The Ensign Group, Inc. (ENSG) 10-K 6 Feb 19 2018 FY Annual report Financial data

DEI Info Cover Page Document

DEI Info Cover Page Document - USD ($)	12 Months Ended
	Dec. 31, 2018	Feb. 05, 2019	Jun. 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-K
Current Reporting Status	Yes
Document Period End Date	Dec. 31, 2018
Document Fiscal Year Focus	2,018
Document Fiscal Period Focus	FY
Amendment Flag	false
Entity Emerging Growth Company	false
Entity Small Business	false
Entity Well-known Seasoned Issuer	Yes
Entity Voluntary Filers	No
Entity Shell Company	false
Entity Common Stock, Shares Outstanding		52,696,096
Entity Public Float			$ 1,312,000,000

Consolidated Balance Sheets

Consolidated Balance Sheets - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Current assets:
Cash and cash equivalents	$ 31,083	$ 42,337
Accounts receivable—less allowance for doubtful accounts of $2,886 and $43,961 at December 31, 2018 and 2017, respectively (Note 3)	276,099	265,068
Investments—current	8,682	13,092
Prepaid income taxes	6,219	19,447
Prepaid expenses and other current assets	24,130	28,132
Assets held for sale - current	1,859	0
Total current assets	348,072	368,076
Property and equipment, net	618,874	537,084
Insurance subsidiary deposits and investments	36,168	28,685
Escrow deposits	7,271	228
Deferred tax assets	11,650	12,745
Restricted and other assets	20,844	16,501
Intangible assets, net	31,000	32,803
Goodwill	80,477	81,062
Other indefinite-lived intangibles	27,602	25,249
Total assets	1,181,958	1,102,433
Current liabilities:
Accounts payable	44,236	39,043
Accrued wages and related liabilities	119,656	90,508
Accrued self-insurance liabilities—current	25,446	22,516
Other accrued liabilities	69,784	63,815
Current maturities of long-term debt	10,105	9,939
Total current liabilities	269,227	225,821
Long-term debt—less current maturities	233,135	302,990
Accrued self-insurance liabilities—less current portion	54,605	50,220
Deferred rent and other long-term liabilities	11,234	11,268
Deferred gain related to sale-leaseback (Note 16)	11,417	12,075
Total liabilities	579,618	602,374
Commitments and contingencies (Notes 14, 16 and 18)
Equity:
Common stock; $0.001 par value; 75,000 shares authorized; 55,089 and 52,584 shares issued and outstanding at December 31, 2018, respectively, and 53,675 and 51,360 shares issued and outstanding at December 31, 2017, respectively (Note 20)	55	53
Additional paid-in capital	284,384	266,058
Retained earnings	344,901	264,691
Common stock in treasury, at cost, 1,932 shares at December 31, 2018 and 2017, respectively	(38,405)	(38,405)
Total Ensign Group, Inc. stockholders' equity	590,935	492,397
Non-controlling interest	11,405	7,662
Total equity	602,340	500,059
Total liabilities and equity	$ 1,181,958	$ 1,102,433

Consolidated Balance Sheets Bal

Consolidated Balance Sheets Balance Sheet (Paranthetical) - USD ($) shares in Thousands, $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Current assets:
Allowance for doubtful accounts	$ 2,886	$ 43,961
Equity:
Common stock, par value	$ 0.001	$ 0.001
Common stock, shares authorized	75,000	75,000
Common stock, shares issued	55,089	53,675
Common stock, shares outstanding	52,584	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	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Revenue
Total revenue	$ 2,040,659	$ 1,849,317	$ 1,654,864
Expense
Cost of services	1,627,672	1,497,703	1,341,814
(Return of unclaimed class action settlement)/charges related to class action lawsuit (Note 18)	(1,664)	11,000	0
Losses related to divestitures (Note 6 and 16)	0	2,321	(11,225)
Rent—cost of services (Note 16)	138,512	131,919	124,581
General and administrative expense	100,307	80,617	69,165
Depreciation and amortization	47,344	44,472	38,682
Total expenses	1,912,171	1,768,032	1,563,017
Income from operations	128,488	81,285	91,847
Other income (expense):
Interest expense	(15,182)	(13,616)	(7,136)
Interest income	2,063	1,609	1,107
Other expense, net	(13,119)	(12,007)	(6,029)
Income before provision for income taxes	115,369	69,278	85,818
Provision for income taxes	22,841	28,445	32,975
Net income	92,528	40,833	52,843
Less: net income attributable to noncontrolling interests	164	358	2,853
Net income attributable to The Ensign Group, Inc.	$ 92,364	$ 40,475	$ 49,990
Basic:
Basic net income per common share attributable to The Ensign Group, Inc.	$ 1.78	$ 0.79	$ 0.99
Diluted:
Diluted net income per common share attributable to The Ensign Group, Inc.	$ 1.70	$ 0.77	$ 0.96
Weighted average common shares outstanding:
Basic	52,016	50,932	50,555
Diluted	54,397	52,829	52,133
Health Care, Patient Service [Member]
Revenue
Total revenue	$ 1,888,862	$ 1,712,670	$ 1,531,228
Health Care, Resident Service [Member]
Revenue
Total revenue	$ 151,797	$ 136,647	$ 123,636

Consolidated Statement of Stock

Consolidated Statement of Stockholders' Equity Statement - USD ($) shares in Thousands, $ in Thousands	Total	Common Stock [Member]	Additional Paid-in Capital [Member]	Retained Earnings [Member]	Treasury Stock [Member]	Noncontrolling Interest [Member]
Balance - January 1, at Dec. 31, 2015	$ 426,985	$ 51	$ 235,076	$ 193,420	$ (1,223)	$ (339)
Balance - January 1 (in shares) at Dec. 31, 2015		51,370
Balance - January 1 (in treasury shares) at Dec. 31, 2015					123
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		668			(55)
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	$ 4,152	$ 1	4,045		$ 106
Issuance of restricted stock to employees (in shares)	299	252
Issuance of restricted stock to employees	$ 2,517		2,517
Repurchase of common stock (Note 20) (in shares)		(1,452)			1,452
Repurchase of common stock (Note 20)	(30,000)				$ (30,000)
Dividends declared	(8,282)			(8,282)
Employee stock award compensation	7,776		7,776
Excess tax benefit from share-based compensation	3,079		3,079
Noncontrolling interest assumed related to acquisition	100					100
Noncontrolling interest attributable to subsidiary equity plan (Note 15)	1,325			(107)		1,432
Less: net income attributable to noncontrolling interests	2,853					2,853
Net Income (Loss) Attributable to the Ensign Group, Inc.	49,990			49,990
Balance - December 31, at Dec. 31, 2016	460,495	$ 52	252,493	235,021	$ (31,117)	4,046
Balance - December 31 (in shares) at Dec. 31, 2016		50,838
Balance - December 31 (in treasury shares) at Dec. 31, 2016					1,520
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		807			0
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	$ 5,128	$ 1	5,127		$ 0
Issuance of restricted stock to employees (in shares)	173	127
Issuance of restricted stock to employees	$ 146		146
Repurchase of common stock (Note 20) (in shares)		(412)			412
Repurchase of common stock (Note 20)	(7,288)				$ (7,288)
Dividends declared	(8,867)			(8,867)
Employee stock award compensation	8,331		8,331
Acquisition of noncontrolling interest, net of tax	(83)		(39)			(44)
Noncontrolling interest attributable to subsidiary equity plan (Note 15)	1,364			(1,938)		3,302
Less: net income attributable to noncontrolling interests	358					358
Net Income (Loss) Attributable to the Ensign Group, Inc.	40,475			40,475
Balance - December 31, at Dec. 31, 2017	$ 500,059	$ 53	266,058	264,691	$ (38,405)	7,662
Balance - December 31 (in shares) at Dec. 31, 2017	51,360	51,360
Balance - December 31 (in treasury shares) at Dec. 31, 2017					1,932
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		1,100			0
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	$ 9,182	$ 2	9,180		$ 0
Issuance of restricted stock to employees (in shares)	367	124
Issuance of restricted stock to employees	$ 187		187
Dividends declared	(9,615)			(9,615)
Employee stock award compensation	8,959		8,959
Noncontrolling interest attributable to subsidiary equity plan (Note 15)	1,378			(2,539)		3,917
Noncontrolling interest attributable to distribution	(338)					(338)
Less: net income attributable to noncontrolling interests	164					164
Net Income (Loss) Attributable to the Ensign Group, Inc.	92,364			92,364
Balance - December 31, at Dec. 31, 2018	$ 602,340	$ 55	$ 284,384	$ 344,901	$ (38,405)	$ 11,405
Balance - December 31 (in shares) at Dec. 31, 2018	52,584	52,584
Balance - December 31 (in treasury shares) at Dec. 31, 2018					1,932

Consolidated Statement of Sto_2

Consolidated Statement of Stockholders' Equity (Parenthetical) - $ / shares	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Statement of Stockholders' Equity [Abstract]
Dividends Per Share	$ 0.1825	$ 0.1725	$ 0.1625

Consolidated Statements of Cash

Consolidated Statements of Cash Flows - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Cash flows from operating activities:
Net income	$ 92,528	$ 40,833	$ 52,843
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation and amortization	47,344	44,472	38,682
Impairment of long-lived assets and goodwill (Note 8 and 10)	9,145	111	137
Amortization of deferred financing fees	1,175	1,039	825
Amortization of deferred gain on sale-leaseback (Note 16)	(658)	(421)	0
Write-off of deferred financing fees	0	0	321
Deferred income taxes	1,095	10,329	(2,208)
Provision for doubtful accounts (Note 3)	2,823	31,023	28,512
Share-based compensation	10,337	9,695	9,101
Excess tax benefit from share-based compensation	0	0	3,079
Cash received from insurance proceeds related to replacement properties and business interruptions	2,568	477	0
Gain on insurance claims and disposal of assets	(1,014)	278	164
Income tax refund	11,000	0	0
Gain on sale of urgent care centers	0	0	(19,160)
Change in operating assets and liabilities
Accounts receivable (Note 3)	(13,099)	(52,301)	(63,617)
Prepaid income taxes	2,228	(19,145)	7,839
Prepaid expenses and other assets	1,297	(9,380)	(1,465)
Insurance subsidiary deposits	0	(6,592)	(467)
Liabilities related to operational closures (Note 6 and 16)	0	2,210	7,205
Accounts payable	3,082	3,329	577
Accrued wages and related liabilities	29,148	5,822	(4,978)
Income taxes payable	0	(1,182)	987
Other accrued liabilities	5,597	5,777	12,588
Accrued self-insurance liabilities	5,740	6,095	8,125
Deferred rent and other long-term liability	(34)	483	956
Net cash provided by operating activities	210,302	72,952	73,888
Cash flows from investing activities:
Purchase of property and equipment	(54,948)	(57,166)	(65,699)
Cash payments for business acquisitions (Note 7)	(4,725)	(89,565)	(64,310)
Cash payments for asset acquisitions (Note 7)	(85,314)	(195)	(120,935)
Escrow deposits	(7,271)	(228)	(1,582)
Escrow deposits used to fund acquisitions	228	1,582	400
Cash received from sale of urgent care centers and franchising businesses, net of note receivable	0	0	40,734
Cash proceeds from sale-leaseback (Note 16)	0	38,000	0
Cash proceeds from the sale of assets and insurance proceeds	4,772	3,215	391
Change in other assets	(3,953)	(2,236)	365
Net cash used in investing activities	(151,211)	(106,593)	(210,636)
Cash flows from financing activities:
Proceeds from revolving credit facility and other debt (Note 14)	845,000	1,022,015	844,000
Payments on revolving credit facility and other debt (Note 14)	(914,939)	(990,154)	(659,514)
Issuance of treasury stock upon exercise of options	0	0	106
Issuance of common stock upon exercise of options and vesting of restricted stock	9,369	5,274	6,563
Proceeds from sale of subsidiary shares (Note 15)	1,972	0	0
Repurchase of shares of common stock and subsidiary shares (Note 15 and Note 18)	(1,972)	(7,288)	(30,000)
Dividends paid	(9,419)	(8,717)	(8,173)
Excess tax benefit from share-based compensation (Note 2)	0	0	3,181
Non-controlling interest distribution	(338)	0	0
Purchase of non-controlling interest	0	(83)	0
Payments of deferred financing costs	(18)	(2,775)	(3,278)
Net cash (used in)/provided by financing activities	(70,345)	18,272	152,885
Net (decrease)/increase in cash and cash equivalents	(11,254)	(15,369)	16,137
Cash and cash equivalents beginning of period	42,337	57,706	41,569
Cash and cash equivalents end of period	31,083	42,337	57,706
Cash paid during the period for:
Interest	15,992	13,284	6,428
Income taxes	19,563	38,382	23,163
Non-cash financing and investing activity:
Accrued capital expenditures	3,500	3,550	6,828
Note receivable from sale of ancillary business and asset acquisition	126	0	700
Favorable lease included in the fair value of assets acquisitions	$ 0	$ 0	$ 7,190

