue 9,271 7,066 Cash held in trust for patients 2,848 2,609 Resident deposits 6,754 6,574 Dividends payable 2,377 2,328 Property taxes 11,832 10,088 Other 10,798 8,625 Other accrued liabilities $ 74,297 $ 63,815 Quality assurance fee represents 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. Deferred revenue occurs 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 accompanying condensed consolidated balance sheets.

Income Taxes

Income Taxes	9 Months Ended
	Sep. 30, 2018
Income Tax Disclosure [Abstract]
Income Tax Disclosure [Text Block]	INCOME TAXES Effective January 1, 2018, the Tax Act reduced the corporate rate from 35.0% to 21.0%. The final impact of U.S. tax reform may differ, possibly materially, due to factors such as changes in interpretations of the Tax Act, any legislative action to address uncertainties that arise because of the Tax Act, and additional guidance that may be issued by the U.S. government. The Company has adopted ASU 2018-05, Income Taxes (Topic 740): Amendments to SEC Paragraph Pursuant to SEC Staff Accounting Bulletin No. 118 , which allows the company to record provisional amounts during the period of enactment. Any change to the provisional amounts will be recorded as an adjustment to the provision for income taxes in the period the amounts are determined. The measurement period ends when the company has obtained, prepared and analyzed the information necessary to finalize its accounting, but cannot extend beyond one year of the enactment date. As of September 30, 2018 the Company has not completed its accounting for the tax effects of the enactment of the Tax Act. The Company continues to analyze certain aspects of the Tax Act and refine the estimates of its calculations, which could potentially impact the measurement of the Company's tax balances. In addition, these estimates may be impacted as the Company further analyzes available tax accounting methods and elections, and state tax conformity to the federal tax changes and guidance issued by regulatory bodies that provide interpretive guidance of the Tax Act. Any adjustments to the provisional amounts will be recognized as a component of the provision for income taxes in period in which such adjustment are determined within the annual period following the enactment of the Tax Act. In the three and nine months ended September 30, 2018, there were no adjustments to the provisional amounts recorded in the period ended December 31, 2017. The Company filed for a non-automatic change in accounting method under the Internal Revenue Service (“IRS”) tangible property regulations. Under the change in accounting method, the Company is permitted to deduct the costs of certain asset improvements that were previously being capitalized and depreciated for tax purposes on its income tax return. The Company estimates the non-automatic change in accounting method will be an income tax benefit. This impact has not been reported in the financial statements as of September 30, 2018 as it is a non-automatic change and is subject to review and approval by the IRS. The Company will continue to work with the IRS on the filing requirements on the accounting method change. The Company recorded income tax expense of $18,078 for the nine months ended September 30, 2018, or 21.5% of earnings before income taxes, compared to 35.8% for the nine month period ended September 30, 2017. The Company’s effective tax rate for three and nine months ended September 30, 2018 includes the benefits of the lower federal income tax rate of 21.0% and stock-based compensation excess benefit; however, these benefits are offset by a return of unclaimed class action settlement funds and various non-deductible expenses, including the impact of non-deductible compensation from the enactment of the Tax Act. The Company is not currently under examination by any major income tax jurisdiction. During 2018, the statutes of limitations will lapse on the Company's 2014 Federal tax year and certain 2013 and 2014 state tax years. The Company does not believe the Federal or state statute lapses or any other event will significantly impact the balance of unrecognized tax benefits in the next twelve months. The net balance of unrecognized tax benefits was not material to the Interim Financial Statements for the nine months ended September 30, 2018 or 2017.

Debt

Debt	9 Months Ended
	Sep. 30, 2018
Debt Disclosure [Abstract]
Debt Disclosure [Text Block]	DEBT Long-term debt consists of the following: September 30, 2018 December 31, 2017 Term loan with SunTrust $ 135,000 $ 140,625 Revolving credit facility with SunTrust — 50,000 Mortgage loans and promissory note 123,591 125,394 258,591 316,019 Less: current maturities (10,080 ) (9,939 ) Less: debt issuance costs (2,907 ) (3,090 ) $ 245,604 $ 302,990 Credit Facility with a Lending Consortium Arranged by SunTrust The Company maintains a credit facility with a lending consortium arranged by SunTrust (as amended to date, the Credit Facility). The Company originally entered into the Credit Facility in an aggregate principal amount of $150,000 in May 2014. Under the Credit Facility, the Company could seek to obtain incremental revolving or term loans in an aggregate amount not to exceed $75,000 . The interest rates applicable to loans under the Credit Facility are, at the Company’s option, equal to either a base rate plus a margin ranging from 1.25% to 2.25% per annum or LIBOR plus a margin ranging from 2.25% to 3.25% per annum, based on the debt to Consolidated EBITDA ratio of the Company and its operating subsidiaries as defined in the agreement. In addition, the Company will pay a commitment fee on the unused portion of the commitments under the Credit Facility that will range from 0.30% to 0.50% per annum, depending on the debt to Consolidated EBITDA ratio of the Company and its operating subsidiaries. Loans made under the Credit Facility are not subject to interim amortization. The Company is not required to repay any loans under the Credit Facility prior to maturity, other than to the extent the outstanding borrowings exceed the aggregate commitments under the Credit Facility. On February 5, 2016, the Company amended its existing revolving credit facility to increase its aggregate principal amount available to $250,000 (the Amended Credit Facility). Under the credit facility, the Company may seek to obtain incremental revolving or term loans in an aggregate amount not to exceed $150,000 . The interest rates applicable to loans under the credit facility are, at the Company's option, equal to either a base rate plus a margin ranging from 0.75% to 1.75% per annum or LIBOR plus a margin ranging from 1.75% to 2.75% per annum, based on the Consolidated Total Net Debt to Consolidated EBITDA ratio (as defined in the agreement). In addition, the Company will pay a commitment fee on the unused portion of the commitments under the credit facility that will range from 0.30% to 0.50% per annum, depending on the Consolidated Total Net Debt to Consolidated EBITDA ratio of the Company and its subsidiaries. The Company is permitted to prepay all or any portion of the loans under the credit facility prior to maturity without premium or penalty, subject to reimbursement of any LIBOR breakage costs of the lenders. On July 19, 2016, the Company entered into the second amendment to the credit facility (Second Amended Credit Facility), which amended the existing credit agreement to increase the aggregate principal amount up to $450,000 . The Second Amended Credit Facility is comprised of a $300,000 revolving credit facility and a $150,000 term loan. Borrowings under the term loan portion of the Second Amended Credit Facility mature on February 5, 2021 and amortize in equal quarterly installments, in an aggregate annual amount equal to 5.0% per annum of the original principal amount. The interest rates and commitment fee applicable to the Second Amended Credit Facility are similar to the Amended Credit Facility discussed below. Except as set forth in the Second Amended Credit Facility, all other terms and conditions of the Amended Credit Facility remained in full force and effect as described below. The Credit Facility is guaranteed, jointly and severally, by certain of the Company’s wholly owned subsidiaries, and is secured by a pledge of stock of the Company's material operating subsidiaries as well as a first lien on substantially all of its personal property. The credit facility contains customary covenants that, among other things, restrict, subject to certain exceptions, the ability of the Company and its operating subsidiaries to grant liens on their assets, incur indebtedness, sell assets, make investments, engage in acquisitions, mergers or consolidations, amend certain material agreements and pay certain dividends and other restricted payments. Under the Credit Facility, the Company must comply with financial maintenance covenants to be tested quarterly, consisting of a maximum Consolidated Total Net Debt to consolidated EBITDA ratio (which shall be increased to 3.50 : 1.00 for the first fiscal quarter and the immediate following three fiscal quarters), and a minimum interest/rent coverage ratio (which cannot be below 1.50 : 1.00 ). The majority of lenders can require that the Company and its operating subsidiaries mortgage certain of its real property assets to secure the Amended Credit Facility if an event of default occurs, the Consolidated Total Net Debt to consolidated EBITDA ratio is above 2.75 : 1.00 for two consecutive fiscal quarters, or its liquidity is equal or less than 10% of the Aggregate Revolving Commitment Amount (as defined in the agreement) for ten consecutive business days, provided that such mortgages will no longer be required if the event of default is cured, the Consolidated Total Net Debt to consolidated EBITDA ratio is below 2.75 : 1.00 for two consecutive fiscal quarters, or its liquidity is above 10% of the Aggregate Revolving Commitment Amount (as defined in the agreement) or ninety consecutive days, as applicable. As of September 30, 2018 , the Company's operating subsidiaries had $135,000 outstanding on the term loan under the Credit Facility, of which $7,500 is classified as short-term and the remaining $127,500 is classified as long-term. The Company was in compliance with all loan covenants as of September 30, 2018 . As of October 29, 2018 , there was approximately $135,000 outstanding under the Credit Facility. Mortgage Loans and Promissory Note In December 2017, seventeen of the Company's subsidiaries entered into mortgage loans in the aggregate amount of $112,000 . The mortgage loans are insured with Department of Housing and Urban Development (HUD), which subjects these subsidiaries to HUD oversight and periodic inspections. The mortgage loans and note bear fixed interest rates of 3.3% per annum. Amounts borrowed under the mortgage loans may be prepaid, subject to prepayment fees of the principal balance on the date of prepayment. During the first three years, the prepayment fee is 10% and is reduced by 3% in the fourth year of the loan, and reduced by 1.0% per year for years five through ten of the loan. There is no prepayment penalty after year ten . The terms of the mortgage loans are 30 to 35 -years. The borrowings were arranged by Lancaster Pollard Mortgage Company, LLC, and insured by HUD. Loan proceeds were used to pay down previously drawn amounts on Ensign's revolving line of credit. In addition to refinancing existing borrowings, the proceeds of the HUD-insured debt helped fund acquisitions, to renovate and upgrade existing and future facilities, to cover working capital needs and for other business purposes. In addition to the HUD mortgage loans above, the Company had outstanding indebtedness under mortgage loans insured with HUD and a promissory note issued in connection with various acquisitions. These mortgage loans and note bear fixed interest rates between 2.6% and 5.3% per annum. Amounts borrowed under the mortgage loans may be prepaid starting after the second anniversary of the notes subject to prepayment fees of the principal balance on the date of prepayment. These prepayment fees are reduced by 1.0% per year for years three through eleven of the loan. There is no prepayment penalty after year eleven . The term of the mortgage loans and the note is between 12 and 33 years. The mortgage loans and note are secured by the real property comprising the facilities and the rents, issues and profits thereof, as well as all personal property used in the operation of the facilities. As of September 30, 2018 , the Company's operating subsidiaries had $123,591 outstanding under the mortgage loans and note, of which $2,580 is classified as short-term and the remaining $121,011 is classified as long-term. The Company was in compliance with all loan covenants as of September 30, 2018 . Based on Level 2, the carrying value of the Company's long-term debt is considered to approximate the fair value of such debt for all periods presented based upon the interest rates that the Company believes it can currently obtain for similar debt. Off-Balance Sheet Arrangements During the three months ended September 30, 2018 , the Company decreased its outstanding letters of credit by $1,797 . As of September 30, 2018 , the Company had approximately $4,557 on the credit facility of borrowing capacity pledged as collateral to secure outstanding letters of credit.

Options and Awards

Options and Awards	9 Months Ended
	Sep. 30, 2018
Options and Awards [Abstract]
Disclosure of Compensation Related Costs, Share-based Payments [Text Block]	OPTIONS AND AWARDS Stock-based compensation expense consists of share-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 and nine months ended September 30, 2018 and 2017 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 provides for the issuance of 6,881 shares of common stock. 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 3 years , on the completion of each year of service measured from the grant date. All other options generally vest over 5 years at 20% per year on the anniversary of the grant date. Options expire 10 years from the date of grant. At September 30, 2018 , there were 5,021 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 all share-based payment awards. Determining the appropriate fair-value model and calculating the fair value of stock-based awards at the grant date requires considerable judgment, including estimating stock price volatility, expected option life and forfeiture rates. The Company develops estimates based on historical data and market information, which can change significantly over time. The Company granted 496 options and 316 restricted stock awards from the 2017 Plan during the nine months ended September 30, 2018 . Stock Options The Company used the following assumptions for stock options granted during the three months ended September 30, 2018 and 2017 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2018 101 2.8% 6.3 years 32.0% 0.5% 2017 103 1.9% 6.2 years 35.4% 0.8% The Company used the following assumptions for stock options granted during the nine months ended September 30, 2018 and 2017 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2018 496 2.7% 6.2 years 32.0% 0.5% 2017 383 1.9% 6.2 years 35.7% 0.8% For the nine months ended September 30, 2018 and 2017 , 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 2018 496 $ 33.61 $ 11.64 2017 383 $ 19.64 $ 6.83 The weighted average exercise price equaled the weighted average fair value of common stock on the grant date for all options granted during the periods ended September 30, 2018 and 2017 and therefore, the intrinsic value was $0 at the date of grant. The following table represents the employee stock option activity during the nine months ended September 30, 2018 : Number of Options Outstanding Weighted Average Exercise Price Number of Options Vested Weighted Average Exercise Price of Options Vested January 1, 2018 4,739 $ 13.08 2,776 $ 10.07 Granted 496 33.61 Forfeited (73 ) 19.52 Exercised (763 ) 7.80 September 30, 2018 4,399 $ 16.20 2,658 $ 11.94 The following summary information reflects stock options outstanding, vested and related details as of September 30, 2018 : Stock Options Vested Stock Options Outstanding Number Outstanding Black-Scholes Fair Value Remaining Contractual Life (Years) Vested and Exercisable Year of Grant Exercise Price 2008 2.56 - 4.06 16 30 0 16 2009 4.06 - 4.56 263 564 1 263 2010 4.77 - 4.96 83 201 2 83 2011 5.90 - 7.99 90 309 3 90 2012 6.56 - 7.96 292 1,082 4 292 2013 7.98 - 11.49 465 2,265 5 432 2014 10.55 - 18.94 1,331 7,553 6 1,000 2015 21.47 - 25.24 500 4,546 7 270 2016 18.79 - 19.89 422 2,946 8 145 2017 18.64 - 22.90 451 3,151 9 67 2018 26.53 - 38.59 486 5,662 10 — Total 4,399 28,309 2,658 Restricted Stock Awards The Company granted 42 and 316 restricted stock awards during the three and nine months ended September 30, 2018 , respectively. The Company granted 41 and 140 restricted stock awards during the three and nine months ended September 30, 2017 , respectively. All awards were granted at an issued price of $0 and generally vest over five years . The fair value per share of restricted awards granted during the nine months ended September 30, 2018 and 2017 ranged from $23.61 to $38.59 and $18.47 to $21.53 , 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 September 30, 2018 and changes during the nine months ended September 30, 2018 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2018 383 $ 20.65 Granted 316 34.79 Vested (125 ) 22.25 Forfeited (14 ) 22.98 Nonvested at September 30, 2018 560 $ 28.21 During the three and nine months ended September 30, 2018 , the Company granted 8 and 23 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 ranged from $23.61 to $37.50 based on the market price on the grant date. Share-based compensation expense recognized for the Company's equity incentive plans for the three and nine months ended September 30, 2018 and 2017 was as follows: Three Months Ended September 30, Nine Months Ended September 30, 2018 2017 2018 2017 Share-based compensation expense related to stock options $ 1,213 $ 1,104 $ 3,721 $ 3,629 Share-based compensation expense related to restricted stock awards 968 597 2,220 1,736 Share-based compensation expense related to stock options and restricted stock awards to non-employee directors 281 107 668 371 Total $ 2,462 $ 1,808 $ 6,609 $ 5,736 In future periods, the Company expects to recognize approximately $12,612 and $14,496 in share-based compensation expense for unvested options and unvested restricted stock awards, respectively, that were outstanding as of September 30, 2018 . Future share-based compensation expense will be recognized over 3.4 and 4.0 weighted average years for unvested options and restricted stock awards, respectively. There were 1,741 unvested and outstanding options at September 30, 2018 , of which 1,643 are expected to vest. The weighted average contractual life for options outstanding, vested and expected to vest at September 30, 2018 was 5.9 years. The aggregate intrinsic value of options outstanding, vested, expected to vest and exercised as of September 30, 2018 and December 31, 2017 is as follows: Options September 30, 2018 December 31, 2017 Outstanding $ 95,625 $ 44,060 Vested 69,043 33,976 Expected to vest 23,616 9,311 Exercisable 17,718 10,481 The intrinsic value is calculated as the difference between the market value of the underlying common stock and the exercise price of the options. Equity Instrument Denominated in the Shares of a Subsidiary On May 26, 2016, the Company implemented a management equity plan and granted stock options and restricted stock awards of a subsidiary of the Company to employees and management of that subsidiary (Subsidiary Equity Plan). These awards generally vest over a period of five years or upon the occurrence of certain prescribed events. The value of the stock options and restricted stock awards is tied to the value of the common stock of the subsidiary. The awards can be put to the Company at various prescribed dates, which in no event is earlier than six months after vesting of the restricted awards or exercise of the stock options. The Company can also call the awards, generally upon employee termination. The grant-date fair value of the awards is recognized as compensation expense over the relevant vesting periods, with a corresponding adjustment to noncontrolling interests. The grant value was determined based on an independent valuation of the subsidiary shares. For the three and nine months ended September 30, 2018 , the Company expensed $349 and $1,030 , respectively, in share-based compensation related to the Subsidiary Equity Plan. For the three and nine months ended September 30, 2017 , the Company expensed $348 and $1,019 , respectively, in share-based compensation related to the Subsidiary Equity Plan. The aggregate number of the Company's common shares that would be required to settle these awards at current estimated fair values, including vested and unvested awards, at September 30, 2018 and 2017 is 222 and 250 , respectively. During the third quarter of 2018, the Company repurchased 865 shares of common stock under the Subsidiary Equity Plan for $1,972 . The Company subsequently sold the shares and received net proceeds of $1,972 .