Description of Business

Description of Business	12 Months Ended
	Dec. 31, 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 December 31, 2018 , the Company operated 244 facilities, 54 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, hospice, home care and other ancillary services. The Company's operating subsidiaries have a collective capacity of approximately 19,600 operational skilled nursing beds and 5,700 assisted living and independent living units. As of December 31, 2018 , the Company owned 72 of its 244 affiliated facilities and leased an additional 172 facilities through long-term lease arrangements and had options to purchase 12 of those 172 facilities. 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 Annual 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.

Significant Accounting Policies

Significant Accounting Policies	12 Months Ended
	Dec. 31, 2018
Accounting Policies [Abstract]
Basis of Presentation and Significant Accounting Policies [Text Block]	SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Basis of Presentation — The accompanying consolidated financial statements (Financial Statements) have been prepared in accordance with accounting principles generally accepted in the United States (GAAP). The Company is the sole member or stockholder of various consolidated limited liability companies and corporations established to operate various acquired skilled nursing and 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 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 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 consolidated statements of income. The consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest and the accounts of any variable interest entities (VIEs) where the Company is subject to a majority of the risk of loss from the VIE's activities, or entitled to receive a majority of the entity's residual returns, or both. The Company assesses the requirements related to the consolidation of VIEs, including a qualitative assessment of power and economics that considers which entity has the power to direct the activities that "most significantly impact" the VIE's economic performance and has the obligation to absorb losses of, or the right to receive benefits that could be potentially significant to, the VIE. The Company's relationship with variable interest entities was not material during the year ended December 31, 2018. In December 2018, the Company agreed to terms to sell one of its assisted living operations. The sale of this assisted living operation closed in the first quarter of 2019. Property and equipment assets included in the sale of the one assisted living facility have been presented as held for sale in the accompanying consolidated balance sheets as of December 31, 2018. The sale transaction does not meet the criteria of discontinued operations as it does not represent a strategic shift that has, or will have, a major effect on the Company's operations and financial results. Estimates and Assumptions — The preparation of Financial Statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the Financial Statements and the reported amounts of revenue and expenses during the reporting periods. The most significant estimates in the Company’s Financial Statements relate to revenue, 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 . Cash and Cash Equivalents — Cash and cash equivalents consist of bank term deposits, money market funds and treasury bill related investments with original maturities of three months or less at time of purchase and therefore approximate fair value. The fair value of money market funds is determined based on “Level 1” inputs, which consist of unadjusted quoted prices in active markets that are accessible at the measurement date for identical, unrestricted assets. The Company places its cash and short-term investments with high credit quality financial institutions. Insurance Subsidiary Deposits and Investments — The Company's captive insurance subsidiary cash and cash equivalents, deposits and investments are designated to support long-term insurance subsidiary liabilities and have been classified as short-term and long-term assets based on the timing of expected future payments of the Company's captive insurance liabilities. The majority of these deposits and investments are currently held in AA, A and BBB rated debt security investments and the remainder is held in a bank account with a high credit quality financial institution. See further discussion at Note 5, Fair Value Measurements. The Company evaluates securities for other-than-temporary impairment (“OTTI”) on at least a quarterly basis, and more frequently when economic or market conditions warrant such an evaluation. If securities are in an unrealized loss position, the Company considers the extent and duration of the unrealized loss, and the financial condition and near-term prospects of the issuer. The Company also assesses whether it intends to sell, or it is more likely than not that it will be required to sell, a security in an unrealized loss position before recovery of its amortized cost basis. If either of the criteria regarding intent or requirement to sell is met, the entire difference between amortized cost and fair value is recognized as impairment through earnings. For the years ended December 31, 2017 and 2018, the Company did not recognize any OTTI for its investments. Property and Equipment — Property and equipment are initially recorded at their historical cost. Repairs and maintenance are expensed as incurred. Depreciation is computed using the straight-line method over the estimated useful lives of the depreciable assets (ranging from three to 59 years ). Leasehold improvements are amortized on a straight-line basis over the shorter of their estimated useful lives or the remaining lease term. 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 $5,492 , $111 and $137 during the years ended December 31, 2018, 2017 and 2016 , respectively. See further discussion at Note 8, Property and Equipment . 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 fiscal year of 2018, due to changes in performance and the Company recorded an impairment charge of $3,653 to goodwill and intangible assets during the year ended December 31, 2018 . The Company did not identify any goodwill and intangible assets impairment during the years ended December 31, 2017 and 2016 . 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, Washington and Wyoming for workers' compensation) are self-insured through the Captive, the related assets and liabilities of which are included in the accompanying consolidated balance sheets. The Captive is subject to certain statutory requirements as an insurance provider. 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. The Company’s operating subsidiaries are self-insured for workers’ compensation in California. To protect itself against loss exposure in California with this policy, the Company has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington and Wyoming, are under a loss sensitive plan that insures individual claims that exceed $350 per occurrence. In Washington and Wyoming, the operating subsidiaries' coverage is financed through premiums paid by the employers and employees. The claims and pay benefits are managed through a state insurance pool. Outside of California, Texas, Washington and Wyoming, the Company has purchased insurance coverage that insures individual claims that exceed $350 per accident. In all states except Washington and Wyoming, the Company accrues amounts equal to the estimated costs to settle open claims, as well as an estimate of the cost of claims that have been incurred but not reported. The Company uses actuarial valuations to estimate the liability based on historical experience and industry information. In addition, the Company has recorded an asset and equal liability of $6,969 and $5,394 at December 31, 2018 and 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 believes that adequate provision has been made in the Financial Statements for liabilities that may arise out of patient care, workers’ compensation, healthcare benefits and related services provided to date. The amount of the Company’s reserves was determined based on an estimation process that uses information obtained from both company-specific and industry data. This estimation process requires the Company to continuously monitor and evaluate the life cycle of the claims. Using data obtained from this monitoring and the Company’s assumptions about emerging trends, the Company, with the assistance of an independent actuary, develops information about the size of ultimate claims based on the Company’s historical experience and other available industry information. The most significant assumptions used in the estimation process include determining the trend in costs, the expected cost of claims incurred but not reported and the expected costs to settle or pay damage awards with respect to unpaid claims. The self-insured liabilities are based upon estimates, and while management believes that the estimates of loss are reasonable, the ultimate liability may be in excess of or less than the recorded amounts. Due to the inherent volatility of actuarially determined loss estimates, it is reasonably possible that the Company could experience changes in estimated losses that could be material to net income. If the Company’s actual 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 consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to The Ensign Group, Inc. in its consolidated statements of income 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. See further discussion at Note 3, Revenue and Accounts Receivable . 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 seventeen of the Company's acquisitions during the year ended December 31, 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 six acquisitions during the year ended December 31, 2018 was concentrated in goodwill and as such, these transactions were classified as business acquisitions in accordance with ASC 805. The majority 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 established Topic 842, Leases , by issuing Accounting Standards Update (ASU) No. 2016-02, which requires lessees to recognize leases with terms longer than 12 months on the balance sheet and disclose key information about leasing arrangements. Leases will be classified as either finance or operating, with classification affecting the pattern of expense recognition in the income statement. The classification criteria for distinguishing between operating and finance (previously capital) leases are substantially similar to the previous lease guidance, but with no explicit bright lines. The Company adopted the standard as of January 1, 2019, electing the transition method that allows it to apply the standard as of the adoption date and record a cumulative adjustment in retained earnings, if applicable. The Company has elected the package of practical expedients permitted under the transition guidance within the new guidance, which among other things, allows the Company to carryforward the historical lease classification. The new standard also provides practical expedients for an entity’s ongoing accounting. The Company has made an accounting policy election to keep leases with an initial term of 12 months or less off of the balance sheet and recognize those lease payments in the consolidated statements of income on a straight-line basis over the lease term. The Company has also elected the practical expedient to not separate lease and non-lease components for all of its leases as the non-lease components are not significant to the overall lease costs. The adoption of this standard resulted in recognition of net lease assets and lease liabilities of approximately $1,050,000 and $1,030,000 , respectively, on its consolidated balance sheets as of January 1, 2019. The Company recorded an adjustment, gross of tax, approximately of $12,100 to retained earnings, on the adoption date, related to a deferred gain on a previous sale-leaseback transaction, which will result in an increase in rent expense of approximately $700 annually as we will no longer be able to recognize the gain in our consolidated statement of income as a result of the adoption of the new lease standard. In addition, initial direct cost associated with its lease agreements and favorable lease assets of approximately $27,000 would be classified into right of used assets on adoption date. The Company does not believe the standard will materially affect its consolidated net earnings or have a notable impact on liquidity or debt-covenant compliance under the current agreements.

Revenue and Accounts Receivable

Revenue and Accounts Receivable	12 Months Ended
	Dec. 31, 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 68.5% , 68.4% and 67.8% of the Company's revenue for the years ended December 31, 2018, 2017 and 2016 . 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 Financial Statements for the years ended December 31, 2018, 2017 and 2016 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 residents under reimbursement arrangements with Medicaid, revenue is recorded based on contractually agreed-upon amounts or rates on a per resident, daily basis or as services are rendered. Home Health Revenue Medicare Revenue Net service revenue is recorded under the Medicare prospective payment system based on a 60-day episode payment rate that is subject to adjustment based on certain variables including, but not limited to: (a) an outlier payment if 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 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 consolidated statements of income for the years ended December 31, 2018, 2017 and 2016 . There was no impact to the consolidated balance sheet as of December 31, 2018 or consolidated statements of cash flows for the year ended December 31, 2018 , as such, no impact information was provided. Year Ended December 31, 2018 2017 2016 Total revenue As Reported $ 2,040,659 $ 1,849,317 $ 1,654,864 Impact of ASC 606 32,810 — — Balances as if the previous accounting guidance was in effect $ 2,073,469 $ 1,849,317 $ 1,654,864 Cost of Services: As Reported $ 1,627,672 $ 1,497,703 $ 1,341,814 Impact of ASC 606 32,810 — — Balances as if the previous accounting guidance was in effect $ 1,660,482 $ 1,497,703 $ 1,341,814 Total Expense: As Reported $ 1,912,171 $ 1,768,032 $ 1,563,017 Impact of ASC 606 32,810 — — Balances as if the previous accounting guidance was in effect $ 1,944,981 $ 1,768,032 $ 1,563,017 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 $2,823 and 0.1% , $31,023 and 1.7% and $28,512 and 1.7% for the years ended December 31, 2018, 2017 and 2016 , 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 years ended December 31, 2018, 2017 and 2016 is summarized in the following tables: Year Ended December 31, 2018 2018 adjusted to reflect prior revenue guidance 2017 2016 Revenue % of Revenue Revenue % of Revenue Revenue % of Revenue Revenue % of Revenue Medicaid $ 727,310 35.6 % $ 738,179 35.6 % $ 644,803 34.9 % $ 557,958 33.7 % Medicare 552,577 27.1 556,159 26.8 515,884 27.9 477,019 28.8 Medicaid — skilled 117,686 5.8 119,667 5.8 102,875 5.6 87,517 5.3 Total Medicaid and Medicare 1,397,573 68.5 1,414,005 68.2 1,263,562 68.4 1,122,494 67.8 Managed care 326,325 16.0 333,197 16.1 303,386 16.4 265,508 16.0 Private and other payors (1) 316,761 15.5 326,267 15.7 282,369 15.2 266,862 16.2 Revenue $ 2,040,659 100.0 % $ 2,073,469 100.0 % $ 1,849,317 100.0 % $ 1,654,864 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the years ended December 31, 2018, 2017 and 2016. Balance Sheet Impact Included in the Company’s 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 year ended December 31, 2018 , related to its transitional and skilled services, and home health and hospice services segments. Accounts receivable as of December 31, 2018 and December 31, 2017 is summarized in the following table: Year Ended December 31, 2018 2018 adjusted to reflect prior revenue guidance 2017 Medicaid $ 117,984 $ 130,476 $ 119,441 Managed care 54,682 67,238 68,930 Medicare 50,994 57,580 55,667 Private and other payors 55,325 69,662 64,991 278,985 324,956 309,029 Less: allowance for doubtful accounts (2,886 ) (48,857 ) (43,961 ) Accounts receivable, net $ 276,099 $ 276,099 $ 265,068 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	12 Months Ended
	Dec. 31, 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: Year Ended December 31, 2018 2017 2016 Numerator: Net income $ 92,528 $ 40,833 $ 52,843 Less: net income attributable to noncontrolling interests 164 358 2,853 Net income attributable to The Ensign Group, Inc. $ 92,364 $ 40,475 $ 49,990 Denominator: Weighted average shares outstanding for basic net income per share 52,016 50,932 50,555 Basic net income per common share attributable to The Ensign Group, Inc. $ 1.78 $ 0.79 $ 0.99 A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows: Year Ended December 31, 2018 2017 2016 Numerator: Net income $ 92,528 $ 40,833 $ 52,843 Less: net income attributable to noncontrolling interests 164 358 2,853 Net income attributable to The Ensign Group, Inc. $ 92,364 $ 40,475 $ 49,990 Denominator: Weighted average common shares outstanding 52,016 50,932 50,555 Plus: incremental shares from assumed conversion (1) 2,381 1,897 1,578 Adjusted weighted average common shares outstanding 54,397 52,829 52,133 Diluted net income per common share attributable to The Ensign Group, Inc. $ 1.70 $ 0.77 $ 0.96 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 220 , 1,252 and 838 for the years ended December 31, 2018, 2017 and 2016 , respectively.

Fair Value Measurements

Fair Value Measurements	12 Months Ended
	Dec. 31, 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 December 31, 2018 and 2017: December 31, 2018 2017 Level 1 Level 2 Level 3 Level 1 Level 2 Level 3 Cash and cash equivalents $ 31,083 $ — $ — $ 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. The Company classified $1,859 of land, building and equipment related to the sale of one assisted living operations as held for sale in the consolidated balance sheets as of December 31, 2018. The carrying value of these assets approximates fair value based on Level 2 inputs based on the determined transaction price in the sale agreement. Debt Security Investments - Held to Maturity At December 31, 2018 and 2017, the Company had approximately $44,850 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 inputs. The Company has the intent and ability to hold these debt securities to maturity. Further, as of December 31, 2018 , the debt security investments were held in AA, A and BBB rated debt securities.

Business Segments

Business Segments	12 Months Ended
	Dec. 31, 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, hospice and home care businesses. The Company's Chief Executive Officer, who is its chief operating decision maker, or CODM, reviews financial information at the operating segment level. The Company also reports an “all other” category that includes results from its mobile diagnostics and other ancillary operations. These operations are neither significant individually nor in aggregate, and therefore do not constitute a reportable segment. The reporting segments are business units that offer different services and are managed separately to provide greater visibility into those operations. As of December 31, 2018 , transitional and skilled services included 164 wholly-owned affiliated skilled nursing operations and 24 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 56 wholly-owned affiliated assisted and independent living operations and 24 campuses as mentioned above. Home health, hospice and home care services were provided to patients through 54 affiliated agencies. As of December 31, 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: Year Ended December 31, 2018 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 678,749 $ 36,152 $ 12,409 $ — $ 727,310 35.6 % Medicare 436,580 — 115,997 — 552,577 27.1 Medicaid-skilled 117,686 — — — 117,686 5.8 Subtotal 1,233,015 36,152 128,406 — 1,397,573 68.5 Managed care 301,866 — 24,459 — 326,325 16.0 Private and other 144,131 115,645 16,172 40,813 (1) 316,761 15.5 Total revenue $ 1,679,012 $ 151,797 $ 169,037 $ 40,813 $ 2,040,659 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the year ended December 31, 2018. The following table demonstrates the impact of adopting ASC 606 on the Company's segment revenues by major payor source for the year ended December 31, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Year Ended December 31, 2018 (Adjusted to reflect prior revenue guidance) Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 689,225 $ 36,152 $ 12,802 $ — $ 738,179 35.6 % Medicare 439,433 — 116,726 — 556,159 26.8 Medicaid-skilled 119,667 — — — 119,667 5.8 Subtotal 1,248,325 36,152 129,528 — 1,414,005 68.2 Managed care 308,148 — 25,049 — 333,197 16.1 Private and other 153,515 115,645 16,294 40,813 (1) 326,267 15.7 Total revenue $ 1,709,988 $ 151,797 $ 170,871 $ 40,813 $ 2,073,469 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the year ended December 31, 2018. Year Ended December 31, 2017 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 603,104 $ 30,469 $ 11,230 $ — $ 644,803 34.9 % Medicare 417,870 — 98,014 — 515,884 27.9 Medicaid-skilled 102,875 — — — 102,875 5.6 Subtotal 1,123,849 30,469 109,244 — 1,263,562 68.4 Managed care 281,563 — 21,823 — 303,386 16.4 Private and other 139,798 106,177 11,336 25,058 (1) 282,369 15.2 Total revenue $ 1,545,210 $ 136,646 $ 142,403 $ 25,058 $ 1,849,317 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the year ended December 31, 2017. Year Ended December 31, 2016 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 521,063 $ 26,397 $ 10,498 $ — $ 557,958 33.7 % Medicare 396,519 — 80,500 — 477,019 28.8 Medicaid-skilled 87,517 — — — 87,517 5.3 Subtotal 1,005,099 26,397 90,998 — 1,122,494 67.8 Managed care 247,844 — 17,664 — 265,508 16.0 Private and other 121,860 97,239 7,151 40,612 (1) 266,862 16.2 Total revenue $ 1,374,803 $ 123,636 $ 115,813 $ 40,612 $ 1,654,864 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the year ended December 31, 2016. The following table sets forth selected financial data consolidated by business segment: Year Ended December 31, 2018 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,679,012 $ — $ 169,037 $ 40,813 $ — $ 1,888,862 Assisted and independent living revenue — 151,797 — — — 151,797 Revenue from external customers $ 1,679,012 $ 151,797 $ 169,037 $ 40,813 $ — $ 2,040,659 Intersegment revenue (1) 2,996 — — 4,299 (7,295 ) — Total revenue $ 1,682,008 $ 151,797 $ 169,037 $ 45,112 $ (7,295 ) $ 2,040,659 Segment income (loss) (2) $ 190,924 $ 15,426 $ 26,117 $ (103,979 ) $ — $ 128,488 Interest expense, net of interest income $ (13,119 ) Income before provision for income taxes $ 115,369 Depreciation and amortization $ 31,931 $ 7,282 $ 1,045 $ 7,086 $ — $ 47,344 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $2,996 . Transitional and skilled services, assisted and independent living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines which are included in the "All Other" category of $4,299 . General and administrative expense 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 table demonstrates the impact of adopting ASC 606 on the Company's selected financial data, consolidated by business segment for the year ended December 31, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Year Ended December 31, 2018 (Adjusted to reflect prior revenue guidance) Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,709,988 $ — $ 170,871 $ 40,813 $ — $ 1,921,672 Assisted and independent living revenue — 151,797 — — — 151,797 Revenue from external customers $ 1,709,988 $ 151,797 $ 170,871 $ 40,813 $ — $ 2,073,469 Intersegment revenue (1) 2,996 — — 4,299 (7,295 ) — Total revenue $ 1,712,984 $ 151,797 $ 170,871 $ 45,112 $ (7,295 ) $ 2,073,469 Segment income (loss) (2) $ 190,924 $ 15,426 $ 26,117 $ (103,979 ) $ — $ 128,488 Interest expense, net of interest income $ (13,119 ) Income before provision for income taxes $ 115,369 Depreciation and amortization $ 31,931 $ 7,282 $ 1,045 $ 7,086 $ — $ 47,344 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $2,996 . Transitional and skilled services, assisted and independent living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines which are included in the "All Other" category of $4,299 . General and administrative expense 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. Year Ended December 31, 2017 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,545,210 $ — $ 142,403 $ 25,058 $ — $ 1,712,671 Assisted and independent living revenue — $ 136,646 $ — $ — — 136,646 Revenue from external customers $ 1,545,210 $ 136,646 $ 142,403 $ 25,058 $ — $ 1,849,317 Intersegment revenue (1) 3,023 — — 3,035 (6,058 ) — Total revenue $ 1,548,233 $ 136,646 $ 142,403 $ 28,093 $ (6,058 ) $ 1,849,317 Segment income (loss) (2) $ 140,272 $ 16,736 $ 19,717 $ (95,440 ) $ — $ 81,285 Interest expense, net of interest income $ (12,007 ) Income before provision for income taxes $ 69,278 Depreciation and amortization $ 29,928 $ 6,334 $ 945 $ 7,265 $ — $ 44,472 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $3,023 . Transitional and skilled services, assisted and independent living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines which are included in the "All Other" category of $3,035 . General and administrative expense 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. Year Ended December 31, 2016 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,374,803 $ — $ 115,813 $ 40,612 $ — $ 1,531,228 Assisted and independent living revenue — $ 123,636 $ — $ — — 123,636 Revenue from external customers $ 1,374,803 $ 123,636 $ 115,813 $ 40,612 $ — $ 1,654,864 Intersegment revenue (1) 2,929 — — 2,184 (5,113 ) — Total revenue $ 1,377,732 $ 123,636 $ 115,813 $ 42,796 $ (5,113 ) $ 1,654,864 Segment income (loss) (2) $ 118,118 $ 11,701 $ 16,571 $ (54,543 ) $ — $ 91,847 Interest expense, net of interest income $ (6,029 ) Income before provision for income taxes $ 85,818 Depreciation and amortization $ 26,298 $ 4,157 $ 924 $ 7,303 $ — $ 38,682 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $2,929 . Transitional and skilled services, assisted and independent living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines which are included in the "All Other" category of $2,184 . General and administrative expense and the return of unclaimed class action settlement 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 Company's assisted and independent living services segment income for the year ended December 31, 2018 included an impairment charge to long-lived assets of $4,632 . See Note 8, Property and Equipment for further detail. The Company's transitional and skilled services segment income for the years ended December 31, 2017 and 2016 included continued obligations under the lease related to closed operations, lease termination costs and related closing expenses of $4,017 and $7,935 , respectively. This amount includes the present value of future rental payments of approximately $2,715 and $6,512 and long-lived asset impairment of $111 and $137 for the years ended December 31, 2017 and 2016 , respectively. See Note 16, Leases for further detail. Also included in the year ended December 31, 2017 is the loss recovery of $1,286 related to a facility that was closed in the prior year.