Leases

Leases	9 Months Ended
	Sep. 30, 2018
Leases [Abstract]
Leases of Lessee Disclosure [Text Block]	LEASES The Company leases from CareTrust REIT, Inc. (CareTrust) real property associated with 92 affiliated skilled nursing, assisted living and independent living facilities used in the Company’s operations under eight “triple-net” master lease agreements (collectively, the Master Leases), which range in terms from 12 to 19 years. At the Company’s option, the Master Leases may be extended for two or three five -year renewal terms beyond the initial term, on the same terms and conditions. The extension of the term of any of the Master Leases is subject to the following conditions: (1) no event of default under any of the Master Leases having occurred and being continuing; and (2) the tenants providing timely notice of their intent to renew. The term of the Master Leases is subject to termination prior to the expiration of the then current term upon default by the tenants in their obligations, if not cured within any applicable cure periods set forth in the Master Leases. If the Company elects to renew the term of a Master Lease, the renewal will be effective to all, but not less than all, of the leased property then subject to the Master Lease. The Company does not have the ability to terminate the obligations under a Master Lease prior to its expiration without CareTrust’s consent. If a Master Lease is terminated prior to its expiration other than with CareTrust’s consent, the Company may be liable for damages and incur charges such as continued payment of rent through the end of the lease term as well as maintenance and repair costs for the leased property. Commencing the third year, the rent structure under the Master Leases includes a fixed component, subject to annual escalation equal to the lesser of (1) the percentage change in the Consumer Price Index (but not less than zero) or (2) 2.5% . In addition to rent, the Company is required to pay the following: (1) all impositions and taxes levied on or with respect to the leased properties (other than taxes on the income of the lessor); (2) all utilities and other services necessary or appropriate for the leased properties and the business conducted on the leased properties; (3) all insurance required in connection with the leased properties and the business conducted on the leased properties; (4) all facility maintenance and repair costs; and (5) all fees in connection with any licenses or authorizations necessary or appropriate for the leased properties and the business conducted on the leased properties. Total rent expense under the Master Leases was approximately $14,778 and $43,734 for the three and nine months ended September 30, 2018 , respectively, and $14,418 and $42,751 for the three and nine months ended September 30, 2017 , respectively. Among other things, under the Master Leases, the Company must maintain compliance with specified financial covenants measured on a quarterly basis, including a portfolio coverage ratio and a minimum rent coverage ratio. The Master Leases also include certain reporting, legal and authorization requirements. The Company is not aware of any defaults as of September 30, 2018 . The Company also leases certain affiliated operations and its administrative offices under non-cancelable operating leases, most of which have initial lease terms ranging from five to 20 years . The Company has entered into multiple lease agreements with various landlords to operate newly constructed state-of-the-art, full-service healthcare resorts upon completion of construction. The term of each lease is 15 years with two five -year renewal options and is subject to annual escalation equal to the percentage change in the Consumer Price Index with a stated cap percentage. In addition, the Company leases certain of its equipment under non-cancelable operating leases with initial terms ranging from three to five years . Most of these leases contain renewal options, certain of which involve rent increases. Total rent expense, inclusive of straight-line rent adjustments and rent associated with the Master Leases noted above, was $35,028 and $103,668 for the three and nine months ended September 30, 2018 , respectively, and $34,112 and $98,955 for the three and nine months ended September 30, 2017 , respectively. Thirty-one of the Company’s affiliated facilities, excluding the facilities that are operated under the Master Leases with CareTrust, are operated under five separate master lease arrangements. Under these master leases, a breach at a single facility could subject one or more of the other facilities covered by the same master lease to the same default risk. Failure to comply with Medicare and Medicaid provider requirements is a default under several of the Company’s leases, master lease agreements and debt financing instruments. In addition, other potential defaults related to an individual facility may cause a default of an entire master lease portfolio and could trigger cross-default provisions in the Company’s outstanding debt arrangements and other leases. With an indivisible lease, it is difficult to restructure the composition of the portfolio or economic terms of the lease without the consent of the landlord. In first quarter of 2017, the Company voluntarily discontinued operations at one of its skilled nursing facilities after determining that the facility could not competitively operate in the marketplace without substantial investment renovating the building. After careful consideration, the Company determined that the costs to renovate the facility could outweigh the future returns from the operation. As part of this closure, the Company entered into an agreement with its landlord allowing for the closure of the property, as well as other provisions, to allow its landlord to transfer the property and the licenses free and clear of the applicable master lease. This arrangement does not impact the rent expense paid in 2017, or expected to be paid in future periods, and has no material impact on the Company's lease coverage ratios under the Master Leases. The Company recorded a continued obligation liability under the lease and related closing expenses of $2,830 , including the present value of rental payments of approximately $2,715 during the first quarter of 2017. Residents of the affected facility were transferred to local skilled nursing facilities. In March 2017, the Company entered into definitive agreements to sell the properties of two skilled nursing facilities and one assisted living community. The transaction closed in the second quarter of 2017. Upon closing the transaction, the Company leased the properties under a triple-net master lease with an initial 20 -year term, with three 5 -year optional extensions, at CPI-based annual escalators. The Company received $38,000 in proceeds. The carrying value for the sale was $24,847 . Under applicable accounting guidance, the master lease was classified as an operating lease. The Company recognized a deferred gain on the transaction of $13,153 during the second quarter of 2017 that is amortized over the life of the lease. During the first quarter of 2017, the Company terminated its lease obligations on four transitional care facilities that were under development at that time and one newly constructed stand-alone skilled nursing operation. The Company recorded $1,187 in lease termination costs and long-lived asset impairment. Future minimum lease payments for all leases as of September 30, 2018 are as follows: Year Amount 2018 (remainder) $ 35,338 2019 139,933 2020 139,043 2021 138,428 2022 137,040 2023 135,403 Thereafter 951,177 $ 1,676,362

Commitments and Contingencies

Commitments and Contingencies	9 Months Ended
	Sep. 30, 2018
Commitments and Contingencies Disclosure [Abstract]
Commitments and Contingencies Disclosure [Text Block]	COMMITMENTS AND CONTINGENCIES Regulatory Matters — Laws and regulations governing Medicare and Medicaid programs are complex and subject to interpretation. Compliance with such laws and regulations can be subject to future governmental review and interpretation, as well as significant regulatory action including fines, penalties, and exclusion from certain governmental programs. Included in these laws and regulations is the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which requires healthcare providers (among other things) to safeguard the privacy and security of certain health information. In late December 2016, the Company learned of a potential issue at one of its independent operating entities in Arizona which involved the limited and inadvertent disclosure of certain confidential information. The issue has been internally investigated, addressed and disclosed as is required by law. The Company believes that it is presently in compliance in all material respects with applicable HIPAA laws and regulations. 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 by the Company's 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 employees, under which the Company may be required to indemnify such persons for liabilities arising out of their employment relationships. 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. U.S. Department of Justice Civil Investigative Demand - On May 31, 2018, the Company received a Civil Investigative Demand (CID) from the U.S. Department of Justice stating that it is investigating the Company to determine whether the Company has violated the False Claims Act and/or the Anti-Kickback Statute with respect to the relationships between certain of the Company’s skilled nursing facilities and persons who served as medical directors, advisory board participants or other referral sources. The CID covered the period from October 3, 2013 to the present, and was limited in scope to ten of the Company’s Southern California skilled nursing facilities. In October 2018, the Department of Justice made an additional request for information covering the period of January 1, 2011 to the present, relating to the same topic. As a general matter, the Company’s operating entities maintain policies and procedures to promote compliance with the False Claims Act, the Anti-Kickback Statute, and other applicable regulatory requirements. The Company is fully cooperating with the U.S. Department of Justice to promptly respond to the requests for information. However, the Company cannot predict when the investigation will be resolved, the outcome of the investigation or its potential impact on the Company. 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 operating subsidiaries. The Company, its 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. 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 is 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 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. Some states, including California, Arizona and Texas, have enacted similar whistleblower and false claims laws and regulations. In addition, 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 could face increased scrutiny, potential liability and legal expenses and costs based on claims under state false claims acts in markets in which its 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 (FCA) 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 FCA violation can occur without any affirmative fraudulent action or statement, as long as it 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 is routinely subjected to varying types of claims. One particular type of suit arises from alleged violations of minimum staffing requirements for skilled nursing facilities in those states which have enacted such requirements. Failure to meet these requirements can, among other things, jeopardize a facility's compliance with conditions of participation under certain state and federal healthcare programs; it may also subject the facility to a deficiency, a citation, a civil money penalty, or litigation. These class-action “staffing” suits have the potential to result in large jury verdicts and settlements. The Company expects the plaintiffs' bar to continue to be aggressive in their pursuit of these staffing and similar claims. The Company and its operating subsidiaries have in the past been subject to class action litigation involving claims of alleged violations of regulatory requirements related to staffing. While the Company has been able to settle these claims without a material ongoing 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. If there were a significant increase in the number of these claims or an increase in amounts due as a result of these claims, this could materially adversely affect the Company’s business, financial condition, results of operations, and cash flows. The Company and its operating subsidiaries have been, and continue to be, subject to claims and legal actions that arise in the ordinary course of business, including potential claims related to patient care and treatment, as well as employment related claims. A significant increase in the number of these claims, or an increase in the amounts due as a result of these claims, could materially adversely affect the Company’s business, financial condition, results of operations and cash flows. In August of 2011, the Company was named as a Defendant in a class action litigation alleging violations of state and federal wage and hour law. In January of 2017, the Company participated in an initial mediation session with plaintiffs' counsel. As a result of this discussion and due to (i) the fact no class had been certified (ii) the lack of specificity as to legal theories put forth by the plaintiffs (iii) the nature of the remedies sought and (iv) the lack of any basis on which to compute estimated compensatory and/or exemplary damages, the Company could not predict what the outcome of the pending class action lawsuit would be, what the timing of the ultimate resolution of this lawsuit would be, or an estimate and/or range of possible loss related to it. In March of 2017, the Company was invited to engage in further settlement discussions to determine whether a resolution of the case in advance of a decision on class certification was possible. In April of 2017, the Company reached an agreement in principle to settle the subject class action litigation, without any admission of liability and subject to approval by the California Superior Court. Based upon the change in case status, the Company recorded an accrual for estimated probable losses of $11,000 , exclusive of legal fees, in the first quarter of 2017. The Company funded the settlement amount of $11,000 in December of 2017, and the funds were distributed to the class members in the first quarter of 2018. The Company received $1,664 related to unclaimed class settlement funds remaining after completion of the settlement process, and the recoveries were recorded in the first quarter of 2018. Other claims and suits continue to be filed against the Company and other companies in the post-acute care. By way of example, a general/premises liability lawsuit was filed against one of the Company’s independent operating entities, in connection with an alleged injury to a non-employee/contractor. In addtiion, professional negligence claims have been filed and will likely continue to be filed against the Company's independent operating entities by residents or resident responsible parties. The Company cannot predict or provide any assurance as to the possible outcome of any inquiry, investigation or litigation. If any litigation were to proceed through trial, and the Company and its 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 is alleged or found to be liable in theories of general or professional negligence, 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 civil violations, and may also include the assumption of specific procedural and financial obligations by the Company or its subsidiaries going forward under a corporate integrity agreement and/or other arrangements. Medicare Revenue Recoupments — The Company's operating entities are subject to regulatory reviews relating to Medicare services, billings and potential overpayments as a result of Recovery Audit Contractors (RAC), Zone Program Integrity Contractors (ZPIC), Program Safeguard Contractors (PSC), Unified Program Integrity Contractors (UPIC) and Medicaid Integrity Contributors (MIC) programs, collectively referred to as "Reviews." As of September 30, 2018 , thirteen of the Company's operating subsidiaries had Reviews scheduled and in process, both pre- and post-payment. The Company anticipates that these Reviews will increase in frequency in the future. 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. As of September 30, 2018 , the affiliated operating subsidiaries have responded to the requests and the related claims are currently under Review. U.S. Government Inquiry and Corporate Integrity Agreement — In October 2013, the Company completed and executed a settlement agreement (the Settlement Agreement) with the DOJ, which received the final approval of the Office of Inspector General-HHS and the United States District Court for the Central District of California. Pursuant to the Settlement Agreement, the Company made a single lump-sum remittance to the government in the amount of $48,000 in October 2013. The Company has denied engaging in any illegal conduct and has agreed to the settlement amount without any admission of wrongdoing in order to resolve the allegations and to avoid the uncertainty and expense of protracted litigation. In connection with the settlement and effective as of October 1, 2013, the Company entered into a five-year corporate integrity agreement (the CIA) with the Office of Inspector General-HHS. The CIA acknowledges the existence of the Company’s current compliance program, which is in accord with the Office of the Inspector General (OIG)’s guidance related to an effective compliance program, and requires that the Company continue during the term of the CIA to maintain a program designed to promote compliance with the statutes, regulations, and written directives of Medicare, Medicaid, and all other Federal health care programs. The Company is also required to notify the Office of Inspector General-HHS in writing, of, among other things: (i) any ongoing government investigation or legal proceeding involving an allegation that the Company has committed a crime or has engaged in fraudulent activities; (ii) any other matter that a reasonable person would consider a probable violation of applicable criminal, civil, or administrative laws related to compliance with federal healthcare programs; and (iii) any change in location, sale, closing, purchase, or establishment of a new business unit or location related to items or services that may be reimbursed by federal health care programs. The Company is also required to retain an Independent Review Organization (IRO) to review certain clinical documentation annually for the term of the CIA. The Company and its operating subsidiaries have continued to meet the requirements under the Settlement Agreement and CIA, and pass its IRO audits. Participation in federal healthcare programs by the Company's operating subsidiaries is not affected by the Settlement Agreement or the CIA. In the event of an uncured material breach of the CIA, the Company could be excluded from participation in federal healthcare programs and/or subject to prosecution. 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 approximately 56.3% and 56.7% of its total accounts receivable as of September 30, 2018 and December 31, 2017 , respectively. Revenue from reimbursement under the Medicare and Medicaid programs accounted for 68.6% and 68.2% of the Company's revenue for the three and nine months ended September 30, 2018 , respectively, and 68.8% and 68.4% for the three and nine months ended September 30, 2017 . 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 October 29, 2018 , the Company had approximately $1,219 in uninsured cash deposits. All uninsured bank deposits are held at high quality credit institutions.

Common Stock

Common Stock	9 Months Ended
	Sep. 30, 2018
Common Stock [Abstract]
Common stock offering [Text Block]	COMMON STOCK As approved by the Board of Directors on April 3, 2018, the Company entered into a stock repurchase program pursuant to which the Company may repurchase up to $30,000 of its common stock under the program for a period of approximately 11 months . Under this program, the Company is authorized to repurchase its issued and outstanding common shares from time to time in open-market and privately negotiated transactions and block trades in accordance with federal securities laws. The stock repurchase program is scheduled to expire on February 20, 2019 . To date, the Company has not purchased any shares pursuant to this stock repurchase program. On February 8, 2017, the Company announced that its Board of Directors authorized a stock repurchase program, under which the Company may repurchase up to $30,000 of its common stock under the program for a period of 12 months . The stock repurchase program expired on February 8, 2018 . During the nine months ended September 30, 2017 , the Company repurchased 412 shares of its common stock for a total of $7,288 . The Company did not repurchase shares during the three months ended September 30, 2017 .