Acquisitions

Acquisitions	12 Months Ended
	Dec. 31, 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 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. 2018 Acquisitions During the year ended December 31, 2018 , the Company expanded its operations through a combination of a long-term lease and real estate purchases, with the addition of four stand-alone skilled nursing operations, seven stand-alone assisted living operations, three campus operations, four home health agencies, three hospice agencies and two home care agencies. The Company did not acquire any material assets or assume any liabilities other than the tenant's post-assumption rights and obligations under the long-term lease. The addition of these operations added a total of 744 operational skilled nursing beds and 650 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 year ended December 31, 2018 was $90,039 . The fair value of assets for seventeen 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 six 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 six business combinations was $4,725 , mainly consisted of goodwill and indefinite-lived intangible assets of $4,709 . Subsequent Event Subsequent to December 31, 2018 , the Company acquired one stand-alone skilled nursing operation, which added 120 operational skilled nursing beds to be operated by the Company's operating subsidiaries. The Company also invested in new ancillary services that are complementary to its existing businesses. The aggregate purchase price for these acquisitions was $12,250 . As of the date of this report, the preliminary allocation of the purchase price for the acquisitions acquired subsequent to December 31, 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 will be determined upon completion of the allocation of the purchase price. 2017 Acquisitions The information for prior periods presented below reflects the previous accounting policy prior to the adoption of ASC 805. As such, the majority of the acquisitions acquired during the year ended December 31, 2017 and 2016 were classified as business combinations. During the year ended December 31, 2017 , the Company expanded its operations through a combination of long-term leases and purchases, with the addition of eight stand-alone skilled nursing operations, nine stand-alone assisted and independent living operations, one campus operation, three home health agencies, three hospice agencies and one home care agencies. The Company did not acquire any material assets or assume any liabilities other than the tenant's post-assumption rights and obligations under the long-term leases. The Company has also invested in ancillary services that are complementary to its existing transitional and skilled services, assisted and independent living services, and home health and hospice businesses. The aggregate purchase price for these acquisitions for the year ended December 31, 2017 was $89,683 . The addition of these operations added 905 operational skilled nursing beds and 594 assisted living units operated by the Company's operating subsidiaries. The Company entered into a separate operations transfer agreement with the prior operator as part of each transaction. Additionally, the Company's operating subsidiaries also opened four newly constructed stand-alone skilled nursing operations under long-term lease agreements, which added 455 operational skilled nursing beds. In connection with these acquisitions, the Company recorded land of $9,732 , building and improvements of $53,735 , equipment, furniture, and fixtures of $4,382 , assembled occupancy of $762 , goodwill of $13,962 , other indefinite-lived intangible assets of $7,018 and other assets and liabilities, net of $92 . In addition to the business combinations above, during the year ended December 31, 2017, the Company acquired Medicare and Medicaid licenses to add to its existing operations for an aggregate purchase price of $195 . 2016 Acquisitions During the year ended December 31, 2016, the Company expanded its operations with the addition of two home health agencies and five hospice agencies. In addition, the Company acquired eighteen stand-alone skilled nursing operations and one post-acute care campus through a combination of long-term leases and purchases. As part of these acquisitions, the Company acquired the real estate at two of the skilled nursing operations and one post-acute care campus and entered into long term leases for sixteen skilled nursing operations. The Company did not acquire any material assets or assume any liabilities other than the tenant's post-assumption rights and obligations under the long-term lease. The Company also invested in new ancillary services that are complementary to its existing transitional and skilled services; assisted and independent living services and home health and hospice businesses. The aggregate purchase price for these acquisitions for the year ended December 31, 2016 was $64,521 . The expansion of skilled nursing operations added 2,336 operational skilled nursing beds and ten assisted living units operated by the Company's operating subsidiaries. The Company entered into a separate operations transfer agreement with the prior operator as part of each transaction. Additionally, the Company's operating subsidiaries opened six newly constructed post-acute care campuses under long-term lease agreements, which added 463 operational skilled nursing beds and 142 assisted living units. In connection with these acquisitions, the Company recorded land of $1,054 , building and improvements of $21,057 , equipment, furniture, and fixtures of $8,265 , assembled occupancy of $1,299 , definite-lived intangible assets of $363 , goodwill of $30,343 , favorable leases of $393 , other indefinite-lived intangible assets of $1,741 and other assets and liabilities, net of $6 . In addition to the business combinations above, for the year ended December 31, 2016, the Company acquired the underlying real estate of fifteen assisted living operations, which the Company previously operated under a long-term lease agreement for an aggregate purchase price of $127,348 . The Company’s acquisition strategy has been focused on identifying both opportunistic and strategic acquisitions within its target markets that offer strong opportunities for return on invested capital. The operating subsidiaries acquired by the Company are frequently underperforming financially and can have regulatory and clinical challenges to overcome. Financial information, especially with underperforming operating subsidiaries, is often inadequate, inaccurate or unavailable. Consequently, the Company believes that prior operating results are not a meaningful representation of the Company’s current operating results or indicative of the integration potential of its newly acquired operating subsidiaries. The businesses acquired during the year ended December 31, 2018 were not material acquisitions to the Company individually or in the aggregate. Accordingly, pro forma financial information is not presented. These acquisitions have been included in the December 31, 2018 consolidated balance sheets of the Company, and the operating results have been included in the consolidated statements of operations of the Company since the dates the Company gained effective control.

Property and Equipment

Property and Equipment	12 Months Ended
	Dec. 31, 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: December 31, 2018 2017 Land $ 60,420 $ 49,081 Buildings and improvements 411,096 342,641 Equipment 202,346 181,530 Furniture and fixtures 5,079 5,244 Leasehold improvements 112,935 97,221 Construction in progress 9,729 5,460 801,605 681,177 Less: accumulated depreciation (182,731 ) (144,093 ) Property and equipment, net $ 618,874 $ 537,084 The Company classified $1,859 of land, building and equipment related to the sale of one assisted living operation as held for sale in the consolidated balance sheets as of December 31, 2018. In addition, management evaluated its long-lived assets and recorded an impairment charge of $5,492 . The Company divested of $24,847 of land, building and equipment as part of the sale-leaseback transaction during the year ended December 31, 2017 . See Note 16, Leases for information on the sale-leaseback transaction. See also Note 7, Acquisitions for information on acquisitions during the year ended December 31, 2018 and 2017.

Intangible Assets - Net

Intangible Assets - Net	12 Months Ended
	Dec. 31, 2018
Intangible Assets, Net (Excluding Goodwill) [Abstract]
Intangible Assets Disclosure [Text Block]	INTANGIBLE ASSETS — Net Weighted Average Life (Years) December 31, 2018 2017 Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Lease acquisition costs 14.5 $ 843 $ (251 ) 592 $ 483 $ (99 ) $ 384 Favorable leases 29.7 35,650 (8,724 ) 26,926 35,116 (6,568 ) 28,548 Assembled occupancy 0.4 2,936 (2,870 ) 66 2,659 (2,631 ) 28 Facility trade name 30.0 733 (317 ) 416 733 (293 ) 440 Customer relationships 18.2 4,670 (1,670 ) 3,000 4,933 (1,530 ) 3,403 Total $ 44,832 $ (13,832 ) $ 31,000 $ 43,924 $ (11,121 ) $ 32,803 Amortization expense was $2,837 , $3,035 and $4,634 for the years ended December 31, 2018, 2017 and 2016 , respectively, Estimated amortization expense for each of the years ending December 31 is as follows: Year Amount 2019 2,777 2020 1,616 2021 1,454 2022 1,450 2023 1,391 Thereafter 22,312 $ 31,000

Goodwill and Other Indefinite-L

Goodwill and Other Indefinite-Lived Intangible Assets	12 Months Ended
	Dec. 31, 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 Company performs its goodwill impairment test annually and evaluates goodwill when events or changes in circumstances indicate that its carrying value may not be recoverable. The Company performs the annual impairment testing of goodwill using October 1 as the measurement date. The Company completed its goodwill impairment test as of October 1, 2018. An impairment charge to goodwill and intangible assets of $3,513 and $140 , respectively, was recorded for the year ended December 31, 2018 on one of its ancillary operations. 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 years ended December 31, 2017 and 2016 . Since 1999, the Company has recognized cumulative goodwill impairment losses of $6,912 . As of December 31, 2016, the Company removed $4,103 in goodwill as part of the sale of urgent care centers. The Company anticipates that the majority of total goodwill recognized will be fully deductible for tax purposes as of December 31, 2018 . See further discussion of goodwill acquired at Note 7, Acquisitions . The following table represents activity in goodwill by segment as of and for the year ended December 31, 2018 : Goodwill Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total January 1, 2016 $ 14,221 $ 3,538 $ 16,102 $ 7,025 $ 40,886 Additions 26,415 — 1,799 2,129 30,343 Less: Dispositions — — — (4,103 ) (4,103 ) Purchase price adjustment — — — (26 ) (26 ) December 31, 2016 $ 40,636 $ 3,538 $ 17,901 $ 5,025 $ 67,100 Additions 4,850 420 6,421 2,271 13,962 December 31, 2017 $ 45,486 $ 3,958 $ 24,322 $ 7,296 $ 81,062 Additions — — 2,872 — 2,872 Purchase price adjustment — — 56 — 56 Impairments — — — (3,513 ) (3,513 ) December 31, 2018 $ 45,486 $ 3,958 $ 27,250 $ 3,783 $ 80,477 During the year ended December 31, 2018 , the Company acquired $2,317 in Medicare and Medicaid licenses as part of its acquisitions. Other indefinite-lived intangible assets consists of the following: December 31, 2018 2017 Trade name $ 1,217 $ 1,181 Medicare and Medicaid licenses 26,385 24,068 $ 27,602 $ 25,249

Restricted and Other Assets

Restricted and Other Assets	12 Months Ended
	Dec. 31, 2018
Other Assets [Abstract]
Other Assets Disclosure [Text Block]	RESTRICTED AND OTHER ASSETS Restricted and other assets consist of the following: December 31, 2018 2017 Debt issuance costs, net $ 1,892 $ 2,799 Long-term insurance losses recoverable asset 6,969 5,394 Deposits with landlords 8,694 5,981 Capital improvement reserves with landlords and lenders 3,196 2,327 Note receivable from sale of ancillary business 93 — Restricted and other assets $ 20,844 $ 16,501 Included in restricted and other assets as of December 31, 2018 and 2017 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	12 Months Ended
	Dec. 31, 2018
Accrued Liabilities [Abstract]
Other Liabilities Disclosure [Text Block]	OTHER ACCRUED LIABILITIES Other accrued liabilities consist of the following: December 31, 2018 2017 Quality assurance fee $ 5,375 $ 4,864 Refunds payable 25,118 21,661 Contract liabilities 8,495 7,066 Cash held in trust for patients 2,824 2,609 Resident deposits 6,665 6,574 Dividends payable 2,525 2,328 Property taxes 9,426 10,088 Other 9,356 8,625 Other accrued liabilities $ 69,784 $ 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. Contract liabilities occur when the Company receives payments in advance of services provided. Resident deposits include refundable deposits to patients. Cash held in trust for patients reflects monies received from or on behalf of patients. Maintaining a trust account for patients is a regulatory requirement and, while the trust assets offset the liabilities, the Company assumes a fiduciary responsibility for these funds. The cash balance related to this liability is included in other current assets in the accompanying consolidated balance sheets. Operational closure liability includes the short-term portion of the closing costs that are payable within the next 12 months. The remaining long-term portion is included in other long-term liabilities in the accompanying consolidated balance sheets.

Income Taxes

Income Taxes	12 Months Ended
	Dec. 31, 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 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 are recorded as an adjustment to the provision for income taxes in the period the amounts are determined. During the year ended December 31, 2017, the company recognized a provisional net deferred income tax expense of $3,915 to reflect the revaluation of the Company’s net deferred tax assets based on the U.S. federal tax rate of 21%. In accordance with SAB 118, the Tax Act related income tax effects that were initially reported as provisional estimates were refined as additional analysis was performed. During the quarter ended December 31, 2018, the Company received IRS approval of its application for a non-automatic change in tax accounting method, resulting in an additional deferred tax benefit of $1,233 , which is included in income tax expense from continuing operations. The U.S government may issue additional guidance on the final impact of U.S. tax reform that may differ from current law, possibly materially, due to factors such as changes in interpretations of the Tax Act, and any legislative action to address uncertainties that arise because of the Tax Act. As of December 31, 2018, the Company has completed its accounting for the tax effects of the enactment of the Tax Act. The rate impact of each year's Tax Act adjustment is outlined in the rate reconciliation table below. The provision for income taxes on continuing operations for the years ended December 31, 2018, 2017 and 2016 is summarized as follows: Year Ended December 31, 2018 2017 2016 Current: Federal $ 16,158 $ 15,141 $ 30,043 State 5,588 2,975 5,183 21,746 18,116 35,226 Deferred: Federal 1,778 5,428 (1,034 ) State (683 ) 986 (1,217 ) 1,095 6,414 (2,251 ) Adjustment to deferred taxes for tax rate change — 3,915 — Total $ 22,841 $ 28,445 $ 32,975 A reconciliation of the federal statutory rate to the effective tax rate for income from continuing operations for the years ended December 31, 2018, 2017 and 2016 , respectively, is comprised as follows: December 31, 2018 2017 2016 Income tax expense at statutory rate 21.0 % 35.0 % 35.0 % State income taxes - net of federal benefit 3.1 3.1 3.0 Non-deductible expenses 0.8 1.7 0.9 Non-deductible compensation 1.8 — — Equity compensation (4.8 ) (4.5 ) — Revaluation of deferred (1.1 ) 5.7 — Other adjustments (1.0 ) 0.1 (0.5 ) Total income tax provision 19.8 % 41.1 % 38.4 % The Company's deferred tax assets and liabilities as of December 31, 2018 and 2017 are summarized below. December 31, 2018 2017 Deferred tax assets (liabilities): Accrued expenses $ 22,756 $ 16,500 Allowance for doubtful accounts 12,312 11,090 Tax credits 3,201 3,334 Insurance 5,667 5,135 43,936 36,059 Valuation allowance (791 ) (530 ) Total deferred tax assets 43,145 35,529 State taxes (475 ) (911 ) Depreciation and amortization (28,496 ) (18,248 ) Prepaid expenses (2,524 ) (3,625 ) Total deferred tax liabilities (31,495 ) (22,784 ) Net deferred tax assets $ 11,650 $ 12,745 The Company had state credit carryforwards as of December 31, 2018 and 2017 of $3,201 and $3,334 , respectively. These carryforwards almost entirely relate to state limitations on the application of Enterprise Zone employment-related tax credits. Unless the Company uses the Enterprise Zone credits beforehand, the carryforward will begin to expire in 2023. The remainder of these carryforwards relates to credits against the Texas margin tax and is expected to carry forward until 2027. As of December 31, 2018, a valuation allowance of $1,000 was recorded against the Enterprise Zone credits as the Company believes it is more likely than not that some of the benefit of the credits will not be realized. The Company's operating loss carry forwards for both federal and states were not material during the years ended December 31, 2018 and 2017 . The Federal statutes of limitations on the Company's 2012, 2013, and 2014 income tax years lapsed during the third quarter of 2016, 2017, and 2018, respectively. During the fourth quarter of each year, various state statutes of limitations also lapsed. The lapses for the years ended December 31, 2018, 2017 and 2016 had no impact on the Company's unrecognized tax benefits. As of December 31, 2018, 2017 and 2016 , the Company did not have any unrecognized tax benefits, net of their state benefits, that would affect the Company's effective tax rate. The Company classifies interest and/or penalties on income tax liabilities or refunds as additional income tax expense or income. Such amounts are not material

Debt

Debt	12 Months Ended
	Dec. 31, 2018
Debt Disclosure [Abstract]
Debt Disclosure [Text Block]	DEBT Long-term debt consists of the following: December 31, 2018 2017 Term loan with SunTrust $ 113,125 $ 140,625 Revolving credit facility with SunTrust 10,000 50,000 Mortgage loans and promissory note 122,955 125,394 246,080 316,019 Less: current maturities (10,105 ) (9,939 ) Less: debt issuance costs (2,840 ) (3,090 ) $ 233,135 $ 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 . 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 December 31, 2018 , the Company's operating subsidiaries had $123,125 outstanding under the Credit Facility. The outstanding balance on the term loan was $113,125 , of which $7,500 is classified as short-term and the remaining $105,625 is classified as long-term. The outstanding balance on the revolving Credit Facility was $10,000 , which is classified as long-term. The Company was in compliance with all loan covenants as of December 31, 2018 . As of February 4, 2019 , there was approximately $123,125 outstanding under the Revolving Credit Facility. Mortgage Loans and Promissory Note In December 2017, 17 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 11 of the loan. There is no prepayment penalty after year 11 . 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 December 31, 2018 , the Company's operating subsidiaries had $122,955 outstanding under the mortgage loans and note, of which $2,605 is classified as short-term and the remaining $120,350 is classified as long-term. The Company was in compliance with all loan covenants as of December 31, 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. Future principal payments due under the long-term debt arrangements discussed above are as follows: Years Ending December 31, Amount 2019 10,105 2020 10,203 2021 110,926 2022 2,904 2023 3,016 Thereafter 108,926 $ 246,080 Off-Balance Sheet Arrangements During the year ended December 31, 2018 , the Company decreased its outstanding letters of credit by $1,522 . As of December 31, 2018 , the Company had approximately $4,782 on the credit facility of borrowing capacity pledged as collateral to secure outstanding letters of credit.

Options and Awards

Options and Awards	12 Months Ended
	Dec. 31, 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 consolidated statements of income for the years ended December 31, 2018, 2017 and 2016 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. During the second quarter of 2017, the Company's stockholders approved the 2017 Omnibus Incentive Plan (the 2017 Plan). The Company retired the 2001 Stock Option, Deferred Stock and Restricted Stock Plan (2001 Plan), the 2005 Stock Incentive Plan (2005 Plan), and the 2007 Omnibus Incentive Plan (2007 Plan) as a result of the approval of the 2017 Plan. 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 December 31, 2018 , there were 4,770 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 Black-Scholes model required the Company to make several key judgments including: • The expected option term is calculated by the average of the contractual term of the options and the weighted average vesting period for all options. The calculation of the expected option term is based on the Company's experience due to sufficient history. • Estimated volatility also reflects the application of ASC 718 interpretive guidance and, accordingly, incorporates historical volatility of similar public entities until sufficient information regarding the volatility of the Company's share price becomes available. The Company has utilized its own experience to calculate estimated volatility for options granted. • The dividend yield is based on the Company's historical pattern of dividends as well as expected dividend patterns. • The risk-free rate is based on the implied yield of U.S. Treasury notes as of the grant date with a remaining term approximately equal to the expected term. • Estimated forfeiture rate of approximately 9.63% per year is based on the Company's historical forfeiture activity of unvested stock options. Stock Options The Company granted 640 options and 367 restricted stock awards from the 2017 Plan during the year ended December 31, 2018 . The Company used the following assumptions for stock options granted during the years ended December 31, 2018, 2017 and 2016 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2018 640 2.8% 6.2 years 32.0% 0.5% 2017 481 2.0% 6.2 years 35.2% 0.8% 2016 497 1.4% 6.3 years 37.8% 0.8% For the years ended December 31, 2018, 2017 and 2016 , 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 640 $ 34.53 $ 12.05 2017 481 $ 20.31 $ 7.00 2016 497 $ 19.43 $ 7.00 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 December 31, 2018, 2017 and 2016 and therefore, the intrinsic value was $0 at the date of grant. The following table represents the employee stock option activity during the years ended December 31, 2018, 2017 and 2016 : Number of Options Outstanding Weighted Average Exercise Price Number of Options Vested Weighted Average Exercise Price of Options Vested January 1, 2016 5,448 $ 10.36 2,526 $ 6.35 Granted 497 19.43 Forfeited (127 ) 14.46 Exercised (642 ) 6.47 December 31, 2016 5,176 $ 11.62 2,704 $ 8.18 Granted 481 20.31 Forfeited (178 ) 15.82 Exercised (740 ) 6.93 December 31, 2017 4,739 $ 13.08 2,776 $ 10.07 Granted 640 34.53 Forfeited (120 ) 18.71 Exercised (1,071 ) 8.57 December 31, 2018 4,188 $ 17.35 2,431 $ 12.37 The following summary information reflects stock options outstanding, vested and related details as of December 31, 2018 : Stock Options Outstanding Stock Options Vested Number Outstanding Black-Scholes Fair Value Remaining Contractual Life (Years) Vested and Exercisable Year of Grant Exercise Price 2009 4.06 - 4.56 194 $ 414 1 194 2010 4.77 - 4.96 81 196 2 81 2011 5.90 - 7.99 86 296 3 86 2012 6.56 - 7.96 257 952 4 257 2013 7.98 - 11.49 423 2,047 5 423 2014 10.55 - 18.94 1,201 6,816 6 885 2015 21.47 - 25.24 479 4,351 7 273 2016 18.79 - 19.89 403 2,810 8 151 2017 18.64 - 22.90 441 3,083 9 81 2018 26.53 - 38.59 623 7,523 10 — Total 4,188 $ 28,488 2,431 Restricted Stock Awards The Company granted 367 , 173 and 299 restricted stock awards during the years ended December 31, 2018, 2017 and 2016 , 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 years ended December 31, 2018, 2017 and 2016 ranged from $23.61 to $38.59 , $18.47 to $22.90 and $18.79 to $23.23 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 December 31, 2018 and changes during the years ended December 31, 2018, 2017 and 2016 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2016 425 $ 19.79 Granted 299 20.55 Vested (279 ) 19.58 Forfeited (16 ) 20.85 Nonvested at December 31, 2016 429 $ 20.42 Granted 173 20.21 Vested (195 ) 19.79 Forfeited (24 ) 20.34 Nonvested at December 31, 2017 383 $ 20.65 Granted 367 35.19 Vested (153 ) 22.68 Forfeited (24 ) 23.31 Nonvested at December 31, 2018 573 $ 29.31 During the year ended December 31, 2018 , the Company granted 29 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 $37.78 based on the market price on the grant date. Share-based compensation expense recognized for the Company's equity incentive plans for the years ended December 31, 2018, 2017 and 2016 was as follows: Year Ended December 31, 2018 2017 2016 Share-based compensation expense related to stock options $ 4,905 $ 4,773 $ 4,793 Share-based compensation expense related to restricted stock awards 3,159 2,322 2,371 Share-based compensation expense related to stock options and restricted stock awards to non-employee directors 895 1,236 612 Total $ 8,959 $ 8,331 $ 7,776 In future periods, the Company expects to recognize approximately $13,105 and $15,022 in share-based compensation expense for unvested options and unvested restricted stock awards, respectively, that were outstanding as of December 31, 2018 . Future share-based compensation expense will be recognized over 3.5 and 3.9 weighted average years for unvested options and restricted stock awards, respectively. There were 1,757 unvested and outstanding options at December 31, 2018 , of which 1,653 are expected to vest. The weighted average contractual life for options outstanding, vested and expected to vest at December 31, 2018 was 5.9 years. The aggregate intrinsic value of options outstanding, vested, expected to vest and exercised as of and for the years ended December 31, 2018, 2017 and 2016 is as follows: December 31, Options 2018 2017 2016 Outstanding $ 89,806 $ 44,060 $ 55,610 Vested 64,222 33,976 38,101 Expected to vest 22,963 9,311 15,983 Exercisable 27,646 10,481 9,199 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). The Company granted 3,323 restricted stock awards during the year ended December 31, 2016 at a fair value of $1.37 . The Company did not grant any new restricted shares during the years ended December 31, 2018 and 2017. These awards generally vest over a period of three to five years , or upon the occurrence of certain prescribed events. During the years ended December 31, 2018 and 2017, 976 restricted stock awards vested for both periods. During the year ended December 31, 2016, 375 of the restricted stock awards vested. The Company granted 221 , 174 and 120 of stock options during the years ended December 31, 2018, 2017 and 2016, respectively. 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 years ended December 31, 2018, 2017 and 2016 , the Company expensed $1,378 , $1,364 and $1,325 , 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 December 31, 2018, 2017 and 2016 is 217 , 264 and 212 , respectively. During 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	12 Months Ended
	Dec. 31, 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 20 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 $58,513 , $57,169 , and $56,271 for the years ended December 31, 2018, 2017 and 2016 , 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 December 31, 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. 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 $139,149 , $132,932 and $125,221 for the years ended December 31, 2018, 2017 and 2016 , respectively. Thirty-five of the Company’s affiliated facilities, excluding the facilities that are operated under the Master Leases with CareTrust, are operated under six 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. During the first quarter of 2016, the Company voluntarily discontinued operations at one of its skilled nursing facilities in order to preserve the overall ability to serve the residents in surrounding counties after careful consideration and some clinical survey challenges. 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 rental payments 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 $7,935 , including the present value of rental payments of approximately $6,512 , in 2016. Residents of the affected facility were transferred to local skilled nursing facilities. In 2017, the Company recovered $1,286 of certain losses that were recorded in 2016 related to the closure of the operation. The loss recovery was recorded as a gain in 2017. 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 December 31, 2018 are as follows: Year Amount 2019 142,497 2020 141,536 2021 140,524 2022 139,018 2023 137,349 Thereafter 967,027 $ 1,667,951