Significant Accounting Polici_2

Significant Accounting Policies Level 2 (Policies)	9 Months Ended
	Sep. 30, 2018
Accounting Policies [Abstract]
Basis of Presentation	Basis of Presentation — The accompanying Interim Financial Statements have been prepared in accordance with accounting principles generally accepted in the United States (GAAP). The Company is the sole member or shareholder of various consolidated limited liability companies and corporations established to operate various acquired skilled nursing and assisted living operations, home health, hospice and home care operations, and related ancillary services. All intercompany transactions and balances have been eliminated in consolidation. The condensed consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest. The Company presents noncontrolling interest within the equity section of its condensed consolidated balance sheets. The Company presents the amount of consolidated net income that is attributable to The Ensign Group, Inc. and the noncontrolling interest in its condensed consolidated statements of income.
Estimates and Assumptions	Estimates and Assumptions — The preparation of Interim Financial Statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the Interim Financial Statements and the reported amounts of revenue and expenses during the reporting periods. The most significant estimates in the Company’s Interim Financial Statements relate to revenue, intangible assets and goodwill, impairment of long-lived assets, general and professional liability, workers' compensation and healthcare claims included in accrued self-insurance liabilities, and income taxes. Actual results could differ from those estimates.
Fair Value of Financial Instruments	Fair Value of Financial Instruments — The Company’s financial instruments consist principally of cash and cash equivalents, debt security investments, accounts receivable, insurance subsidiary deposits, accounts payable and borrowings. The Company believes all of the financial instruments’ recorded values approximate fair values because of their nature or respective short durations.
Revenue Recognition	Revenue Recognition — On January 1, 2018, the Company adopted Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (ASC 606) applying the modified retrospective method. Results for reporting periods beginning January 1, 2018 are presented under ASC 606, while prior period amounts are not adjusted and continue to be reported under the accounting standards in effect for the prior period. The adoption of ASC 606 did not have a material impact on the measurement nor on the recognition of revenue of contracts, for which all revenue had not been recognized, as of January 1, 2018, therefore no cumulative adjustment has been made to the opening balance of retained earnings at the beginning of 2018. See Note 3, Revenue and Accounts Receivable .
Accounts Receivable and Allowance for Doubtful Accounts	Accounts Receivable and Allowance for Doubtful Accounts — Accounts receivable consist primarily of amounts due from Medicare and Medicaid programs, other government programs, managed care health plans and private payor sources, net of estimates for variable consideration. The allowance for doubtful accounts reflects the Company’s best estimate of probable losses inherent in the accounts receivable balance. The Company determines the allowance based on known troubled accounts and other currently available evidence. See Note 3, Revenue and Accounts Receivable .
Property and Equipment	Property and Equipment — Property and equipment are initially recorded at their historical cost. Repairs and maintenance are expensed as incurred. Depreciation is computed using the straight-line method over the estimated useful lives of the depreciable assets (ranging from three to 59 years ). Leasehold improvements are amortized on a straight-line basis over the shorter of their estimated useful lives or the remaining lease term.
Impairment of Long-Lived Assets	Impairment of Long-Lived Assets — The Company reviews the carrying value of long-lived assets that are held and used in the Company’s operating subsidiaries for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of these assets is determined based upon expected undiscounted future net cash flows from the operating subsidiaries to which the assets relate, utilizing management’s best estimate, appropriate assumptions, and projections at the time. If the carrying value is determined to be unrecoverable from future operating cash flows, the asset is deemed impaired and an impairment loss would be recognized to the extent the carrying value exceeded the estimated fair value of the asset. The Company estimates the fair value of assets based on the estimated future discounted cash flows of the asset. Management has evaluated its long-lived assets and recorded an impairment charge of $860 and $111 during the nine months ended September 30, 2018 and 2017 , respectively. The Company did not identify any asset impairment during the three months ended September 30, 2018 and 2017 .
Leases and Leasehold Improvements	Leases and Leasehold Improvements - At the inception of each lease, the Company performs an evaluation to determine whether the lease should be classified as an operating or capital lease. The Company records rent expense for operating leases that contain scheduled rent increases on a straight-line basis over the term of the lease. The lease term used for straight-line rent expense is calculated from the date the Company is given control of the leased premises through the end of the lease term. The lease term used for this evaluation also provides the basis for establishing depreciable lives for buildings subject to lease and leasehold improvements, as well as the period over which the Company records straight-line rent expense.
Intangible Assets and Goodwill	Intangible Assets and Goodwill — Definite-lived intangible assets consist primarily of favorable leases, lease acquisition costs, patient base, facility trade names and customer relationships. Favorable leases and lease acquisition costs are amortized over the life of the lease of the facility. Patient base is amortized over a period of four to eight months, depending on the classification of the patients and the level of occupancy in a new acquisition on the acquisition date. Trade names at affiliated facilities are amortized over 30 years and customer relationships are amortized over a period of up to 20 years . The Company's indefinite-lived intangible assets consist of trade names, and Medicare and Medicaid licenses. The Company tests indefinite-lived intangible assets for impairment on an annual basis or more frequently if events or changes in circumstances indicate that the carrying amount of the intangible asset may not be recoverable. Goodwill represents the excess of the purchase price over the fair value of identifiable net assets acquired in business combinations. Goodwill is subject to annual testing for impairment. In addition, goodwill is tested for impairment if events occur or circumstances change that would reduce the fair value of a reporting unit below its carrying amount. The Company performs its annual test for impairment during the fourth quarter of each year. Management evaluated its goodwill and intangible assets during the third quarter, due to changes in circumstances and the Company recorded an impairment charge of $3,653 to goodwill and intangible assets during the three and nine months ended September 30, 2018 . The Company did not identify any goodwill and intangible assets impairment during the three and nine months ended September 30, 2017 . See further discussion at Note 10, Goodwill and Other Indefinite-Lived Intangible Assets .
Self-Insurance	Self-Insurance — The Company is partially self-insured for general and professional liability up to a base amount per claim (the self-insured retention) with an aggregate, one-time deductible above this limit. Losses beyond these amounts are insured through third-party policies with coverage limits per claim, per location and on an aggregate basis for the Company. The combined self-insured retention is $500 per claim, subject to an additional one-time deductible of $750 for California affiliated operations and a separate, one-time, deductible of $1,000 for non-California operations. For all affiliated operations, except those located in Colorado, the third-party coverage above these limits is $1,000 per claim, $3,000 per operation, with a $5,000 blanket aggregate limit and an additional state-specific aggregate where required by state law. In Colorado, the third-party coverage above these limits is $1,000 per claim and $3,000 per operation, which is independent of the aforementioned blanket aggregate limits that apply outside of Colorado. The self-insured retention and deductible limits for general and professional liability and workers' compensation for all states (except Texas and Washington for workers' compensation) are self-insured through the Captive, the related assets and liabilities of which are included in the accompanying condensed consolidated balance sheets. The Captive is subject to certain statutory requirements as an insurance provider. These requirements include, but are not limited to, maintaining statutory capital. The Company’s policy is to accrue amounts equal to the actuarially estimated costs to settle open claims of insureds, as well as an estimate of the cost of insured claims that have been incurred but not reported. The Company develops information about the size of the ultimate claims based on historical experience, current industry information and actuarial analysis, and evaluates the estimates for claim loss exposure on a quarterly basis. Accrued general liability and professional malpractice liabilities on an undiscounted basis, net of anticipated insurance recoveries, were $41,280 and $38,998 as of September 30, 2018 and December 31, 2017 , respectively. The Company’s operating subsidiaries are self-insured for workers’ compensation in California. To protect itself against loss exposure in California with this policy, the Company has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington, are under a loss sensitive plan that insures individual claims that exceed $350 per occurrence. In Washington, the operating subsidiaries' coverage is financed through premiums paid by the employers and employees. The claims and pay benefits are managed through a state insurance pool. Outside of California, Texas and Washington, the Company has purchased insurance coverage that insures individual claims that exceed $350 per accident. In all states except Washington, the Company accrues amounts equal to the estimated costs to settle open claims, as well as an estimate of the cost of claims that have been incurred but not reported. The Company uses actuarial valuations to estimate the liability based on historical experience and industry information. Accrued workers’ compensation liabilities are recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets and were $24,427 and $23,621 as of September 30, 2018 and December 31, 2017 , respectively. In addition, the Company has recorded an asset and equal liability of $6,451 and $5,394 at September 30, 2018 and December 31, 2017 , respectively, in order to present the ultimate costs of malpractice and workers' compensation claims and the anticipated insurance recoveries on a gross basis. See Note 11 Restricted and Other Assets. The Company self-funds medical (including prescription drugs) and dental healthcare benefits to the majority of its employees. The Company is fully liable for all financial and legal aspects of these benefit plans. To protect itself against loss exposure with this policy, the Company has purchased individual stop-loss insurance coverage that insures individual claims that exceed $300 for each covered person with an additional one-time aggregate individual stop loss deductible of $75 . Beginning 2016, the Company's policy does not include the additional one-time aggregate individual stop loss deductible of $75 . The Company’s accrued liability under these plans recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets was $5,659 and $4,723 as of September 30, 2018 and December 31, 2017 , respectively. The Company believes that adequate provision has been made in the Interim Financial Statements for liabilities that may arise out of patient care, workers’ compensation, healthcare benefits and related services provided to date. The amount of the Company’s reserves was determined based on an estimation process that uses information obtained from both company-specific and industry data. This estimation process requires the Company to continuously monitor and evaluate the life cycle of the claims. Using data obtained from this monitoring and the Company’s assumptions about emerging trends, the Company, with the assistance of an independent actuary, develops information about the size of ultimate claims based on the Company’s historical experience and other available industry information. The most significant assumptions used in the estimation process include determining the trend in costs, the expected cost of claims incurred but not reported and the expected costs to settle or pay damage awards with respect to unpaid claims. The self-insured liabilities are based upon estimates, and while management believes that the estimates of loss are reasonable, the ultimate liability may be in excess of or less than the recorded amounts. Due to the inherent volatility of actuarially determined loss estimates, it is reasonably possible that the Company could experience changes in estimated losses that could be material to net income. If the Company’s actual liability exceeds its estimates of loss, its future earnings, cash flows and financial condition would be adversely affected.
Income Taxes	Income Taxes — Deferred tax assets and liabilities are established for temporary differences between the financial reporting basis and the tax basis of the Company’s assets and liabilities at tax rates in effect when such temporary differences are expected to reverse. The Company generally expects to fully utilize its deferred tax assets; however, when necessary, the Company records a valuation allowance to reduce its net deferred tax assets to the amount that is more likely than not to be realized. In determining the need for a valuation allowance or the need for and magnitude of liabilities for uncertain tax positions, the Company makes certain estimates and assumptions. These estimates and assumptions are based on, among other things, knowledge of operations, markets, historical trends and likely future changes and, when appropriate, the opinions of advisors with knowledge and expertise in certain fields. Due to certain risks associated with the Company’s estimates and assumptions, actual results could differ. The Tax Cuts and Jobs Act (the Tax Act), which was enacted in December 2017, decreased the corporate income tax rate from 35.0% to 21.0% beginning on January 1, 2018. The Company’s actual effective tax rate for fiscal 2018 may differ from management’s estimate due to changes in interpretations and assumptions, and the excess tax benefits impact of share-based payment awards. See Note 13, Income Taxes for further detail.
Noncontrolling Interest	Noncontrolling Interest — The noncontrolling interest in a subsidiary is initially recognized at estimated fair value on the acquisition date and is presented within total equity in the Company's condensed consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to The Ensign Group, Inc. in its condensed consolidated statements of income and net income per share is calculated based on net income attributable to The Ensign Group, Inc.'s stockholders. The carrying amount of the noncontrolling interest is adjusted based on an allocation of subsidiary earnings based on ownership interest.
Share-Based Compensation	Share-Based Compensation — The Company measures and recognizes compensation expense for all share-based payment awards made to employees and directors including employee stock options based on estimated fair values, ratably over the requisite service period of the award. Net income has been reduced as a result of the recognition of the fair value of all stock options and restricted stock awards issued, the amount of which is contingent upon the number of future grants and other variables.
Recent Accounting Pronouncements	Recent Accounting Pronouncements — Except for rules and interpretive releases of the Securities and Exchange Commission (SEC) under authority of federal securities laws and a limited number of grandfathered standards, the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) is the sole source of authoritative GAAP literature recognized by the FASB and applicable to the Company. For any new pronouncements announced, the Company considers whether the new pronouncements could alter previous generally accepted accounting principles and determines whether any new or modified principles will have a material impact on the Company's reported financial position or operations in the near term. The applicability of any standard is subject to the formal review of the Company's financial management and certain standards are under consideration. Recent Accounting Standards Adopted by the Company In 2014, the FASB and International Accounting Standards Board issued their final standard on revenue from contracts with customers that outlines a single comprehensive model for entities to use in accounting for revenue arising from contracts with customers. Under this new standard and subsequently issued amendments, revenue is recognized at the time a good or service is transferred to a customer for the amount of consideration received. Entities may apply the new standard either retrospectively to each period presented (full retrospective method) or retrospectively with the cumulative effect recognized in beginning retained earnings as of the date of adoption (modified retrospective method). The Company adopted the new revenue standard as of January 1, 2018 using the modified retrospective transition method. The adoption of ASC 606 did not have a material impact on the measurement, nor on the recognition of revenue of contracts, for which all revenue had not been recognized as of January 1, 2018. Therefore, no cumulative adjustment has been made to the opening balance of retained earnings at the beginning of 2018. The comparative information has not been restated and continues to be reported under the accounting standards in effect for the period presented. In May 2017, the FASB issued amended authoritative guidance to provide guidance on types of changes to the terms or conditions of share-based payment awards to which an entity would be required to apply modification accounting under ASC 718. The new guidance was effective for the Company in the first quarter of fiscal year 2018. The adoption of this standard did not have a material impact on the Company's consolidated financial statements. In January 2017, the FASB issued amended authoritative guidance to clarify the definition of a business and reduce diversity in practice related to the evaluation of whether transactions should be accounted for as acquisitions (or disposals) of assets or businesses. The new provisions provide the requirements needed for an integrated set of assets and activities (the set) to be a business and also establish a practical way to determine when a set is not a business. The accounting standards update (ASU) provides a screen to determine when an integrated set of assets and activities is not a business. The more robust framework helps entities to narrow the definition of outputs created by the set and align it with how outputs are described in the new revenue standard. The new guidance was effective for the Company in the first quarter of fiscal year 2018. The fair value of assets for nine of the Company's acquisitions during the nine months ended September 30, 2018 was concentrated in property and equipment and as such, these transactions were classified as asset acquisitions in accordance with ASC 805. The fair value of assets for the remaining two acquisitions during the nine months ended September 30, 2018 was concentrated in goodwill and as such, these transactions were classified as business acquisitions in accordance with ASC 805. Some of these acquisitions would have been classified as business combinations prior to the adoption of the ASU. The Company anticipates that future acquisitions will be classified as a mixture of business and asset acquisitions under the new guidance. In March 2018, we adopted ASU 2018-05, Income Taxes (Topic 740): Amendments to the SEC Paragraphs Pursuant to SEC Staff Accounting Bulletin No. 118, which updates the income tax accounting in U.S. GAAP to reflect the Securities and Exchange Commission (SEC) interpretive guidance released in December 2017, when the Tax Act was signed into law. Additional information regarding the adoption of this standard is contained in Note 13, Income Taxes. In October 2016, the FASB issued amended authoritative guidance to require companies to recognize the income tax consequences of an intra-entity transfer of an asset, other than inventory, when the transfer occurs. The new guidance is required to be applied on a modified retrospective basis through a cumulative-effect adjustment directly to retained earnings as of the beginning of the period of adoption. The new guidance was effective for the Company in the first quarter of fiscal year 2018. The adoption of this standard did not have a material impact on the Company's consolidated financial statements. In August 2016, the FASB issued amended authoritative guidance to reduce the diversity in practice related to the presentation and classification of certain cash receipts and cash payments in the statement of cash flows. The new provisions target cash flow issues related to (i) debt prepayment or debt extinguishment costs, (ii) settlement of debt instruments with coupon rates that are insignificant relative to effective interest rates, (iii) contingent consideration payments made after a business combination, (iv) proceeds from settlement of insurance claims, (v) proceeds from the settlement of corporate-owned life insurance and bank-owned life insurance policies, (vi) distributions received from equity method investees, (vii) beneficial interests in securitization transactions and (viii) separately identifiable cash flows and application of the predominance principle. The new guidance was effective for the Company in the first quarter of fiscal year 2018. The adoption of this standard did not have a material impact on the Company's consolidated financial statements. Accounting Standards Recently Issued But Not Yet Adopted by the Company In August 2018, the FASB issued amended guidance to simplify fair value measurement disclosure requirements. The new provisions eliminate the requirements to disclose (1) transfers between Level 1 and Level 2 of the fair value hierarchy, (2) policies related to valuation processes and the timing of transfers between levels of the fair value hierarchy, and (3) net asset value disclosure of estimates of timing of future liquidity events. The FASB also modified disclosure requirements of Level 3 fair value measurements. This guidance is effective for annual periods beginning after December 15, 2019, which will be the Company's fiscal year 2020, with early adoption permitted. The adoption of this standard is not expected to have a material impact on the Company's consolidated financial statements. In January 2017, the FASB issued amended authoritative guidance to simplify and reduce the cost and complexity of the goodwill impairment test. The new provisions eliminate step 2 from the goodwill impairment test and shifts the concept of impairment from a measure of loss when comparing the implied fair value of goodwill to its carrying amount to comparing the fair value of a reporting unit with its carrying amount. The FASB also eliminated the requirements for any reporting unit with a zero or negative carrying amount to perform a qualitative assessment or step 2 of the goodwill impairment test. The new guidance does not amend the optional qualitative assessment of goodwill impairment. This guidance is effective for annual periods beginning after December 15, 2019, which will be the Company's fiscal year 2020, with early adoption permitted. The adoption of this standard is not expected to have a material impact on the Company's consolidated financial statements. In February 2016, the FASB issued amended authoritative guidance on accounting for leases. The new provisions require that a lessee of operating leases recognize, in the statement of financial position, a liability to make lease payments (the lease liability) and a right-of-use asset representing its right to use the underlying asset for the lease term. The lease liability will be equal to the present value of lease payments, with the right-of-use asset based upon the lease liability. The classification criteria for distinguishing between finance (or capital) leases and operating leases are substantially similar to the previous lease guidance, but with no explicit bright lines. As such, operating leases will result in straight-line rent expense similar to current practice. For short term leases (term of 12 months or less), a lessee is permitted to make an accounting election not to recognize lease assets and lease liabilities, which would generally result in lease expense being recognized on a straight-line basis over the lease term. This guidance applies to all entities and is effective for annual periods beginning after December 15, 2018, which will be the Company's fiscal year 2019, with early adoption permitted. The Company is currently evaluating the impact this guidance will have on its consolidated financial statements and disclosures and expects that this adoption will result in a material increase in the assets and liabilities on its consolidated balance sheets, primarily related to leases of facilities. The Company is in the process of cataloging its existing lease contracts and implementing changes to the systems, related processes and controls. The Company is planning to elect the several practical expedients upon transition, including retaining the lease classification for any leases that existed prior to adoption of the standard and the application date to be the beginning of the adoption period, which is January 1, 2019.

Revenue and Accounts Receivab_2

Revenue and Accounts Receivable (Tables)	9 Months Ended
	Sep. 30, 2018
REVENUE AND ACCOUNTS RECEIVABLE [Abstract]
Schedule of New Accounting Pronouncements and Changes in Accounting Principles [Table Text Block]	Three Months Ended September 30, Nine Months Ended September 30, 2018 2017 2018 2017 Total revenue As Reported $ 514,364 $ 471,594 $ 1,502,884 $ 1,361,612 Adjustments 7,854 — 25,736 — Pro forma as if the previous accounting guidance was in effect $ 522,218 $ 471,594 $ 1,528,620 $ 1,361,612 Cost of Services: As Reported $ 413,723 $ 381,544 $ 1,200,098 $ 1,103,976 Adjustments 7,854 — 25,736 — Pro forma as if the previous accounting guidance was in effect $ 421,577 $ 381,544 $ 1,225,834 $ 1,103,976 Total Expense: As Reported $ 485,077 $ 446,035 $ 1,408,843 $ 1,306,470 Adjustments 7,854 — 25,736 — Pro forma as if the previous accounting guidance was in effect $ 492,931 $ 446,035 $ 1,434,579 $ 1,306,470
Disaggregation of Revenue [Table Text Block]	Revenue for the three and nine months ended September 30, 2018 and 2017 is summarized in the following tables: Three Months Ended September 30, 2018 2018 Pro Forma (2) 2017 Revenue % of Revenue Revenue % of Revenue Revenue % of Revenue Medicaid $ 188,486 36.6 % $ 190,892 36.6 % $ 169,100 35.9 % Medicare 133,554 26.0 134,670 25.8 127,348 27.0 Medicaid — skilled 30,684 6.0 31,121 6.0 27,737 5.9 Total Medicaid and Medicare 352,724 68.6 356,683 68.4 324,185 68.8 Managed care 80,196 15.6 82,081 15.6 74,723 15.8 Private and other payors (1) 81,444 15.8 83,454 16.0 72,686 15.4 Revenue $ 514,364 100.0 % $ 522,218 100.0 % $ 471,594 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended September 30, 2018 and 2017. (2) The 2018 pro forma results reflect balances assuming previous accounting guidance was still in effect. Nine Months Ended September 30, 2018 2018 Pro Forma (2) 2017 Revenue % of Revenue Revenue % of Revenue Revenue % of Revenue Medicaid $ 529,280 35.2 % $ 537,890 35.2 % $ 470,008 34.5 % Medicare 409,681 27.3 413,078 27.0 385,419 28.3 Medicaid — skilled 86,024 5.7 87,594 5.7 75,667 5.6 Total Medicaid and Medicare 1,024,985 68.2 1,038,562 67.9 931,094 68.4 Managed care 244,062 16.2 249,712 16.3 225,210 16.5 Private and other payors (1) 233,837 15.6 240,346 15.8 205,308 15.1 Revenue $ 1,502,884 100.0 % $ 1,528,620 100.0 % $ 1,361,612 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2018 and 2017. (2) The 2018 pro forma results reflect balances assuming previous accounting guidance was still in effect.
Schedule of Accounts, Notes, Loans and Financing Receivable [Table Text Block]	Accounts receivable as of September 30, 2018 and December 31, 2017 is summarized in the following table: September 30, December 31, 2018 2018 Pro Forma (1) 2017 Medicaid $ 101,310 $ 117,227 $ 119,441 Managed care 53,825 67,150 68,930 Medicare 47,367 54,428 55,667 Private and other payors 61,436 72,516 64,991 263,938 311,321 309,029 Less: allowance for doubtful accounts (2,484 ) (49,867 ) (43,961 ) Accounts receivable, net $ 261,454 $ 261,454 $ 265,068 (1) The 2018 pro forma results reflect balances assuming previous accounting guidance was still in effect.

Computation of Net Income Per_2

Computation of Net Income Per Common Share (Tables)	9 Months Ended
	Sep. 30, 2018
COMPUTATION OF NET INCOME PER COMMON SHARE [Abstract]
Schedule of Earnings Per Share, Basic, by Common Class, Including Two Class Method [Table Text Block]	A reconciliation of the numerator and denominator used in the calculation of basic net income per common share follows: Three Months Ended September 30, Nine Months Ended September 30, 2018 2017 2018 2017 Numerator: Net income $ 20,350 $ 14,275 $ 65,969 $ 29,611 Less: net (loss)/income attributable to noncontrolling interests (511 ) 63 (35 ) 342 Net income attributable to The Ensign Group, Inc. $ 20,861 $ 14,212 $ 66,004 $ 29,269 Denominator: Weighted average shares outstanding for basic net income per share 52,139 50,911 51,870 50,795 Basic net income per common share attributable to The Ensign Group, Inc. $ 0.40 $ 0.28 $ 1.27 $ 0.58
Schedule of Earnings Per Share, Diluted, by Common Class, Including Two Class Method [Table Text Block]	A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows: Three Months Ended September 30, Nine Months Ended September 30, 2018 2017 2018 2017 Numerator: Net income $ 20,350 $ 14,275 $ 65,969 $ 29,611 Less: net (loss)/income attributable to noncontrolling interests (511 ) 63 (35 ) 342 Net income attributable to The Ensign Group, Inc. $ 20,861 $ 14,212 $ 66,004 $ 29,269 Denominator: Weighted average common shares outstanding 52,139 50,911 51,870 50,795 Plus: incremental shares from assumed conversion (1) 2,493 1,917 2,306 1,879 Adjusted weighted average common shares outstanding 54,632 52,828 54,176 52,674 Diluted net income per common share attributable to The Ensign Group, Inc. $ 0.38 $ 0.27 $ 1.22 $ 0.56 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 244 and 163 for the three and nine months ended September 30, 2018 , respectively and 1,352 and 1,326 for the three and nine months ended September 30, 2017 , respectively.

Fair Value Measurements (Tables

Fair Value Measurements (Tables)	9 Months Ended
	Sep. 30, 2018
Fair Value Disclosures [Abstract]
Fair Value, Assets Measured on Recurring Basis [Table Text Block]	The following table summarizes the financial assets and liabilities measured at fair value on a recurring basis as of September 30, 2018 and December 31, 2017 : September 30, 2018 December 31, 2017 Level 1 Level 2 Level 3 Level 1 Level 2 Level 3 Cash and cash equivalents $ 45,657 $ — $ — $ 42,337 $ — $ —

Business Segments (Tables)

Business Segments (Tables)	9 Months Ended
	Sep. 30, 2018
Segment Reporting [Abstract]
Reconciliation of Revenue from Segments to Consolidated [Table Text Block]	Segment revenues by major payor source were as follows: Three Months Ended September 30, 2018 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 176,009 $ 9,284 $ 3,193 $ — $ 188,486 36.6 % Medicare 103,506 — 30,048 — 133,554 26.0 Medicaid-skilled 30,684 — — — 30,684 6.0 Subtotal 310,199 9,284 33,241 — 352,724 68.6 Managed care 73,897 — 6,299 — 80,196 15.6 Private and other 37,668 28,774 4,297 10,705 (1) 81,444 15.8 Total revenue $ 421,764 $ 38,058 $ 43,837 $ 10,705 $ 514,364 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended September 30, 2018. The following pro forma table demonstrates the impact of adopting ASC 606 on the Company's segment revenues by major payor source for the three months ended September 30, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Three Months Ended September 30, 2018 (Pro forma) Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 178,323 $ 9,284 $ 3,285 $ — $ 190,892 36.6 % Medicare 104,392 — 30,278 — 134,670 25.8 Medicaid-skilled 31,121 — — — 31,121 6.0 Subtotal 313,836 9,284 33,563 — 356,683 68.4 Managed care 75,677 — 6,404 — 82,081 15.6 Private and other 39,675 28,774 4,300 10,705 (1) 83,454 16.0 Total revenue $ 429,188 $ 38,058 $ 44,267 $ 10,705 $ 522,218 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended September 30, 2018. Three Months Ended September 30, 2017 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 158,099 $ 8,083 $ 2,918 $ — $ 169,100 35.9 % Medicare 102,449 — 24,899 — 127,348 27.0 Medicaid-skilled 27,737 — — — 27,737 5.9 Subtotal 288,285 8,083 27,817 — 324,185 68.8 Managed care 69,335 — 5,388 — 74,723 15.8 Private and other 36,501 27,372 2,760 6,053 (1) 72,686 15.4 Total revenue $ 394,121 $ 35,455 $ 35,965 $ 6,053 $ 471,594 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended September 30, 2017. Nine Months Ended September 30, 2018 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 494,104 $ 26,225 $ 8,951 $ — $ 529,280 35.2 % Medicare 323,696 — 85,985 — 409,681 27.3 Medicaid-skilled 86,024 — — — 86,024 5.7 Subtotal 903,824 26,225 94,936 — 1,024,985 68.2 Managed care 225,865 — 18,197 — 244,062 16.2 Private and other 107,609 85,110 11,711 29,407 (1) 233,837 15.6 Total revenue $ 1,237,298 $ 111,335 $ 124,844 $ 29,407 $ 1,502,884 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2018. The following pro forma table demonstrates the impact of adopting ASC 606 on the Company's segment revenues by major payor source for the nine months ended September 30, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Nine Months Ended September 30, 2018 (Pro forma) Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 502,415 $ 26,225 $ 9,250 $ — $ 537,890 35.2 % Medicare 326,389 — 86,689 — 413,078 27.0 Medicaid-skilled 87,594 — — — 87,594 5.7 Subtotal 916,398 26,225 95,939 — 1,038,562 67.9 Managed care 231,025 — 18,687 — 249,712 16.3 Private and other 114,047 85,110 11,782 29,407 (1) 240,346 15.8 Total revenue $ 1,261,470 $ 111,335 $ 126,408 $ 29,407 $ 1,528,620 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2018. Nine Months Ended September 30, 2017 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 439,757 $ 22,322 $ 7,929 $ — $ 470,008 34.5 % Medicare 314,827 — 70,592 — 385,419 28.3 Medicaid-skilled 75,667 — — — 75,667 5.6 Subtotal 830,251 22,322 78,521 — 931,094 68.4 Managed care 208,957 — 16,253 — 225,210 16.5 Private and other 102,469 78,488 7,945 16,406 (1) 205,308 15.1 Total revenue $ 1,141,677 $ 100,810 $ 102,719 $ 16,406 $ 1,361,612 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2017.
Schedule of Segment Reporting Information, by Segment [Table Text Block]	The following table sets forth selected financial data consolidated by business segment: Three Months Ended September 30, 2018 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 421,764 $ — $ 43,837 $ 10,705 $ — $ 476,306 Assisted and independent living revenue — 38,058 — — — 38,058 Revenue from external customers $ 421,764 $ 38,058 $ 43,837 $ 10,705 $ — $ 514,364 Intersegment revenue (1) 857 — — 851 (1,708 ) — Total revenue $ 422,621 $ 38,058 $ 43,837 $ 11,556 $ (1,708 ) $ 514,364 Segment income (loss) (2) $ 46,350 $ 4,733 $ 7,297 $ (29,093 ) $ — $ 29,287 Interest expense, net of interest income $ (3,522 ) Income before provision for income taxes $ 25,765 Depreciation and amortization $ 8,061 $ 1,902 $ 263 $ 1,676 $ — $ 11,902 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense and goodwill and intangible assets impairment for the three months ended September 30, 2018 are included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. The following pro forma table demonstrates the impact of adopting ASC 606 on the Company's selected financial data consolidated by business segment for the three months ended September 30, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Three Months Ended September 30, 2018 (Pro forma) Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 429,188 $ — $ 44,267 $ 10,705 $ — $ 484,160 Assisted and independent living revenue — 38,058 — — — 38,058 Revenue from external customers $ 429,188 $ 38,058 $ 44,267 $ 10,705 $ — $ 522,218 Intersegment revenue (1) 857 — — 851 (1,708 ) — Total revenue $ 430,045 $ 38,058 $ 44,267 $ 11,556 $ (1,708 ) $ 522,218 Segment income (loss) (2) $ 46,350 $ 4,733 $ 7,297 $ (29,093 ) $ — $ 29,287 Interest expense, net of interest income $ (3,522 ) Income before provision for income taxes $ 25,765 Depreciation and amortization $ 8,061 $ 1,902 $ 263 $ 1,676 $ — $ 11,902 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense and goodwill and intangible assets impairment for the three months ended September 30, 2018 are included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. Three Months Ended September 30, 2017 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 394,121 $ — $ 35,965 $ 6,053 $ — $ 436,139 Assisted and independent living revenue — $ 35,455 $ — $ — — 35,455 Revenue from external customers $ 394,121 $ 35,455 $ 35,965 $ 6,053 $ — $ 471,594 Intersegment revenue (1) 739 — — 583 (1,322 ) — Total revenue $ 394,860 $ 35,455 $ 35,965 $ 6,636 $ (1,322 ) $ 471,594 Segment income (loss) (2) $ 36,868 $ 4,342 $ 4,695 $ (20,346 ) $ — $ 25,559 Interest expense, net of interest income $ (3,124 ) Income before provision for income taxes $ 22,435 Depreciation and amortization $ 7,881 $ 1,572 $ 235 $ 1,760 $ — $ 11,448 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense during the three months ended September 30, 2017 is included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. Nine Months Ended September 30, 2018 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,237,298 $ — $ 124,844 $ 29,407 $ — $ 1,391,549 Assisted and independent living revenue — $ 111,335 $ — $ — — 111,335 Revenue from external customers $ 1,237,298 $ 111,335 $ 124,844 $ 29,407 $ — $ 1,502,884 Intersegment revenue (1) 2,191 — — 3,045 (5,236 ) — Total revenue $ 1,239,489 $ 111,335 $ 124,844 $ 32,452 $ (5,236 ) $ 1,502,884 Segment income (loss) (2) $ 135,755 $ 14,361 $ 19,623 $ (75,698 ) $ — $ 94,041 Interest expense, net of interest income $ (9,994 ) Income before provision for income taxes $ 84,047 Depreciation and amortization $ 23,571 $ 5,362 $ 789 $ 5,423 $ — $ 35,145 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense, the return of unclaimed class action settlement and goodwill and intangible assets impairment for the nine months ended September 30, 2018, are included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. The following pro forma table demonstrates the impact of adopting ASC 606 on the Company's selected financial data consolidated by business segment for the nine months ended September 30, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Nine Months Ended September 30, 2018 (Pro forma) Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,261,470 $ — $ 126,408 $ 29,407 $ — $ 1,417,285 Assisted and independent living revenue — 111,335 — — — 111,335 Revenue from external customers $ 1,261,470 $ 111,335 $ 126,408 $ 29,407 $ — $ 1,528,620 Intersegment revenue (1) 2,191 — — 3,045 (5,236 ) — Total revenue $ 1,263,661 $ 111,335 $ 126,408 $ 32,452 $ (5,236 ) $ 1,528,620 Segment income (loss) (2) $ 135,755 $ 14,361 $ 19,623 $ (75,698 ) $ — $ 94,041 Interest expense, net of interest income $ (9,994 ) Income before provision for income taxes $ 84,047 Depreciation and amortization $ 23,571 $ 5,362 $ 789 $ 5,423 $ — $ 35,145 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense, the return of unclaimed class action settlement and goodwill and intangible assets impairment for the nine months ended September 30, 2018, are included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue. Nine Months Ended September 30, 2017 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,141,677 $ — $ 102,719 $ 16,406 $ — $ 1,260,802 Assisted and independent living revenue — $ 100,810 $ — $ — — 100,810 Revenue from external customers $ 1,141,677 $ 100,810 $ 102,719 $ 16,406 $ — $ 1,361,612 Intersegment revenue (1) 2,114 — — 2,196 (4,310 ) — Total revenue $ 1,143,791 $ 100,810 $ 102,719 $ 18,602 $ (4,310 ) $ 1,361,612 Segment income (loss) (2) $ 100,362 $ 12,438 $ 13,912 $ (71,570 ) $ — $ 55,142 Interest expense, net of interest income $ (9,044 ) Income before provision for income taxes $ 46,098 Depreciation and amortization $ 22,038 $ 4,687 $ 700 $ 5,287 $ — $ 32,712 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries to the Company's other business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. General and administrative expense, including charges related to class action lawsuit during the nine months ended September 30, 2017, is included in the "All Other" category. (3) The Company's campuses represent facilities that offer skilled nursing, assisted and/or independent living services. Revenue and expenses related to skilled nursing, assisted and independent living services have been allocated and recorded in the respective reportable segment. Due to the adoption of ASC 606, the presentation of revenue changed from presenting total revenue to service revenue and assisted and independent living revenue.