Self-Insurance Reserves

Self-Insurance Reserves	12 Months Ended
	Dec. 31, 2018
Self-Insurance Reserves [Abstract]
Liability for Future Policy Benefits and Unpaid Claims Disclosure [Text Block]	SELF INSURANCE RESERVES The following table represents activity in our insurance reserves as of and for the years ended December 31, 2018 and 2017 : General and Professional Liability Workers' Compensation Health Total Balance January 1, 2017 $ 36,310 $ 23,402 $ 5,639 $ 65,351 Current year provisions 20,396 15,202 53,796 89,394 Claims paid and direct expenses (16,133 ) (12,455 ) (54,712 ) (83,300 ) Change in long-term insurance losses recoverable 361 930 — 1,291 Balance December 31, 2017 $ 40,934 $ 27,079 $ 4,723 $ 72,736 Current year provisions 23,113 14,970 49,988 88,071 Claims paid and direct expenses (19,476 ) (13,967 ) (48,888 ) (82,331 ) Change in long-term insurance losses recoverable 795 780 — 1,575 Balance December 31, 2018 $ 45,366 $ 28,862 $ 5,823 $ 80,051 Included in long-term insurance losses recoverable as of as of December 31, 2018 and 2017, are anticipated insurance recoveries related to the Company's general and professional liability claims that are recorded on a gross rather than net basis in accordance with GAAP.

Commitments and Contingencies

Commitments and Contingencies	12 Months Ended
	Dec. 31, 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 of 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 independent operating subsidiary, (iii) certain lending agreements, under which the Company may be required to indemnify the lender against various claims and liabilities, and (iv) certain agreements with the Company’s officers, directors and 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 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 independently operating 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 independent operating entities. 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 independent 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 independent operating subsidiaries. The Company, its independent operating subsidiaries, and others in the industry are subject to an increasing number of claims and lawsuits, including professional liability claims, alleging that services provided have resulted in personal injury, elder abuse, wrongful death or other related claims. 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 independent operating subsidiaries do business. In May 2009, Congress passed the Fraud Enforcement and Recovery Act (FERA) which made significant changes to the Federal False Claims Act (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's independent operating subsidiaries are 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 independent 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 independent 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 was possible in advance of a decision on class certification. 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 post-acute care providers. 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 addition, 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 independent operating subsidiaries are subjected to, alleged to be liable for, or agree to a settlement of, claims or obligations under Federal Medicare statutes, the Federal False Claims Act, or similar State and Federal statutes and related regulations, or if the Company or its independent operating subsidiaries are alleged or found to be liable on theories of general or professional negligence, 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 independent 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 December 31, 2018 , 16 of the Company's independent operating subsidiaries had Reviews scheduled, on appeal, or in a dispute resolution 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 December 31, 2018 , the Company's independent operating subsidiaries have responded to the requests and the related claims are currently under Review, on appeal or in a dispute resolution process. 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 independent 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 independent 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's independent operating subsidiaries 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 60.6% and 56.7% of its total accounts receivable as of December 31, 2018 and 2017, respectively. Revenue from reimbursement under the Medicare and Medicaid programs accounted for 68.5% , 68.4% and 67.8% of the Company's revenue for the years ended December 31, 2018, 2017 and 2016 , respectively. Cash in Excess of FDIC Limits — The Company currently has bank deposits with financial institutions in the U.S. that exceed FDIC insurance limits. FDIC insurance provides protection for bank deposits up to $250 . In addition, the Company has uninsured bank deposits with a financial institution outside the U.S. As of February 4, 2019 , the Company had approximately $593 in uninsured cash deposits. All uninsured bank deposits are held at high quality credit institutions.

Defined Contribution Plan

Defined Contribution Plan	12 Months Ended
	Dec. 31, 2018
Defined Contribution Plan [Abstract]
Compensation and Employee Benefit Plans [Text Block]	DEFINED CONTRIBUTION PLAN The Company has a 401(k) defined contribution plan (the 401(k) Plan), whereby eligible employees may contribute up to 15% of their annual basic earnings. Additionally, the 401(k) Plan provides for discretionary matching contributions (as defined in the 401(k) Plan) by the Company. The Company expensed matching contributions to the 401(k) Plan of $1,283 , $1,028 and $862 during the years ended December 31, 2018, 2017 and 2016 , respectively. Beginning in 2007, the 401(k) Plan allowed eligible employees to contribute up to 90% of their eligible compensation, subject to applicable annual Internal Revenue Code limits.

Common Stock

Common Stock	12 Months Ended
	Dec. 31, 2018
Common Stock [Abstract]
Common stock [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 year ended December 31, 2017 , the Company repurchased 412 shares of its common stock for a total of $7,288 . The Company did not repurchase shares during the year ended December 31, 2017 . On February 9, 2016, the Company announced that its Board of Directors authorized a stock repurchase program, under which the Company may repurchase up to $15,000 of its common stock over a period of 12 months . During the first quarter of 2016, the Company repurchased 746 shares of its common stock for a total of $15,000 and the repurchase program expired upon the repurchase of the full authorized amount under the plan.

Divestitures

Divestitures	12 Months Ended
	Dec. 31, 2018
Divestitures [Abstract]
Disposal Groups, Including Discontinued Operations, Disclosure [Text Block]	DIVESTITURES In 2016, the Company completed the sale of seventeen urgent care centers for an aggregate sale price of $41,492 . As a result of the sale, the Company recognized a pretax gain of $19,160 , which is included in operating income. Due to the disposition of the clinics, the Company is no longer the primary beneficiary and the variable interest entities associated with the urgent care operations was deconsolidated from the Company's consolidated financial statements as of December 31, 2016. At deconsolidation, the Company eliminated intercompany balances that previously existed. The sale of this investment supports the Company's increased focus on growth opportunities in its business lines that are complementary to its existing transitional and skilled services. The sale transactions did not meet the criteria of a discontinued operation as they do not represent a strategic shift that has or will have a major effect on the Company’s operations and financial results.