Property and Equipment (Tables)

Property and Equipment (Tables)	9 Months Ended
	Sep. 30, 2018
Property, Plant and Equipment [Abstract]
Property, Plant and Equipment [Table Text Block]	Property and equipment, net consist of the following: September 30, 2018 December 31, 2017 Land $ 58,579 $ 49,081 Buildings and improvements 390,529 342,641 Equipment 198,568 181,530 Furniture and fixtures 5,410 5,244 Leasehold improvements 108,821 97,221 Construction in progress 8,001 5,460 769,908 681,177 Less: accumulated depreciation (176,820 ) (144,093 ) Property and equipment, net $ 593,088 $ 537,084

Intangible Assets - Net (Tables

Intangible Assets - Net (Tables)	9 Months Ended
	Sep. 30, 2018
Intangible Assets, Net (Excluding Goodwill) [Abstract]
Schedule of Finite-Lived Intangible Assets [Table Text Block]	Weighted Average Life (Years) September 30, 2018 December 31, 2017 Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Lease acquisition costs 14.5 $ 843 $ (191 ) $ 652 $ 483 $ (99 ) $ 384 Favorable leases 29.7 35,650 (8,168 ) 27,482 35,116 (6,568 ) 28,548 Assembled occupancy 0.4 2,786 (2,778 ) 8 2,659 (2,631 ) 28 Facility trade name 30.0 733 (311 ) 422 733 (293 ) 440 Customer relationships 18.2 4,670 (1,614 ) 3,056 4,933 (1,530 ) 3,403 Total $ 44,682 $ (13,062 ) $ 31,620 $ 43,924 $ (11,121 ) $ 32,803
Schedule of Finite-Lived Intangible Assets, Future Amortization Expense [Table Text Block]	Estimated amortization expense for each of the years ending December 31 is as follows: Year Amount 2018 (remainder) $ 686 2019 2,711 2020 1,616 2021 1,454 2022 1,450 2023 1,389 Thereafter 22,314 $ 31,620

Goodwill and Other Indefinite_2

Goodwill and Other Indefinite-Lived Intangible Assets (Tables)	9 Months Ended
	Sep. 30, 2018
Indefinite-Lived Intangible Assets (Including Goodwill) [Abstract]
Schedule of Goodwill [Table Text Block]	The following table represents activity in goodwill by segment as of and for the nine months ended September 30, 2018 : Goodwill Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total January 1, 2018 $ 45,486 $ 3,958 $ 24,322 $ 7,296 $ 81,062 Additions — — 1,007 — 1,007 Purchase price adjustment — — 56 — 56 Impairments $ — $ — $ — (3,513 ) (3,513 ) September 30, 2018 $ 45,486 $ 3,958 $ 25,385 $ 3,783 $ 78,612
Schedule of Acquired Indefinite-lived Intangible Assets by Major Class [Table Text Block]	Other indefinite-lived intangible assets consists of the following: September 30, 2018 December 31, 2017 Trade name $ 1,181 $ 1,181 Medicare and Medicaid licenses 25,020 24,068 $ 26,201 $ 25,249

Restricted and Other Assets (Ta

Restricted and Other Assets (Tables)	9 Months Ended
	Sep. 30, 2018
Other Assets [Abstract]
Schedule of Other Assets [Table Text Block]	Restricted and other assets consist of the following: September 30, 2018 December 31, 2017 Debt issuance costs, net $ 2,118 $ 2,799 Long-term insurance losses recoverable asset 6,451 5,394 Deposits with landlords 8,788 5,981 Capital improvement reserves with landlords and lenders 2,999 2,327 Note receivable from sale of ancillary business 103 — Restricted and other assets $ 20,459 $ 16,501

Other Accrued Liabilities (Tabl

Other Accrued Liabilities (Tables)	9 Months Ended
	Sep. 30, 2018
Accrued Liabilities [Abstract]
Schedule of Accrued Liabilities [Table Text Block]	Other accrued liabilities consist of the following: September 30, 2018 December 31, 2017 Quality assurance fee $ 5,070 $ 4,864 Refunds payable 25,347 21,661 Deferred revenue 9,271 7,066 Cash held in trust for patients 2,848 2,609 Resident deposits 6,754 6,574 Dividends payable 2,377 2,328 Property taxes 11,832 10,088 Other 10,798 8,625 Other accrued liabilities $ 74,297 $ 63,815

Debt (Tables)

Debt (Tables)	9 Months Ended
	Sep. 30, 2018
Debt Disclosure [Abstract]
Schedule of Long-term Debt Instruments [Table Text Block]	Long-term debt consists of the following: September 30, 2018 December 31, 2017 Term loan with SunTrust $ 135,000 $ 140,625 Revolving credit facility with SunTrust — 50,000 Mortgage loans and promissory note 123,591 125,394 258,591 316,019 Less: current maturities (10,080 ) (9,939 ) Less: debt issuance costs (2,907 ) (3,090 ) $ 245,604 $ 302,990

Options and Awards (Tables)

Options and Awards (Tables)	9 Months Ended
	Sep. 30, 2018
Options and Awards [Abstract]
Schedule of Share-based Payment Award, Stock Options, Valuation Assumptions [Table Text Block]	The Company used the following assumptions for stock options granted during the three months ended September 30, 2018 and 2017 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2018 101 2.8% 6.3 years 32.0% 0.5% 2017 103 1.9% 6.2 years 35.4% 0.8% The Company used the following assumptions for stock options granted during the nine months ended September 30, 2018 and 2017 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2018 496 2.7% 6.2 years 32.0% 0.5% 2017 383 1.9% 6.2 years 35.7% 0.8%
Share-based Compensation Arrangement by Share-based Payment Award, Options, Grants in Period, Weighted Average Grant Date Fair Value [Table Text Block]	For the nine months ended September 30, 2018 and 2017 , 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 2018 496 $ 33.61 $ 11.64 2017 383 $ 19.64 $ 6.83
Schedule of Common Stock Outstanding Roll Forward [Table Text Block]	The following table represents the employee stock option activity during the nine months ended September 30, 2018 : Number of Options Outstanding Weighted Average Exercise Price Number of Options Vested Weighted Average Exercise Price of Options Vested January 1, 2018 4,739 $ 13.08 2,776 $ 10.07 Granted 496 33.61 Forfeited (73 ) 19.52 Exercised (763 ) 7.80 September 30, 2018 4,399 $ 16.20 2,658 $ 11.94
Schedule of Share-based Compensation, Shares Authorized under Stock Option Plans, by Exercise Price Range [Table Text Block]	The following summary information reflects stock options outstanding, vested and related details as of September 30, 2018 : Stock Options Vested Stock Options Outstanding Number Outstanding Black-Scholes Fair Value Remaining Contractual Life (Years) Vested and Exercisable Year of Grant Exercise Price 2008 2.56 - 4.06 16 30 0 16 2009 4.06 - 4.56 263 564 1 263 2010 4.77 - 4.96 83 201 2 83 2011 5.90 - 7.99 90 309 3 90 2012 6.56 - 7.96 292 1,082 4 292 2013 7.98 - 11.49 465 2,265 5 432 2014 10.55 - 18.94 1,331 7,553 6 1,000 2015 21.47 - 25.24 500 4,546 7 270 2016 18.79 - 19.89 422 2,946 8 145 2017 18.64 - 22.90 451 3,151 9 67 2018 26.53 - 38.59 486 5,662 10 — Total 4,399 28,309 2,658
Schedule of Nonvested Restricted Stock Units Activity [Table Text Block]	A summary of the status of the Company's non-vested restricted stock awards as of September 30, 2018 and changes during the nine months ended September 30, 2018 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2018 383 $ 20.65 Granted 316 34.79 Vested (125 ) 22.25 Forfeited (14 ) 22.98 Nonvested at September 30, 2018 560 $ 28.21
Schedule of Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Table Text Block]	Share-based compensation expense recognized for the Company's equity incentive plans for the three and nine months ended September 30, 2018 and 2017 was as follows: Three Months Ended September 30, Nine Months Ended September 30, 2018 2017 2018 2017 Share-based compensation expense related to stock options $ 1,213 $ 1,104 $ 3,721 $ 3,629 Share-based compensation expense related to restricted stock awards 968 597 2,220 1,736 Share-based compensation expense related to stock options and restricted stock awards to non-employee directors 281 107 668 371 Total $ 2,462 $ 1,808 $ 6,609 $ 5,736
Share-based Compensation, Schedule of Intrisice Values by Option Category [Table Text Block]	The aggregate intrinsic value of options outstanding, vested, expected to vest and exercised as of September 30, 2018 and December 31, 2017 is as follows: Options September 30, 2018 December 31, 2017 Outstanding $ 95,625 $ 44,060 Vested 69,043 33,976 Expected to vest 23,616 9,311 Exercisable 17,718 10,481

Leases (Tables)

Leases (Tables)	9 Months Ended
	Sep. 30, 2018
Leases [Abstract]
Schedule of Future Minimum Rental Payments for Operating Leases [Table Text Block]	Future minimum lease payments for all leases as of September 30, 2018 are as follows: Year Amount 2018 (remainder) $ 35,338 2019 139,933 2020 139,043 2021 138,428 2022 137,040 2023 135,403 Thereafter 951,177 $ 1,676,362

Description of Business (Detail

Description of Business (Details)	Sep. 30, 2018businessBedsfacilities	Dec. 31, 2017facilities
Skilled nursing, assisted living and independent living facilities [Abstract]
Number of Real Estate Properties	68	63
Number of Real Estate Properties Leased	168	167
Number of Real Estate Properties Leased with an Option to Purchase	12	11
Number of Real Estate Properties Operated	236	230
Home Health, Hospice and Home Care Operations | business	49
Operational Skilled Nursing Beds | Beds	19,300
Operational Skilled Nursing, Assisted Living and Independent Living Beds [Abstract]
Operational Assisted Living and Independent Living Units | Beds	5,200

Significant Accounting Polici_3

Significant Accounting Policies Revenue Recognition (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Jan. 01, 2018	Dec. 31, 2017
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Retained Earnings	$ 321,448		$ 264,691
Difference between Revenue Guidance in Effect before and after Topic 606 [Member]
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Retained Earnings		$ 0

Significant Accounting Polici_4

Significant Accounting Policies Property and Equipment (Details)	9 Months Ended
	Sep. 30, 2018
Minimum [Member]
Property, Plant and Equipment [Line Items]
Property, Plant and Equipment, Useful Life	3 years
Maximum [Member]
Property, Plant and Equipment [Line Items]
Property, Plant and Equipment, Useful Life	59 years

Significant Accounting Polici_5

Significant Accounting Policies Impairment (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Accounting Policies [Abstract]
Goodwill and intangible asset impairment	$ 3,653	$ 0	$ 3,653	$ 0
Impairment of Long-Lived Assets to be Disposed of	$ 0	$ 0	$ 860	$ 111

Significant Accounting Polici_6

Significant Accounting Policies Intangible Assets and Goodwill (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Finite-Lived Intangible Assets [Line Items]
Impairment of Long-Lived Assets to be Disposed of	$ 0	$ 0	$ 860	$ 111
Impairments			3,513
Goodwill and intangible asset impairment	$ 3,653	$ 0	$ 3,653	$ 0
Assembled occupancy | Minimum [Member]
Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Asset, Useful Life			4 months
Assembled occupancy | Maximum [Member]
Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Asset, Useful Life			8 months
Trade name
Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Asset, Useful Life			30 years
Customer relationships
Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Asset, Useful Life			20 years

Significant Accounting Polici_7

Significant Accounting Policies Self-Insurance General and Professional (Details) - General and Professional Liability Insurance [Member] - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 41,280	$ 38,998
Self-insurance retention per claim [Member] | Parent Company [Member]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	500
Aggregate Deductible [Member] | Parent Company [Member] | CALIFORNIA
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	750
Aggregate Deductible [Member] | Parent Company [Member] | Non-California [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	1,000
Blanket Aggregate [Member] | Third-Party Payor [Member] | All States Except Colorado [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	5,000
Per Facility [Member] | Third-Party Payor [Member] | All States Except Colorado [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	3,000
Per Facility [Member] | Third-Party Payor [Member] | COLORADO
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	3,000
Per Occurence [Member] | Third-Party Payor [Member] | All States Except Colorado [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	1,000
Per Occurence [Member] | Third-Party Payor [Member] | COLORADO
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 1,000

Significant Accounting Polici_8

Significant Accounting Policies Self-Insurance Workers' Compensation (Details) - Workers' Compensation [Member] - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 24,427	$ 23,621
Stop-Loss Insurance limit per claim [Member]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	500
Stop-Loss Insurance limit per claim [Member] | TEXAS
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	750
Loss-Sensitive limit per claim [Member] [Member] | Other states, except California, Texas and Washington [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 350

Significant Accounting Polici_9

Significant Accounting Policies Self Insurance Recoveries (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Accounting Policies [Abstract]
Long-term insurance losses recoverable asset	$ 6,451	$ 5,394

Significant Accounting Polic_10

Significant Accounting Policies Self-Insurance Health Insurance (Details) - Health Liability Insurance [Member] - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 5,659	$ 4,723
Stop-Loss Insurance limit per claim [Member]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	300
Stop Loss Deductible [Member]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 75

Significant Accounting Polic_11

Significant Accounting Policies Recent Accounting Standards Adopted (Details)	9 Months Ended
	Sep. 30, 2018Operations
Asset Acquisition [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Number of Businesses Acquired	9
Business Acquisitions [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Number of Businesses Acquired	2

Revenue and Accounts Receivab_3

Revenue and Accounts Receivable Revenue from Medicare and Medicaid Programs (Details)	3 Months Ended		9 Months Ended
	Sep. 30, 2018Rate	Sep. 30, 2017Rate	Sep. 30, 2018Rate	Sep. 30, 2017Rate
Total Medicare and Medicaid
Disaggregation of Revenue [Line Items]
Revenue by payor as a percent of total revenue	68.60%	68.80%	68.20%	68.40%

Revenue and Accounts Receivab_4

Revenue and Accounts Receivable Impact of New Revenue Guidance (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Total revenue	$ 514,364	$ 471,594	$ 1,502,884	$ 1,361,612
Cost of services	413,723	381,544	1,200,098	1,103,976
Total Expense	485,077	446,035	1,408,843	1,306,470
Provision for Doubtful Accounts	$ 1,128	$ 7,288	$ 2,101	$ 21,934
Bad Debt Expense as a Percent of Total Revenue	0.20%	1.50%	0.10%	1.60%
Difference between Revenue Guidance in Effect before and after Topic 606 [Member]
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Total revenue	$ 7,854	$ 0	$ 25,736	$ 0
Cost of services	7,854	0	25,736	0
Total Expense	7,854	0	25,736	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Total revenue	522,218	471,594	1,528,620	1,361,612
Cost of services	421,577	381,544	1,225,834	1,103,976
Total Expense	$ 492,931	$ 446,035	$ 1,434,579	$ 1,306,470

Revenue and Accounts Receivab_5

Revenue and Accounts Receivable Revenue (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Disaggregation of Revenue [Line Items]
Total revenue	$ 514,364	$ 471,594	$ 1,502,884	$ 1,361,612
Percentage of revenue	100.00%		100.00%
Medicaid
Disaggregation of Revenue [Line Items]
Total revenue	$ 188,486		$ 529,280
Percentage of revenue	36.60%		35.20%
Medicare
Disaggregation of Revenue [Line Items]
Total revenue	$ 133,554		$ 409,681
Percentage of revenue	26.00%		27.30%
Medicaid — skilled
Disaggregation of Revenue [Line Items]
Total revenue	$ 30,684		$ 86,024
Percentage of revenue	6.00%		5.70%
Total Medicaid and Medicare
Disaggregation of Revenue [Line Items]
Total revenue	$ 352,724		$ 1,024,985
Percentage of revenue	68.60%		68.20%
Managed care
Disaggregation of Revenue [Line Items]
Total revenue	$ 80,196		$ 244,062
Percentage of revenue	15.60%		16.20%
Private Pay and Other
Disaggregation of Revenue [Line Items]
Total revenue	$ 81,444		$ 233,837
Percentage of revenue	15.80%		15.60%
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Disaggregation of Revenue [Line Items]
Total revenue	$ 522,218	$ 471,594	$ 1,528,620	$ 1,361,612
Percentage of revenue	100.00%	100.00%	100.00%	100.00%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid
Disaggregation of Revenue [Line Items]
Total revenue	$ 190,892	$ 169,100	$ 537,890	$ 470,008
Percentage of revenue	36.60%	35.90%	35.20%	34.50%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare
Disaggregation of Revenue [Line Items]
Total revenue	$ 134,670	$ 127,348	$ 413,078	$ 385,419
Percentage of revenue	25.80%	27.00%	27.00%	28.30%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid — skilled
Disaggregation of Revenue [Line Items]
Total revenue	$ 31,121	$ 27,737	$ 87,594	$ 75,667
Percentage of revenue	6.00%	5.90%	5.70%	5.60%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Total Medicaid and Medicare
Disaggregation of Revenue [Line Items]
Total revenue	$ 356,683	$ 324,185	$ 1,038,562	$ 931,094
Percentage of revenue	68.40%	68.80%	67.90%	68.40%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care
Disaggregation of Revenue [Line Items]
Total revenue	$ 82,081	$ 74,723	$ 249,712	$ 225,210
Percentage of revenue	15.60%	15.80%	16.30%	16.50%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private Pay and Other
Disaggregation of Revenue [Line Items]
Total revenue	$ 83,454	$ 72,686	$ 240,346	$ 205,308
Percentage of revenue	16.00%	15.40%	15.80%	15.10%

Revenue and Accounts Receivab_6

Revenue and Accounts Receivable Contract Balances (Details)	Sep. 30, 2018USD ($)
REVENUE AND ACCOUNTS RECEIVABLE [Abstract]
Contract with Customer, Liability	$ 0

Revenue and Accounts Receivab_7

Revenue and Accounts Receivable Accounts Receivable (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	$ 263,938
Less: allowance for doubtful accounts	(2,484)	$ (43,961)
Accounts receivable, net	261,454
Medicaid
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	101,310
Managed care
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	53,825
Medicare
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	47,367
Private Pay and Other
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	61,436
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	311,321	309,029
Less: allowance for doubtful accounts	(49,867)	(43,961)
Accounts receivable, net	261,454	265,068
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	117,227	119,441
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	67,150	68,930
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	54,428	55,667
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private Pay and Other
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	$ 72,516	$ 64,991

Computation of Net Income Per_3

Computation of Net Income Per Common Share (Details) - USD ($) $ / shares in Units, shares in Thousands, $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Numerator:
Net income	$ 20,350	$ 14,275	$ 65,969	$ 29,611
Less: net (loss)/income attributable to noncontrolling interests	(511)	63	(35)	342
Net income attributable to The Ensign Group, Inc.	$ 20,861	$ 14,212	$ 66,004	$ 29,269
Denominator:
Weighted average shares outstanding for basic net income per share	52,139	50,911	51,870	50,795
Adjusted weighted average common shares outstanding	54,632	52,828	54,176	52,674
Basic net income (loss) per common share:
Basic net income per common share attributable to The Ensign Group, Inc.	$ 0.40	$ 0.28	$ 1.27	$ 0.58
Diluted net (loss) income per common share:
Diluted net income per common share attributable to The Ensign Group, Inc.	$ 0.38	$ 0.27	$ 1.22	$ 0.56
Common Class A [Member]
Denominator:
Weighted average shares outstanding for basic net income per share	52,139	50,911	51,870	50,795
Plus: incremental shares from assumed conversion (1)	2,493	1,917	2,306	1,879

Computation of Net Income Per_4

Computation of Net Income Per Common Share Antidilutive Shares (Details) - shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Earnings Per Share, Diluted, Other Disclosures [Abstract]
Antidilutive Securities Excluded from Computation of Earnings Per Share, Amount	244	1,352	163	1,326

Fair Value Measurements (Detail

Fair Value Measurements (Details) - Cash and cash equivalents - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Level 1
Cash and cash equivalents	$ 45,657	$ 42,337
Level 2
Cash and cash equivalents	0	0
Level 3
Cash and cash equivalents	$ 0	$ 0

Fair Value Measurements Investm

Fair Value Measurements Investments (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Debt Security, Corporate, US [Member]
Schedule of Held-to-maturity Securities [Line Items]
Debt Securities, Held-to-maturity	$ 42,175	$ 41,777

Business Segments (Details)

Business Segments (Details) $ in Thousands	3 Months Ended			9 Months Ended
	Sep. 30, 2018USD ($)businessfacilities	Sep. 30, 2017USD ($)	Jun. 30, 2017USD ($)	Sep. 30, 2018USD ($)businessfacilitiesSegments	Sep. 30, 2017USD ($)
Segment Reporting Information [Line Items]
Number of Reportable Segments | Segments				3
Transitional and Skilled Service Facilities | facilities	163			163
Transitional and Skilled Services and Assistant and Independent Living Campuses | facilities	22			22
Assisted and Independent Living Facilities | facilities	51			51
Home Health, Hospice and Home Care Operations | business	49			49
Business Exit Costs	$ 0	$ 0	$ (1,286)	$ 0	$ 2,731
Gain (Loss) on Contract Termination					2,715
Impairment of Long-Lived Assets to be Disposed of	$ 0	$ 0		$ 860	111
Contract Termination and Facility Closing [Member]
Segment Reporting Information [Line Items]
Business Exit Costs					$ 4,017

Business Segments Revenue by Se

Business Segments Revenue by Segment (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 514,364	$ 471,594	$ 1,502,884	$ 1,361,612
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	100.00%		100.00%
Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 421,764		$ 1,237,298
Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	38,058		111,335
Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	43,837		124,844
All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	10,705		29,407
Medicaid
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 188,486		$ 529,280
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	36.60%		35.20%
Medicaid | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 176,009		$ 494,104
Medicaid | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	9,284		26,225
Medicaid | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	3,193		8,951
Medicaid | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 133,554		$ 409,681
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	26.00%		27.30%
Medicare | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 103,506		$ 323,696
Medicare | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Medicare | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	30,048		85,985
Medicare | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Medicaid — skilled
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 30,684		$ 86,024
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	6.00%		5.70%
Medicaid — skilled | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 30,684		$ 86,024
Medicaid — skilled | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Medicaid — skilled | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Medicaid — skilled | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Total Medicaid and Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 352,724		$ 1,024,985
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	68.60%		68.20%
Total Medicaid and Medicare | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 310,199		$ 903,824
Total Medicaid and Medicare | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	9,284		26,225
Total Medicaid and Medicare | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	33,241		94,936
Total Medicaid and Medicare | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Managed care
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 80,196		$ 244,062
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	15.60%		16.20%
Managed care | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 73,897		$ 225,865
Managed care | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Managed care | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	6,299		18,197
Managed care | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0		0
Private and other payors(1)
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 81,444		$ 233,837
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	15.80%		15.60%
Private and other payors(1) | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 37,668		$ 107,609
Private and other payors(1) | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	28,774		85,110
Private and other payors(1) | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	4,297		11,711
Private and other payors(1) | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	10,705		29,407
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 522,218	$ 471,594	$ 1,528,620	$ 1,361,612
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	100.00%	100.00%	100.00%	100.00%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 429,188	$ 394,121	$ 1,261,470	$ 1,141,677
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	38,058	35,455	111,335	100,810
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	44,267	35,965	126,408	102,719
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	10,705	6,053	29,407	16,406
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 190,892	$ 169,100	$ 537,890	$ 470,008
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	36.60%	35.90%	35.20%	34.50%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 178,323	$ 158,099	$ 502,415	$ 439,757
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	9,284	8,083	26,225	22,322
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	3,285	2,918	9,250	7,929
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 134,670	$ 127,348	$ 413,078	$ 385,419
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	25.80%	27.00%	27.00%	28.30%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 104,392	$ 102,449	$ 326,389	$ 314,827
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	30,278	24,899	86,689	70,592
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid — skilled
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 31,121	$ 27,737	$ 87,594	$ 75,667
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	6.00%	5.90%	5.70%	5.60%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid — skilled | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 31,121	$ 27,737	$ 87,594	$ 75,667
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid — skilled | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid — skilled | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid — skilled | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Total Medicaid and Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 356,683	$ 324,185	$ 1,038,562	$ 931,094
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	68.40%	68.80%	67.90%	68.40%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Total Medicaid and Medicare | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 313,836	$ 288,285	$ 916,398	$ 830,251
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Total Medicaid and Medicare | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	9,284	8,083	26,225	22,322
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Total Medicaid and Medicare | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	33,563	27,817	95,939	78,521
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Total Medicaid and Medicare | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 82,081	$ 74,723	$ 249,712	$ 225,210
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	15.60%	15.80%	16.30%	16.50%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 75,677	$ 69,335	$ 231,025	$ 208,957
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	6,404	5,388	18,687	16,253
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private and other payors(1)
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 83,454	$ 72,686	$ 240,346	$ 205,308
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	16.00%	15.40%	15.80%	15.10%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private and other payors(1) | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 39,675	$ 36,501	$ 114,047	$ 102,469
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private and other payors(1) | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	28,774	27,372	85,110	78,488
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private and other payors(1) | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	4,300	2,760	11,782	7,945
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private and other payors(1) | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 10,705	$ 6,053	$ 29,407	$ 16,406

Business Segments Schedule of S

Business Segments Schedule of Segment Reporting Information, by Segment (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Segment Reporting Information [Line Items]
Revenue from external customers	$ 514,364	$ 471,594	$ 1,502,884	$ 1,361,612
Intersegment revenue (1)	0		0
Total revenue	514,364		1,502,884
Segment income (loss) (2)	29,287	25,559	94,041	55,142
Interest expense, net of interest income	(3,522)	(3,124)	(9,994)	(9,044)
Income before provision for income taxes	25,765	22,435	84,047	46,098
Depreciation and amortization	11,902	11,448	35,145	32,712
Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	421,764		1,237,298
Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	38,058		111,335
Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	43,837		124,844
All Other
Segment Reporting Information [Line Items]
Revenue from external customers	10,705		29,407
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	522,218	471,594	1,528,620	1,361,612
Intersegment revenue (1)	0	0	0	0
Total revenue	522,218	471,594	1,528,620	1,361,612
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	429,188	394,121	1,261,470	1,141,677
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	38,058	35,455	111,335	100,810
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	44,267	35,965	126,408	102,719
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	10,705	6,053	29,407	16,406
Health Care, Patient Service [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	476,306	436,139	1,391,549	1,260,802
Health Care, Patient Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	484,160	436,139	1,417,285	1,260,802
Health Care, Resident Service [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	38,058	35,455	111,335	100,810
Health Care, Resident Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	38,058	35,455	111,335	100,810
Operating Segments [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	421,764	394,121	1,237,298	1,141,677
Total revenue	422,621	394,860	1,239,489	1,143,791
Segment income (loss) (2)	46,350	36,868	135,755	100,362
Depreciation and amortization	8,061	7,881	23,571	22,038
Operating Segments [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	38,058	35,455	111,335	100,810
Total revenue	38,058	35,455	111,335	100,810
Segment income (loss) (2)	4,733	4,342	14,361	12,438
Depreciation and amortization	1,902	1,572	5,362	4,687
Operating Segments [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	43,837	35,965	124,844	102,719
Total revenue	43,837	35,965	124,844	102,719
Segment income (loss) (2)	7,297	4,695	19,623	13,912
Depreciation and amortization	263	235	789	700
Operating Segments [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	10,705	6,053	29,407	16,406
Total revenue	11,556	6,636	32,452	18,602
Segment income (loss) (2)	(29,093)	(20,346)	(75,698)	(71,570)
Depreciation and amortization	1,676	1,760	5,423	5,287
Operating Segments [Member] | Elimination
Segment Reporting Information [Line Items]
Total revenue	(1,708)	(1,322)	(5,236)	(4,310)
Operating Segments [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	429,188		1,261,470
Total revenue	430,045		1,263,661
Operating Segments [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	38,058		111,335
Total revenue	38,058		111,335
Operating Segments [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	44,267		126,408
Total revenue	44,267		126,408
Operating Segments [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	10,705		29,407
Total revenue	11,556		32,452
Operating Segments [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Elimination
Segment Reporting Information [Line Items]
Total revenue	(1,708)		(5,236)
Operating Segments [Member] | Health Care, Patient Service [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	421,764	394,121	1,237,298	1,141,677
Operating Segments [Member] | Health Care, Patient Service [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	0	0	0	0
Operating Segments [Member] | Health Care, Patient Service [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	43,837	35,965	124,844	102,719
Operating Segments [Member] | Health Care, Patient Service [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	10,705	6,053	29,407	16,406
Operating Segments [Member] | Health Care, Patient Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	429,188		1,261,470
Operating Segments [Member] | Health Care, Patient Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	0		0
Operating Segments [Member] | Health Care, Patient Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	44,267		126,408
Operating Segments [Member] | Health Care, Patient Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	10,705		29,407
Operating Segments [Member] | Health Care, Resident Service [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	0	0	0	0
Operating Segments [Member] | Health Care, Resident Service [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	38,058	35,455	111,335	100,810
Operating Segments [Member] | Health Care, Resident Service [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	0	0	0	0
Operating Segments [Member] | Health Care, Resident Service [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	0	0	0	0
Operating Segments [Member] | Health Care, Resident Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	0		0
Operating Segments [Member] | Health Care, Resident Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	38,058		111,335
Operating Segments [Member] | Health Care, Resident Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	0		0
Operating Segments [Member] | Health Care, Resident Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	0		0
Consolidation, Eliminations [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Intersegment revenue (1)	857	739	2,191	2,114
Consolidation, Eliminations [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Intersegment revenue (1)	0	0	0	0
Consolidation, Eliminations [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Intersegment revenue (1)	0	0	0	0
Consolidation, Eliminations [Member] | All Other
Segment Reporting Information [Line Items]
Intersegment revenue (1)	851	583	3,045	2,196
Consolidation, Eliminations [Member] | Elimination
Segment Reporting Information [Line Items]
Intersegment revenue (1)	(1,708)	$ (1,322)	(5,236)	$ (4,310)
Consolidation, Eliminations [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Intersegment revenue (1)	857		2,191
Consolidation, Eliminations [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Intersegment revenue (1)	0		0
Consolidation, Eliminations [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Intersegment revenue (1)	0		0
Consolidation, Eliminations [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting Information [Line Items]
Intersegment revenue (1)	851		3,045
Consolidation, Eliminations [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Elimination
Segment Reporting Information [Line Items]
Intersegment revenue (1)	$ (1,708)		$ (5,236)