Significant Accounting Polici_2

Significant Accounting Policies Level 2 (Policies)	12 Months Ended
	Dec. 31, 2018
Accounting Policies [Abstract]
Basis of Presentation	Basis of Presentation — The accompanying consolidated financial statements (Financial Statements) have been prepared in accordance with accounting principles generally accepted in the United States (GAAP). The Company is the sole member or stockholder of various consolidated limited liability companies and corporations established to operate various acquired skilled nursing and 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 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 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 consolidated statements of income. The consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest and the accounts of any variable interest entities (VIEs) where the Company is subject to a majority of the risk of loss from the VIE's activities, or entitled to receive a majority of the entity's residual returns, or both. The Company assesses the requirements related to the consolidation of VIEs, including a qualitative assessment of power and economics that considers which entity has the power to direct the activities that "most significantly impact" the VIE's economic performance and has the obligation to absorb losses of, or the right to receive benefits that could be potentially significant to, the VIE. The Company's relationship with variable interest entities was not material during the year ended December 31, 2018. In December 2018, the Company agreed to terms to sell one of its assisted living operations. The sale of this assisted living operation closed in the first quarter of 2019. Property and equipment assets included in the sale of the one assisted living facility have been presented as held for sale in the accompanying consolidated balance sheets as of December 31, 2018. The sale transaction does not meet the criteria of discontinued operations as it does not represent a strategic shift that has, or will have, a major effect on the Company's operations and financial results.
Estimates and Assumptions	Estimates and Assumptions — The preparation of Financial Statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the Financial Statements and the reported amounts of revenue and expenses during the reporting periods. The most significant estimates in the Company’s Financial Statements relate to revenue, 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 .
Cash and Cash Equivalents	Cash and Cash Equivalents — Cash and cash equivalents consist of bank term deposits, money market funds and treasury bill related investments with original maturities of three months or less at time of purchase and therefore approximate fair value. The fair value of money market funds is determined based on “Level 1” inputs, which consist of unadjusted quoted prices in active markets that are accessible at the measurement date for identical, unrestricted assets. The Company places its cash and short-term investments with high credit quality financial institutions.
Insurance Subsidiary Deposits and Investments	Insurance Subsidiary Deposits and Investments — The Company's captive insurance subsidiary cash and cash equivalents, deposits and investments are designated to support long-term insurance subsidiary liabilities and have been classified as short-term and long-term assets based on the timing of expected future payments of the Company's captive insurance liabilities. The majority of these deposits and investments are currently held in AA, A and BBB rated debt security investments and the remainder is held in a bank account with a high credit quality financial institution. See further discussion at Note 5, Fair Value Measurements. The Company evaluates securities for other-than-temporary impairment (“OTTI”) on at least a quarterly basis, and more frequently when economic or market conditions warrant such an evaluation. If securities are in an unrealized loss position, the Company considers the extent and duration of the unrealized loss, and the financial condition and near-term prospects of the issuer. The Company also assesses whether it intends to sell, or it is more likely than not that it will be required to sell, a security in an unrealized loss position before recovery of its amortized cost basis. If either of the criteria regarding intent or requirement to sell is met, the entire difference between amortized cost and fair value is recognized as impairment through earnings. For the years ended December 31, 2017 and 2018, the Company did not recognize any OTTI for its investments.
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. 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 $5,492 , $111 and $137 during the years ended December 31, 2018, 2017 and 2016 , respectively. See further discussion at Note 8, Property and Equipment .
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 fiscal year of 2018, due to changes in performance and the Company recorded an impairment charge of $3,653 to goodwill and intangible assets during the year ended December 31, 2018 . The Company did not identify any goodwill and intangible assets impairment during the years ended December 31, 2017 and 2016 . 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, Washington and Wyoming for workers' compensation) are self-insured through the Captive, the related assets and liabilities of which are included in the accompanying consolidated balance sheets. The Captive is subject to certain statutory requirements as an insurance provider. 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. The Company’s operating subsidiaries are self-insured for workers’ compensation in California. To protect itself against loss exposure in California with this policy, the Company has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington and Wyoming, are under a loss sensitive plan that insures individual claims that exceed $350 per occurrence. In Washington and Wyoming, the operating subsidiaries' coverage is financed through premiums paid by the employers and employees. The claims and pay benefits are managed through a state insurance pool. Outside of California, Texas, Washington and Wyoming, the Company has purchased insurance coverage that insures individual claims that exceed $350 per accident. In all states except Washington and Wyoming, the Company accrues amounts equal to the estimated costs to settle open claims, as well as an estimate of the cost of claims that have been incurred but not reported. The Company uses actuarial valuations to estimate the liability based on historical experience and industry information. In addition, the Company has recorded an asset and equal liability of $6,969 and $5,394 at December 31, 2018 and 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 believes that adequate provision has been made in the Financial Statements for liabilities that may arise out of patient care, workers’ compensation, healthcare benefits and related services provided to date. The amount of the Company’s reserves was determined based on an estimation process that uses information obtained from both company-specific and industry data. This estimation process requires the Company to continuously monitor and evaluate the life cycle of the claims. Using data obtained from this monitoring and the Company’s assumptions about emerging trends, the Company, with the assistance of an independent actuary, develops information about the size of ultimate claims based on the Company’s historical experience and other available industry information. The most significant assumptions used in the estimation process include determining the trend in costs, the expected cost of claims incurred but not reported and the expected costs to settle or pay damage awards with respect to unpaid claims. The self-insured liabilities are based upon estimates, and while management believes that the estimates of loss are reasonable, the ultimate liability may be in excess of or less than the recorded amounts. Due to the inherent volatility of actuarially determined loss estimates, it is reasonably possible that the Company could experience changes in estimated losses that could be material to net income. If the Company’s actual 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 consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to The Ensign Group, Inc. in its consolidated statements of income 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. See further discussion at Note 3, Revenue and Accounts Receivable . 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 seventeen of the Company's acquisitions during the year ended December 31, 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 six acquisitions during the year ended December 31, 2018 was concentrated in goodwill and as such, these transactions were classified as business acquisitions in accordance with ASC 805. The majority 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 established Topic 842, Leases , by issuing Accounting Standards Update (ASU) No. 2016-02, which requires lessees to recognize leases with terms longer than 12 months on the balance sheet and disclose key information about leasing arrangements. Leases will be classified as either finance or operating, with classification affecting the pattern of expense recognition in the income statement. The classification criteria for distinguishing between operating and finance (previously capital) leases are substantially similar to the previous lease guidance, but with no explicit bright lines. The Company adopted the standard as of January 1, 2019, electing the transition method that allows it to apply the standard as of the adoption date and record a cumulative adjustment in retained earnings, if applicable. The Company has elected the package of practical expedients permitted under the transition guidance within the new guidance, which among other things, allows the Company to carryforward the historical lease classification. The new standard also provides practical expedients for an entity’s ongoing accounting. The Company has made an accounting policy election to keep leases with an initial term of 12 months or less off of the balance sheet and recognize those lease payments in the consolidated statements of income on a straight-line basis over the lease term. The Company has also elected the practical expedient to not separate lease and non-lease components for all of its leases as the non-lease components are not significant to the overall lease costs. The adoption of this standard resulted in recognition of net lease assets and lease liabilities of approximately $1,050,000 and $1,030,000 , respectively, on its consolidated balance sheets as of January 1, 2019. The Company recorded an adjustment, gross of tax, approximately of $12,100 to retained earnings, on the adoption date, related to a deferred gain on a previous sale-leaseback transaction, which will result in an increase in rent expense of approximately $700 annually as we will no longer be able to recognize the gain in our consolidated statement of income as a result of the adoption of the new lease standard. In addition, initial direct cost associated with its lease agreements and favorable lease assets of approximately $27,000 would be classified into right of used assets on adoption date. The Company does not believe the standard will materially affect its consolidated net earnings or have a notable impact on liquidity or debt-covenant compliance under the current agreements.

Revenue and Accounts Receivab_2

Revenue and Accounts Receivable (Tables)	12 Months Ended
	Dec. 31, 2018
REVENUE AND ACCOUNTS RECEIVABLE [Abstract]
Schedule of New Accounting Pronouncements and Changes in Accounting Principles [Table Text Block]	Year Ended December 31, 2018 2017 2016 Total revenue As Reported $ 2,040,659 $ 1,849,317 $ 1,654,864 Impact of ASC 606 32,810 — — Balances as if the previous accounting guidance was in effect $ 2,073,469 $ 1,849,317 $ 1,654,864 Cost of Services: As Reported $ 1,627,672 $ 1,497,703 $ 1,341,814 Impact of ASC 606 32,810 — — Balances as if the previous accounting guidance was in effect $ 1,660,482 $ 1,497,703 $ 1,341,814 Total Expense: As Reported $ 1,912,171 $ 1,768,032 $ 1,563,017 Impact of ASC 606 32,810 — — Balances as if the previous accounting guidance was in effect $ 1,944,981 $ 1,768,032 $ 1,563,017
Disaggregation of Revenue [Table Text Block]	Revenue for the years ended December 31, 2018, 2017 and 2016 is summarized in the following tables: Year Ended December 31, 2018 2018 adjusted to reflect prior revenue guidance 2017 2016 Revenue % of Revenue Revenue % of Revenue Revenue % of Revenue Revenue % of Revenue Medicaid $ 727,310 35.6 % $ 738,179 35.6 % $ 644,803 34.9 % $ 557,958 33.7 % Medicare 552,577 27.1 556,159 26.8 515,884 27.9 477,019 28.8 Medicaid — skilled 117,686 5.8 119,667 5.8 102,875 5.6 87,517 5.3 Total Medicaid and Medicare 1,397,573 68.5 1,414,005 68.2 1,263,562 68.4 1,122,494 67.8 Managed care 326,325 16.0 333,197 16.1 303,386 16.4 265,508 16.0 Private and other payors (1) 316,761 15.5 326,267 15.7 282,369 15.2 266,862 16.2 Revenue $ 2,040,659 100.0 % $ 2,073,469 100.0 % $ 1,849,317 100.0 % $ 1,654,864 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the years ended December 31, 2018, 2017 and 2016.
Schedule of Accounts, Notes, Loans and Financing Receivable [Table Text Block]	Accounts receivable as of December 31, 2018 and December 31, 2017 is summarized in the following table: Year Ended December 31, 2018 2018 adjusted to reflect prior revenue guidance 2017 Medicaid $ 117,984 $ 130,476 $ 119,441 Managed care 54,682 67,238 68,930 Medicare 50,994 57,580 55,667 Private and other payors 55,325 69,662 64,991 278,985 324,956 309,029 Less: allowance for doubtful accounts (2,886 ) (48,857 ) (43,961 ) Accounts receivable, net $ 276,099 $ 276,099 $ 265,068

Computation of Net Income Per_2

Computation of Net Income Per Common Share (Tables)	12 Months Ended
	Dec. 31, 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: Year Ended December 31, 2018 2017 2016 Numerator: Net income $ 92,528 $ 40,833 $ 52,843 Less: net income attributable to noncontrolling interests 164 358 2,853 Net income attributable to The Ensign Group, Inc. $ 92,364 $ 40,475 $ 49,990 Denominator: Weighted average shares outstanding for basic net income per share 52,016 50,932 50,555 Basic net income per common share attributable to The Ensign Group, Inc. $ 1.78 $ 0.79 $ 0.99
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: Year Ended December 31, 2018 2017 2016 Numerator: Net income $ 92,528 $ 40,833 $ 52,843 Less: net income attributable to noncontrolling interests 164 358 2,853 Net income attributable to The Ensign Group, Inc. $ 92,364 $ 40,475 $ 49,990 Denominator: Weighted average common shares outstanding 52,016 50,932 50,555 Plus: incremental shares from assumed conversion (1) 2,381 1,897 1,578 Adjusted weighted average common shares outstanding 54,397 52,829 52,133 Diluted net income per common share attributable to The Ensign Group, Inc. $ 1.70 $ 0.77 $ 0.96 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 220 , 1,252 and 838 for the years ended December 31, 2018, 2017 and 2016 , respectively.

Fair Value Measurements (Tables

Fair Value Measurements (Tables)	12 Months Ended
	Dec. 31, 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 December 31, 2018 and 2017: December 31, 2018 2017 Level 1 Level 2 Level 3 Level 1 Level 2 Level 3 Cash and cash equivalents $ 31,083 $ — $ — $ 42,337 $ — $ —

Business Segments (Tables)