Acquisitions Acquisition Summar

Acquisitions Acquisition Summary (Details) $ in Thousands	Oct. 01, 2018USD ($)OperationsBeds	Sep. 30, 2018USD ($)Beds	Sep. 30, 2018USD ($)OperationsBeds	Sep. 30, 2017USD ($)
Business Acquisition [Line Items]
Cash payments for asset acquisitions | $			$ 57,859	$ 310
Payments to Acquire Business and Asset Acquisitions | $			$ 59,484
Operational Skilled Nursing Beds | Beds		19,300	19,300
Operational Assisted Living and Independent Living Units | Beds		5,200	5,200
621610 Home Health Care Services [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired			2
Hospice Agencies [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired			1
Home Care Agency [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired			1
8051 Services, Skilled Nursing Care Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired			3
Operational Skilled Nursing Beds | Beds		468	468
Transitional and Skilled Services and Assisted and Independent Campuses [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired			1
Assisted Living Facility [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired			2
Operational Assisted Living and Independent Living Units | Beds		218	218
Asset Acquisition [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired			9
Business Acquisitions [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired			2
Subsequent Event [Member] | Assisted Living Facility [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired	1
Operational Assisted Living Units | Beds	53
Office Building [Member]
Business Acquisition [Line Items]
Cash payments for asset acquisitions | $		$ 30,959
Assisted Living Facility [Member] | Subsequent Event [Member]
Business Acquisition [Line Items]
Cash payments for asset acquisitions | $	$ 5,250

Acquisitions (Details)

Acquisitions (Details) - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross	$ 1,625	$ 84,063
Business Combination, Recognized Identifiable Assets Acquired and Liabilities Assumed, Net		292
Assembled occupancy
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		772
Goodwill & Indefinite-lived Intangible Assets [Member]
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross	$ 1,609
Goodwill
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		10,563
Other indefinite-lived intangible assets
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		5,808
Land
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		9,732
Building and improvements
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		52,805
Equipment, furniture, and fixtures
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		$ 4,091

Property and Equipment (Details

Property and Equipment (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Property, Plant and Equipment [Line Items]
Property and equipment	$ 769,908	$ 681,177
Less: accumulated depreciation	(176,820)	(144,093)
Property and equipment, net	593,088	537,084
Land
Property, Plant and Equipment [Line Items]
Property and equipment	58,579	49,081
Building and improvements
Property, Plant and Equipment [Line Items]
Property and equipment	390,529	342,641
Equipment
Property, Plant and Equipment [Line Items]
Property and equipment	198,568	181,530
Furniture and fixtures
Property, Plant and Equipment [Line Items]
Property and equipment	5,410	5,244
Leasehold improvements
Property, Plant and Equipment [Line Items]
Property and equipment	108,821	97,221
Construction in progress
Property, Plant and Equipment [Line Items]
Property and equipment	$ 8,001	$ 5,460

Intangible Assets - Net (Detail

Intangible Assets - Net (Details) - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2018	Dec. 31, 2017
Acquired Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Assets, Gross	$ 44,682	$ 43,924
Accumulated Amortization	(13,062)	(11,121)
Intangible assets, net	$ 31,620	32,803
Lease acquisition costs
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	14 years 6 months
Finite-Lived Intangible Assets, Gross	$ 843	483
Accumulated Amortization	(191)	(99)
Intangible assets, net	$ 652	384
Favorable leases
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	29 years 8 months
Finite-Lived Intangible Assets, Gross	$ 35,650	35,116
Accumulated Amortization	(8,168)	(6,568)
Intangible assets, net	$ 27,482	28,548
Assembled occupancy
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	4 months 30 days
Finite-Lived Intangible Assets, Gross	$ 2,786	2,659
Accumulated Amortization	(2,778)	(2,631)
Intangible assets, net	$ 8	28
Trade name
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	30 years
Finite-Lived Intangible Assets, Gross	$ 733	733
Accumulated Amortization	(311)	(293)
Intangible assets, net	$ 422	440
Customer relationships
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	18 years 2 months
Finite-Lived Intangible Assets, Gross	$ 4,670	4,933
Accumulated Amortization	(1,614)	(1,530)
Intangible assets, net	$ 3,056	$ 3,403

Intangible Assets - Net Additio

Intangible Assets - Net Additional Disclosures (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Finite-Lived Intangible Assets [Line Items]
Amortization of Intangible Assets	$ 761	$ 979	$ 2,067	$ 2,280

Intangible Assets - Net Future

Intangible Assets - Net Future Amortization (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Finite-Lived Intangible Assets, Net, Amortization Expense, Fiscal Year Maturity [Abstract]
2018 (remainder)	$ 686
2,019	2,711
2,020	1,616
2,021	1,454
2,022	1,450
2,023	1,389
Thereafter	22,314
Intangible assets, net	$ 31,620	$ 32,803

Goodwill and Other Indefinite_3

Goodwill and Other Indefinite-Lived Intangible Assets Goodwill Rollforward (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Goodwill [Line Items]
January 1			$ 81,062
Additions			1,007
Purchase price adjustment			56
Impairments			(3,513)
September 30	$ 78,612		78,612
Goodwill and intangible asset impairment	3,653	$ 0	3,653	$ 0
Transitional and Skilled Services Segment
Goodwill [Line Items]
January 1			45,486
Additions			0
Purchase price adjustment			0
Impairments			0
September 30	45,486		45,486
Assisted and Independent Living Services Segment
Goodwill [Line Items]
January 1			3,958
Additions			0
Purchase price adjustment			0
Impairments			0
September 30	3,958		3,958
Home Health and Hospice Services
Goodwill [Line Items]
January 1			24,322
Additions			1,007
Purchase price adjustment			56
Impairments			0
September 30	25,385		25,385
All Other
Goodwill [Line Items]
January 1			7,296
Additions			0
Purchase price adjustment			0
Impairments			(3,513)
September 30	$ 3,783		$ 3,783

Goodwill and Other Indefinite_4

Goodwill and Other Indefinite-Lived Intangible Assets Indefinite-lived intangble assets (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 26,201	$ 25,249
Medicare and Medicaid licenses
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	952
Home Health and Hospice Services | Trade name
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	1,181	1,181
Home Health and Hospice Services | Medicare and Medicaid licenses
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 25,020	$ 24,068

Restricted and Other Assets (De

Restricted and Other Assets (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Other Assets [Abstract]
Debt issuance costs, net	$ 2,118	$ 2,799
Long-term insurance losses recoverable asset	6,451	5,394
Deposits with landlords	8,788	5,981
Capital improvement reserves with landlords and lenders	2,999	2,327
Note receivable from sale of ancillary business	103	0
Restricted and other assets	$ 20,459	$ 16,501

Other Accrued Liabilities (Deta

Other Accrued Liabilities (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Accrued Liabilities [Abstract]
Quality assurance fee	$ 5,070	$ 4,864
Refunds payable	25,347	21,661
Deferred revenue	9,271	7,066
Cash held in trust for patients	2,848	2,609
Resident deposits	6,754	6,574
Dividends payable	2,377	2,328
Property taxes	11,832	10,088
Other	10,798	8,625
Other accrued liabilities	$ 74,297	$ 63,815

Income Taxes Expense (Details)

Income Taxes Expense (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Income Tax Disclosure [Abstract]
Provision for income taxes	$ 5,415	$ 8,160	$ 18,078	$ 16,487
Effective Income Tax Rate Reconciliation, Percent			21.50%	35.80%

Income Taxes Other Disclosures

Income Taxes Other Disclosures (Details) $ in Thousands	9 Months Ended
	Sep. 30, 2018USD ($)
Operating Loss Carryforwards [Line Items]
Income Tax Expense (Benefit), Continuing Operations, Adjustment of Deferred Tax (Asset) Liability	$ 0

Debt (Details)

Debt (Details) - USD ($) $ in Thousands	Sep. 30, 2018	Dec. 31, 2017
Debt Instrument [Line Items]
Long-term Debt, Gross	$ 258,591	$ 316,019
Current maturities of long-term debt	(10,080)	(9,939)
Long Term Debt, net of Current Maturities and Debt Discount	245,604	302,990
SunTrust Bank [Member] | Revolving Credit Facility [Member]
Debt Instrument [Line Items]
Revolving credit facility with SunTrust	0	50,000
Second Amended Credit Facility [Member] | SunTrust Bank [Member] | Revolving Credit Facility [Member]
Debt Instrument [Line Items]
Term loan with SunTrust	135,000	140,625
Less: debt issuance costs	(2,907)	(3,090)
Collateralized Debt Obligations [Member] | Notes Payable, Other Payables [Member]
Debt Instrument [Line Items]
Mortgage loans and promissory note	$ 123,591	$ 125,394

Debt Additional Disclosures (De

Debt Additional Disclosures (Details) $ in Thousands	Feb. 05, 2016USD ($)Rate	May 30, 2014USD ($)Rate	Oct. 29, 2018USD ($)	Sep. 30, 2018USD ($)	Dec. 31, 2017USD ($)	Jul. 19, 2016USD ($)Rate
Secured Debt [Member] | Senior Debt Obligations [Member]
Long-Term Debt Additional Disclosures [Line Items]
Decrease in Letters of Credit				$ 1,797
Pledged Financial Instruments, Not Separately Reported, Securities for Letter of Credit Facilities				4,557
SunTrust Bank [Member] | Revolving Credit Facility [Member]
Long-Term Debt Additional Disclosures [Line Items]
Revolving credit facility with SunTrust				0	$ 50,000
Line of Credit Facility, Current Borrowing Capacity	$ 250,000	$ 150,000
Line of Credit Facility, Maximum Borrowing Capacity	$ 150,000	$ 75,000
Total Net Debt Ratio, Maximum	3.50
Total Net Debt Ratio, Minimum	1.50
EBITDA Ratio, Maximum	1
EBITDA Ratio, Minimum	1
Total Net Debt Ratio, Default	2.75
EBITDA Ratio, Default	1
Aggregate Revolving Commitment Percentage | Rate	10.00%
Total Net Debt Ratio, Cured	2.75
EBITDA Ratio, Cured	1
SunTrust Bank [Member] | Revolving Credit Facility [Member] | Second Amended Credit Facility [Member]
Long-Term Debt Additional Disclosures [Line Items]
Term Loan, Amount Outstanding, Current				7,500
Term Loan, Amount Outstanding, Noncurrent				127,500
Line of Credit Facility, Current Borrowing Capacity						$ 450,000
Long-term Line of Credit						300,000
Term Loan, Borrowing Capacity						$ 150,000
Line of Credit Facility, Interest Rate at Period End | Rate						5.00%
Term loan with SunTrust				$ 135,000	$ 140,625
SunTrust Bank [Member] | Revolving Credit Facility [Member] | Subsequent Event [Member] | Second Amended Credit Facility [Member]
Long-Term Debt Additional Disclosures [Line Items]
Term loan with SunTrust			$ 135,000
SunTrust Bank [Member] | Revolving Credit Facility [Member] | Minimum [Member]
Long-Term Debt Additional Disclosures [Line Items]
Line of Credit Facility, Interest Rate, Additional Margin | Rate	0.75%	1.25%
Line of Credit Facility, Interest Rate, LIBOR | Rate	1.75%	2.25%
Line of Credit Facility, Unused Capacity, Commitment Fee Percentage | Rate	0.30%	0.30%
SunTrust Bank [Member] | Revolving Credit Facility [Member] | Maximum [Member]
Long-Term Debt Additional Disclosures [Line Items]
Line of Credit Facility, Interest Rate, Additional Margin | Rate	1.75%	2.25%
Line of Credit Facility, Interest Rate, LIBOR | Rate	2.75%	3.25%
Line of Credit Facility, Unused Capacity, Commitment Fee Percentage | Rate	0.50%	0.50%

Debt Other Additional Disclosur

Debt Other Additional Disclosures (Details) - Collateralized Debt Obligations [Member] $ in Thousands	Dec. 31, 2014	Dec. 27, 2017USD ($)facilitiesRate	Sep. 30, 2018USD ($)	Dec. 31, 2017USD ($)	Dec. 31, 2016Rate
Mortgages [Member]
Debt Instrument [Line Items]
Number of Operating Subsidiaries | facilities		17
Prepayment Penalty Reduced Rate During First Three Years		10.00%
Prepayment Penalty Reduced Rate During the Fourth Year		3.00%
Prepayment Penalty Reduced Rate for the Fifth through Tenth Years		1.00%
Prepayment penalty reduced rate					1.00%
Notes Payable | $		$ 112,000
Mortgages [Member] | Minimum [Member]
Debt Instrument [Line Items]
Debt Instrument, pre-payment fee reduction, term	3 years	5 years
Debt Instrument, Term	12 years	30 years
Mortgages [Member] | Maximum [Member]
Debt Instrument [Line Items]
Debt Instrument, pre-payment fee reduction, term	11 years	10 years
Debt Instrument, Term	33 years	35 years
Notes Payable, Other Payables [Member]
Debt Instrument [Line Items]
Notes Payable | $			$ 123,591	$ 125,394
Notes Payable, Current | $			2,580
Notes Payable, Noncurrent | $			$ 121,011
Notes Payable to Banks [Member]
Debt Instrument [Line Items]
Debt Instrument, Interest Rate, Stated Percentage		3.30%
Notes Payable to Banks [Member] | Minimum [Member]
Debt Instrument [Line Items]
Debt Instrument, Interest Rate, Stated Percentage					2.60%
Notes Payable to Banks [Member] | Maximum [Member]
Debt Instrument [Line Items]
Debt Instrument, Interest Rate, Stated Percentage					5.30%

Options and Awards Lead Paragra

Options and Awards Lead Paragraphs (Details) shares in Thousands	May 25, 2017shares	Sep. 30, 2018Agreementsshares	Sep. 30, 2017shares	Sep. 30, 2018Agreementsshares	Sep. 30, 2017shares
Stock Options granted [Line Items]
Number of Option Plans | Agreements		1		1
Stock Issued or Granted During Period, Share-based Compensation [Abstract]
Award Vesting Period				5 years
Options Granted		101	103	496	383
Nonvested Restricted Awards, Granted		42	41	316	140
2017 Plan [Member]
Stock Issued or Granted During Period, Share-based Compensation [Abstract]
Number of Shares Available for Grant		5,021		5,021
Number of Shares Authorized	6,881
Conversion to Reduce Shares Availability	1
Other than Options, Conversion to Reduce Shares Availability	2.5
Award Vesting Period	5 years
Award Vesting Rights, Percentage	20.00%
Expiration Period	10 years
2017 Plan [Member] | Director [Member]
Stock Issued or Granted During Period, Share-based Compensation [Abstract]
Award Vesting Period	3 years
Award Requisite Service Period	3 years

Options and Awards Valuation As

Options and Awards Valuation Assumptions (Details) - shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Options and Awards [Abstract]
Options Granted	101	103	496	383
Fair Value Assumptions and Methodology
Weighted Average Risk-Free Rate	2.80%	1.90%	2.70%	1.90%
Expected Life	6 years 3 months	6 years 2 months	6 years 2 months	6 years 2 months
Weighted Average Volatility	32.00%	35.40%	32.00%	35.70%
Weighted Average Dividend Yield	0.50%	0.80%	0.50%	0.80%

Options and Awards Exercise Pri

Options and Awards Exercise Price and Fair Value (Details) - $ / shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Share-based Compensation Arrangement by Share-based Payment Award, Options, Grants in Period, Net of Forfeitures [Abstract]
Options Granted	101	103	496	383
Weighted Average Exercise Price			$ 33.61	$ 19.64
Weighted Average Fair Value of Options			11.64	6.83
Intrinsic Value of Options Granted on Grant Date [Abstract]
Grant Date Intrinsic Value			$ 0	$ 0

Options and Awards Options Outs

Options and Awards Options Outstanding Rollforward (Details) - $ / shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Options outstanding January 1,			4,739
Weighted average exercise price January 1,			$ 13.08
Options vested January 1,			2,776
Weighted Average Exercise Price of Options Vested January 1,			$ 10.07
Options Granted	101	103	496	383
Weighted Average Exercise Price, Options Granted			$ 33.61	$ 19.64
Options Forfeited in Period			(73)
Weighted Average Exercise Price, Options Forfeited in Period			$ 19.52
Options Exercised in Period			(763)
Weighted Average Exercise Price, Options Exercised in Period			$ 7.80
Options outstanding September 30,	4,399		4,399
Weighted average exercise price September 30,	$ 16.20		$ 16.20
Options vested September 30,	2,658		2,658
Weighted Average Exercise Price of Options Vested September 30,	$ 11.94		$ 11.94

Options and Awards Options Ou_2

Options and Awards Options Outstanding by Exercise Price (Details) $ / shares in Units, shares in Thousands, $ in Thousands	9 Months Ended
	Sep. 30, 2018USD ($)$ / sharesshares
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Number of Outstanding Options	4,399
Black-Scholes Fair Value | $	$ 28,309
Stock Options Vested and Exercisable	2,658
2,008
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 2.56
Exercise Price, Upper Range Limit | $ / shares	$ 4.06
Number of Outstanding Options	16
Black-Scholes Fair Value | $	$ 30
Remaining Contractual Life (Years)	0 years
Stock Options Vested and Exercisable	16
2,009
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 4.06
Exercise Price, Upper Range Limit | $ / shares	$ 4.56
Number of Outstanding Options	263
Black-Scholes Fair Value | $	$ 564
Remaining Contractual Life (Years)	1 year
Stock Options Vested and Exercisable	263
2,010
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 4.77
Exercise Price, Upper Range Limit | $ / shares	$ 4.96
Number of Outstanding Options	83
Black-Scholes Fair Value | $	$ 201
Remaining Contractual Life (Years)	2 years
Stock Options Vested and Exercisable	83
2,011
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 5.90
Exercise Price, Upper Range Limit | $ / shares	$ 7.99
Number of Outstanding Options	90
Black-Scholes Fair Value | $	$ 309
Remaining Contractual Life (Years)	3 years
Stock Options Vested and Exercisable	90
2,012
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 6.56
Exercise Price, Upper Range Limit | $ / shares	$ 7.96
Number of Outstanding Options	292
Black-Scholes Fair Value | $	$ 1,082
Remaining Contractual Life (Years)	4 years
Stock Options Vested and Exercisable	292
2,013
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 7.98
Exercise Price, Upper Range Limit | $ / shares	$ 11.49
Number of Outstanding Options	465
Black-Scholes Fair Value | $	$ 2,265
Remaining Contractual Life (Years)	5 years
Stock Options Vested and Exercisable	432
2,014
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 10.55
Exercise Price, Upper Range Limit | $ / shares	$ 18.94
Number of Outstanding Options	1,331
Black-Scholes Fair Value | $	$ 7,553
Remaining Contractual Life (Years)	6 years
Stock Options Vested and Exercisable	1,000
2,015
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 21.47
Exercise Price, Upper Range Limit | $ / shares	$ 25.24
Number of Outstanding Options	500
Black-Scholes Fair Value | $	$ 4,546
Remaining Contractual Life (Years)	7 years
Stock Options Vested and Exercisable	270
2,016
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 18.79
Exercise Price, Upper Range Limit | $ / shares	$ 19.89
Number of Outstanding Options	422
Black-Scholes Fair Value | $	$ 2,946
Remaining Contractual Life (Years)	8 years
Stock Options Vested and Exercisable	145
2,017
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 18.64
Exercise Price, Upper Range Limit | $ / shares	$ 22.90
Number of Outstanding Options	451
Black-Scholes Fair Value | $	$ 3,151
Remaining Contractual Life (Years)	9 years
Stock Options Vested and Exercisable	67
2,018
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 26.53
Exercise Price, Upper Range Limit | $ / shares	$ 38.59
Number of Outstanding Options	486
Black-Scholes Fair Value | $	$ 5,662
Remaining Contractual Life (Years)	10 years
Stock Options Vested and Exercisable	0

Options and Awards Restricted A

Options and Awards Restricted Awards Granted (Details) - USD ($) $ / shares in Units, shares in Thousands, $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Restricted awards granted [Line Items]
Restricted Awards Grant Date Fair Value Range, Minimum			$ 23.61	$ 18.47
Restricted Awards Grant Date Fair Value Range, Maximum			$ 38.59	$ 21.53
Share-based Compensation, Restricted Awards, Exercise Price			$ 0
Issuance of restricted stock to employees (in shares)	42	41	316	140
Award Vesting Period			5 years
Director [Member]
Restricted awards granted [Line Items]
Restricted Awards Grant Date Fair Value Range, Minimum			$ 23.61
Restricted Awards Grant Date Fair Value Range, Maximum			$ 37.50
Options Granted to Non-employee Directors	8		23

Options and Awards Restricted_2

Options and Awards Restricted Award Rollforward (Details) - $ / shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Restricted Stock Rollforward [Line Items]
Nonvested Restricted Awards, Nonvested at January 1,			383
Weighted Average Grant Date Fair Value, Nonvested at January 1,			$ 20.65
Nonvested Restricted Awards, Granted	42	41	316	140
Weighted Average Grant Date Fair Value, Restricted Awards Granted in the Period			$ 34.79
Nonvested Restricted Awards, Vested in the Period			(125)
Weighted Average Grant Date Fair Value, Restricted Awards Vested in the Period			$ 22.25
Nonvested Restricted Awards, Forfeited in the Period			(14)
Weighted Average Grant Date Fair Value, Restricted Awards Forfeited in the Period			$ 22.98
Nonvested Restricted Awards, Nonvested at September 30,	560		560
Weighted Average Grant Date Fair Value, Nonvested at September 30,	$ 28.21		$ 28.21

Options and Awards Compensation

Options and Awards Compensation Expense (Details) - USD ($) shares in Thousands, $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 2,462	$ 1,808	$ 6,609	$ 5,736
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized [Abstract]
Share-based Compensation Arrangement by Share-based Payment Award, Options, Outstanding, Weighted Average Remaining Contractual Term			5 years 10 months 15 days
Stock Options
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	1,213	1,104	$ 3,721	3,629
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized [Abstract]
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized	$ 12,612		$ 12,612
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized, Period for Recognition			3 years 5 months
Employee Service Share-based Compensation, Nonvested Awards	1,741		1,741
Share-based Compensation Arrangement by Share-based Payment Award, Options, Expected to Vest, Number	1,643		1,643
Restricted Stock Awards
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 968	597	$ 2,220	1,736
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized [Abstract]
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized	14,496		$ 14,496
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized, Period for Recognition			4 years
Stock awards
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 281	$ 107	$ 668	$ 371

Options and Awards Intrinsic Va

Options and Awards Intrinsic Values (Details) - Stock Options - USD ($) $ in Thousands	9 Months Ended	12 Months Ended
	Sep. 30, 2018	Dec. 31, 2017
Outstanding	$ 95,625	$ 44,060
Vested	69,043	33,976
Expected to Vest	23,616	9,311
Exercised	$ 17,718	$ 10,481

Options and Awards Subsidiary E

Options and Awards Subsidiary Equity Plan Share-based Payments (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2018	Sep. 30, 2017	Sep. 30, 2018	Sep. 30, 2017
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Award Vesting Period			5 years
Employee stock award compensation	$ 2,462	$ 1,808	$ 6,609	$ 5,736
Subsidiaries [Member] | Subsidiaries Stock awards [Member]
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Award Vesting Period			5 years
Employee stock award compensation	$ 349	$ 348	$ 1,030	$ 1,019

Options and Awards Subsidiary C

Options and Awards Subsidiary Common Stock Shares (Details) - shares shares in Thousands	Sep. 30, 2018	Sep. 30, 2017
Subsidiaries Stock awards [Member] | Subsidiaries [Member]
Class of Stock [Line Items]
Common Stock Required to Settle Subsidiary Shares	222	250

Options and Awards Sale of Stoc

Options and Awards Sale of Stock by Subsidiary (Details) - USD ($) shares in Thousands, $ in Thousands	3 Months Ended	9 Months Ended
	Sep. 30, 2018	Sep. 30, 2018	Sep. 30, 2017
Subsidiary, Sale of Stock [Line Items]
Payments for Repurchase of Common Stock		$ 1,972	$ 7,288
Proceeds from sale of subsidiary shares (Note 15)		$ 1,972	$ 0
Subsidiaries [Member] | Subsidiaries Stock awards [Member]
Subsidiary, Sale of Stock [Line Items]
Sale of Stock, Number of Shares Issued in Transaction	865
Stock Repurchased During Period, Shares	865
Payments for Repurchase of Common Stock	$ 1,972
Proceeds from sale of subsidiary shares (Note 15)	$ 1,972

Leases (Details)

Leases (Details) $ in Thousands	Jun. 01, 2014facilitiesRenewals	Sep. 30, 2018USD ($)facilitiesRenewals	Sep. 30, 2017USD ($)	Sep. 30, 2018USD ($)facilitiesRenewals	Sep. 30, 2017USD ($)
Operating Leased Assets [Line Items]
Rent | $		$ 34,851	$ 33,782	$ 103,173	$ 98,267
Facilities under Master Lease Arrangement		31		31
Master Lease Agreements		5		5
Various Landlords [Member] [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract		15 years		15 years
Lessee Leasing Arrangements, Operating Leases, Number of Renewal Terms | Renewals		2		2
Lessee, Operating Lease, Renewal Term		5 years		5 years
CareTrust REIT [Member]
Operating Leased Assets [Line Items]
Skilled Nursing, Assisted Living and Independent Living Facilities	92
Operating Leases of Lessee, Contingent Rentals, Description of Variable Rate Basis	0.025
Payments for Rent | $		$ 14,778	14,418	$ 43,734	42,751
Lessee, Operating Lease, Renewal Term	5 years
Master Lease Agreements	8
Minimum [Member] | Various Landlords [Member] [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract		5 years		5 years
Average Term of Non-Cancellable Equipment Leases				3 years
Minimum [Member] | CareTrust REIT [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract	12 years
Lessee Leasing Arrangements, Operating Leases, Number of Renewal Terms | Renewals	2
Maximum [Member] | Various Landlords [Member] [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract		20 years		20 years
Average Term of Non-Cancellable Equipment Leases				5 years
Maximum [Member] | CareTrust REIT [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract	19 years
Lessee Leasing Arrangements, Operating Leases, Number of Renewal Terms | Renewals	3
Cost of Sales and General and Administrative Expense [Member]
Operating Leased Assets [Line Items]
Rent | $		$ 35,028	$ 34,112	$ 103,668	$ 98,955

Leases Additional Disclosures (

Leases Additional Disclosures (Details) $ in Thousands	3 Months Ended			9 Months Ended
	Sep. 30, 2018USD ($)	Sep. 30, 2017USD ($)	Jun. 30, 2017USD ($)	Sep. 30, 2018USD ($)	Sep. 30, 2017USD ($)facilities
Operating Leased Assets [Line Items]
Gain (Loss) on Contract Termination					$ 2,715
Business Exit Costs	$ 0	$ 0	$ (1,286)	$ 0	$ 2,731
Skilled Nursing, Assisted Living and Independent Living Facilities [Member]
Operating Leased Assets [Line Items]
Number of Businesses with Lease Terminations | facilities					4
8051 Services, Skilled Nursing Care Facilities [Member]
Operating Leased Assets [Line Items]
Number of Businesses with Lease Terminations | facilities					1
Disposal Group, Disposed of by Means Other than Sale, Not Discontinued Operations [Member] | 8051 Services, Skilled Nursing Care Facilities [Member]
Operating Leased Assets [Line Items]
Number of Businesses Closed | facilities					1
Facility Closing [Member]
Operating Leased Assets [Line Items]
Business Exit Costs					$ 2,830
Contract Termination [Member]
Operating Leased Assets [Line Items]
Business Exit Costs					$ 1,187

Leases Sale Leaseback Transacti

Leases Sale Leaseback Transactions (Details) $ in Thousands	Jun. 01, 2017USD ($)
Sale Leaseback Transaction [Line Items]
Sale Leaseback Transaction, Lease Terms	20
Sale Leaseback Transaction, Gross Proceeds, Investing Activities	$ 38,000
Sale Leaseback Transaction, Historical Cost	24,847
Sale Leaseback Transaction, Current Period Gain Recognized	$ 13,153
Number of Optional Lease Extension [Member] [Member]
Sale Leaseback Transaction [Line Items]
Sale Leaseback Transaction, Lease Terms	3
Optional Lease Extension [Member]
Sale Leaseback Transaction [Line Items]
Sale Leaseback Transaction, Lease Terms	5
8051 Services, Skilled Nursing Care Facilities [Member]
Sale Leaseback Transaction [Line Items]
Sale Leaseback Transaction, Description of Asset(s)	2
Assisted Living Facility [Member]
Sale Leaseback Transaction [Line Items]
Sale Leaseback Transaction, Description of Asset(s)	1

Leases Future minimum lease pay

Leases Future minimum lease payments (Details) $ in Thousands	Sep. 30, 2018USD ($)
Leases [Abstract]
2,018	$ 35,338
2,019	139,933
2,020	139,043
2,021	138,428
2,022	137,040
2,023	135,403
Thereafter	951,177
Operating Leases, Future Minimum Payments Due	$ 1,676,362

Commitments and Contingencies L

Commitments and Contingencies Litigation (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2018	Dec. 31, 2017	Mar. 31, 2017
Litigation [Line Items]
Litigation Settlement, Amount Awarded to Other Party			$ 11,000
Payments for Legal Settlements		$ 11,000
Litigation Settlement, Return of Unclaimed Settlement	$ 1,664

Commitments and Contingencies R

Commitments and Contingencies Revenue Recoupments (Details)	Sep. 30, 2018facilities
Probe Reviews [Abstract]
Facilities under Medicare Probe Reviews	13

Commitments and Contingencies O

Commitments and Contingencies Other Matters (Details) $ in Thousands	12 Months Ended
	Dec. 31, 2013USD ($)
Other Commitments [Line Items]
Litigation Settlement Paid to U.S. Government	$ 48,000

Commitments and Contingencies C

Commitments and Contingencies Concentrations (Details) - Total Medicaid and Medicare	3 Months Ended		9 Months Ended
	Sep. 30, 2018Rate	Sep. 30, 2017Rate	Sep. 30, 2018Rate	Sep. 30, 2017Rate	Dec. 31, 2017Rate
Concentration Risk [Line Items]
Accounts receivable by payor as a percent of total accounts receivable	56.30%		56.30%		56.70%
% of Revenue	68.60%	68.80%	68.20%	68.40%

Commitments and Contingencies_2

Commitments and Contingencies Cash in Excess of FDIC Limits (Details) - USD ($) $ in Thousands	Oct. 29, 2018	Sep. 30, 2018
Cash in Excess of FDIC limits [Line Items]
Cash, FDIC Insured Amount		$ 250
Subsequent Event [Member]
Cash in Excess of FDIC limits [Line Items]
Cash, Uninsured Amount	$ 1,219

Common Stock (Details)

Common Stock (Details) - USD ($) shares in Thousands, $ in Thousands	Apr. 03, 2018	Feb. 08, 2017	Sep. 30, 2018	Sep. 30, 2017
Common Stock Transactions [Line Items]
Stock Repurchase Program, Period in Force	11 months	12 months
Stock Repurchase Program Expiration Date	Feb. 20, 2019	Feb. 8, 2018
Payments for Repurchase of Common Stock			$ 1,972	$ 7,288
Common Stock [Member]
Common Stock Transactions [Line Items]
Stock Repurchase Program, Authorized Amount	$ 30,000	$ 30,000
Stock Repurchased During Period, Shares				412
Payments for Repurchase of Common Stock				$ 7,288