Business Segments (Tables)	12 Months Ended
	Dec. 31, 2018
Segment Reporting [Abstract]
Reconciliation of Revenue from Segments to Consolidated [Table Text Block]	Segment revenues by major payor source were as follows: Year Ended December 31, 2018 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 678,749 $ 36,152 $ 12,409 $ — $ 727,310 35.6 % Medicare 436,580 — 115,997 — 552,577 27.1 Medicaid-skilled 117,686 — — — 117,686 5.8 Subtotal 1,233,015 36,152 128,406 — 1,397,573 68.5 Managed care 301,866 — 24,459 — 326,325 16.0 Private and other 144,131 115,645 16,172 40,813 (1) 316,761 15.5 Total revenue $ 1,679,012 $ 151,797 $ 169,037 $ 40,813 $ 2,040,659 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the year ended December 31, 2018. The following table demonstrates the impact of adopting ASC 606 on the Company's segment revenues by major payor source for the year ended December 31, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Year Ended December 31, 2018 (Adjusted to reflect prior revenue guidance) Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 689,225 $ 36,152 $ 12,802 $ — $ 738,179 35.6 % Medicare 439,433 — 116,726 — 556,159 26.8 Medicaid-skilled 119,667 — — — 119,667 5.8 Subtotal 1,248,325 36,152 129,528 — 1,414,005 68.2 Managed care 308,148 — 25,049 — 333,197 16.1 Private and other 153,515 115,645 16,294 40,813 (1) 326,267 15.7 Total revenue $ 1,709,988 $ 151,797 $ 170,871 $ 40,813 $ 2,073,469 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the year ended December 31, 2018. Year Ended December 31, 2017 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 603,104 $ 30,469 $ 11,230 $ — $ 644,803 34.9 % Medicare 417,870 — 98,014 — 515,884 27.9 Medicaid-skilled 102,875 — — — 102,875 5.6 Subtotal 1,123,849 30,469 109,244 — 1,263,562 68.4 Managed care 281,563 — 21,823 — 303,386 16.4 Private and other 139,798 106,177 11,336 25,058 (1) 282,369 15.2 Total revenue $ 1,545,210 $ 136,646 $ 142,403 $ 25,058 $ 1,849,317 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the year ended December 31, 2017. Year Ended December 31, 2016 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 521,063 $ 26,397 $ 10,498 $ — $ 557,958 33.7 % Medicare 396,519 — 80,500 — 477,019 28.8 Medicaid-skilled 87,517 — — — 87,517 5.3 Subtotal 1,005,099 26,397 90,998 — 1,122,494 67.8 Managed care 247,844 — 17,664 — 265,508 16.0 Private and other 121,860 97,239 7,151 40,612 (1) 266,862 16.2 Total revenue $ 1,374,803 $ 123,636 $ 115,813 $ 40,612 $ 1,654,864 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the year ended December 31, 2016.
Schedule of Segment Reporting Information, by Segment [Table Text Block]	The following table sets forth selected financial data consolidated by business segment: Year Ended December 31, 2018 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,679,012 $ — $ 169,037 $ 40,813 $ — $ 1,888,862 Assisted and independent living revenue — 151,797 — — — 151,797 Revenue from external customers $ 1,679,012 $ 151,797 $ 169,037 $ 40,813 $ — $ 2,040,659 Intersegment revenue (1) 2,996 — — 4,299 (7,295 ) — Total revenue $ 1,682,008 $ 151,797 $ 169,037 $ 45,112 $ (7,295 ) $ 2,040,659 Segment income (loss) (2) $ 190,924 $ 15,426 $ 26,117 $ (103,979 ) $ — $ 128,488 Interest expense, net of interest income $ (13,119 ) Income before provision for income taxes $ 115,369 Depreciation and amortization $ 31,931 $ 7,282 $ 1,045 $ 7,086 $ — $ 47,344 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $2,996 . Transitional and skilled services, assisted and independent living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines which are included in the "All Other" category of $4,299 . General and administrative expense 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 table demonstrates the impact of adopting ASC 606 on the Company's selected financial data, consolidated by business segment for the year ended December 31, 2018 , by showing revenue amounts as if the previous accounting guidance was still in effect. Year Ended December 31, 2018 (Adjusted to reflect prior revenue guidance) Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,709,988 $ — $ 170,871 $ 40,813 $ — $ 1,921,672 Assisted and independent living revenue — 151,797 — — — 151,797 Revenue from external customers $ 1,709,988 $ 151,797 $ 170,871 $ 40,813 $ — $ 2,073,469 Intersegment revenue (1) 2,996 — — 4,299 (7,295 ) — Total revenue $ 1,712,984 $ 151,797 $ 170,871 $ 45,112 $ (7,295 ) $ 2,073,469 Segment income (loss) (2) $ 190,924 $ 15,426 $ 26,117 $ (103,979 ) $ — $ 128,488 Interest expense, net of interest income $ (13,119 ) Income before provision for income taxes $ 115,369 Depreciation and amortization $ 31,931 $ 7,282 $ 1,045 $ 7,086 $ — $ 47,344 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $2,996 . Transitional and skilled services, assisted and independent living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines which are included in the "All Other" category of $4,299 . General and administrative expense 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. Year Ended December 31, 2017 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,545,210 $ — $ 142,403 $ 25,058 $ — $ 1,712,671 Assisted and independent living revenue — $ 136,646 $ — $ — — 136,646 Revenue from external customers $ 1,545,210 $ 136,646 $ 142,403 $ 25,058 $ — $ 1,849,317 Intersegment revenue (1) 3,023 — — 3,035 (6,058 ) — Total revenue $ 1,548,233 $ 136,646 $ 142,403 $ 28,093 $ (6,058 ) $ 1,849,317 Segment income (loss) (2) $ 140,272 $ 16,736 $ 19,717 $ (95,440 ) $ — $ 81,285 Interest expense, net of interest income $ (12,007 ) Income before provision for income taxes $ 69,278 Depreciation and amortization $ 29,928 $ 6,334 $ 945 $ 7,265 $ — $ 44,472 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $3,023 . Transitional and skilled services, assisted and independent living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines which are included in the "All Other" category of $3,035 . General and administrative expense 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. Year Ended December 31, 2016 Transitional and Skilled Services (3) Assisted and Independent Living Services (3) Home Health and Hospice Services All Other Elimination Total Service revenue $ 1,374,803 $ — $ 115,813 $ 40,612 $ — $ 1,531,228 Assisted and independent living revenue — $ 123,636 $ — $ — — 123,636 Revenue from external customers $ 1,374,803 $ 123,636 $ 115,813 $ 40,612 $ — $ 1,654,864 Intersegment revenue (1) 2,929 — — 2,184 (5,113 ) — Total revenue $ 1,377,732 $ 123,636 $ 115,813 $ 42,796 $ (5,113 ) $ 1,654,864 Segment income (loss) (2) $ 118,118 $ 11,701 $ 16,571 $ (54,543 ) $ — $ 91,847 Interest expense, net of interest income $ (6,029 ) Income before provision for income taxes $ 85,818 Depreciation and amortization $ 26,298 $ 4,157 $ 924 $ 7,303 $ — $ 38,682 (1) Intersegment revenue represents services provided at the Company's operating subsidiaries between the Company's business lines. (2) Segment income (loss) includes depreciation and amortization expense and excludes general and administrative expense and interest expense for transitional and skilled services, assisted and independent living services and home health and hospice services segments. Home health and hospice services segment income also excludes intercompany expenses for services provided at transitional and skilled operations of $2,929 . Transitional and skilled services, assisted and independent living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines which are included in the "All Other" category of $2,184 . General and administrative expense and the return of unclaimed class action settlement 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.

Property and Equipment (Tables)

Property and Equipment (Tables)	12 Months Ended
	Dec. 31, 2018
Property, Plant and Equipment [Abstract]
Property, Plant and Equipment [Table Text Block]	Property and equipment, net consist of the following: December 31, 2018 2017 Land $ 60,420 $ 49,081 Buildings and improvements 411,096 342,641 Equipment 202,346 181,530 Furniture and fixtures 5,079 5,244 Leasehold improvements 112,935 97,221 Construction in progress 9,729 5,460 801,605 681,177 Less: accumulated depreciation (182,731 ) (144,093 ) Property and equipment, net $ 618,874 $ 537,084

Intangible Assets - Net (Tables

Intangible Assets - Net (Tables)	12 Months Ended
	Dec. 31, 2018
Intangible Assets, Net (Excluding Goodwill) [Abstract]
Schedule of Finite-Lived Intangible Assets [Table Text Block]	Weighted Average Life (Years) December 31, 2018 2017 Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Lease acquisition costs 14.5 $ 843 $ (251 ) 592 $ 483 $ (99 ) $ 384 Favorable leases 29.7 35,650 (8,724 ) 26,926 35,116 (6,568 ) 28,548 Assembled occupancy 0.4 2,936 (2,870 ) 66 2,659 (2,631 ) 28 Facility trade name 30.0 733 (317 ) 416 733 (293 ) 440 Customer relationships 18.2 4,670 (1,670 ) 3,000 4,933 (1,530 ) 3,403 Total $ 44,832 $ (13,832 ) $ 31,000 $ 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 2019 2,777 2020 1,616 2021 1,454 2022 1,450 2023 1,391 Thereafter 22,312 $ 31,000

Goodwill and Other Indefinite_2

Goodwill and Other Indefinite-Lived Intangible Assets (Tables)	12 Months Ended
	Dec. 31, 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 year ended December 31, 2018 : Goodwill Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total January 1, 2016 $ 14,221 $ 3,538 $ 16,102 $ 7,025 $ 40,886 Additions 26,415 — 1,799 2,129 30,343 Less: Dispositions — — — (4,103 ) (4,103 ) Purchase price adjustment — — — (26 ) (26 ) December 31, 2016 $ 40,636 $ 3,538 $ 17,901 $ 5,025 $ 67,100 Additions 4,850 420 6,421 2,271 13,962 December 31, 2017 $ 45,486 $ 3,958 $ 24,322 $ 7,296 $ 81,062 Additions — — 2,872 — 2,872 Purchase price adjustment — — 56 — 56 Impairments — — — (3,513 ) (3,513 ) December 31, 2018 $ 45,486 $ 3,958 $ 27,250 $ 3,783 $ 80,477
Schedule of Acquired Indefinite-lived Intangible Assets by Major Class [Table Text Block]	Other indefinite-lived intangible assets consists of the following: December 31, 2018 2017 Trade name $ 1,217 $ 1,181 Medicare and Medicaid licenses 26,385 24,068 $ 27,602 $ 25,249

Restricted and Other Assets (Ta

Restricted and Other Assets (Tables)	12 Months Ended
	Dec. 31, 2018
Other Assets [Abstract]
Schedule of Other Assets [Table Text Block]	Restricted and other assets consist of the following: December 31, 2018 2017 Debt issuance costs, net $ 1,892 $ 2,799 Long-term insurance losses recoverable asset 6,969 5,394 Deposits with landlords 8,694 5,981 Capital improvement reserves with landlords and lenders 3,196 2,327 Note receivable from sale of ancillary business 93 — Restricted and other assets $ 20,844 $ 16,501

Other Accrued Liabilities (Tabl

Other Accrued Liabilities (Tables)	12 Months Ended
	Dec. 31, 2018
Accrued Liabilities [Abstract]
Schedule of Accrued Liabilities [Table Text Block]	Other accrued liabilities consist of the following: December 31, 2018 2017 Quality assurance fee $ 5,375 $ 4,864 Refunds payable 25,118 21,661 Contract liabilities 8,495 7,066 Cash held in trust for patients 2,824 2,609 Resident deposits 6,665 6,574 Dividends payable 2,525 2,328 Property taxes 9,426 10,088 Other 9,356 8,625 Other accrued liabilities $ 69,784 $ 63,815

Income Taxes (Tables)

Income Taxes (Tables)	12 Months Ended
	Dec. 31, 2018
Income Tax Disclosure [Abstract]
Schedule of Components of Income Tax Expense (Benefit) [Table Text Block]	The provision for income taxes on continuing operations for the years ended December 31, 2018, 2017 and 2016 is summarized as follows: Year Ended December 31, 2018 2017 2016 Current: Federal $ 16,158 $ 15,141 $ 30,043 State 5,588 2,975 5,183 21,746 18,116 35,226 Deferred: Federal 1,778 5,428 (1,034 ) State (683 ) 986 (1,217 ) 1,095 6,414 (2,251 ) Adjustment to deferred taxes for tax rate change — 3,915 — Total $ 22,841 $ 28,445 $ 32,975
Schedule of Effective Income Tax Rate Reconciliation [Table Text Block]	A reconciliation of the federal statutory rate to the effective tax rate for income from continuing operations for the years ended December 31, 2018, 2017 and 2016 , respectively, is comprised as follows: December 31, 2018 2017 2016 Income tax expense at statutory rate 21.0 % 35.0 % 35.0 % State income taxes - net of federal benefit 3.1 3.1 3.0 Non-deductible expenses 0.8 1.7 0.9 Non-deductible compensation 1.8 — — Equity compensation (4.8 ) (4.5 ) — Revaluation of deferred (1.1 ) 5.7 — Other adjustments (1.0 ) 0.1 (0.5 ) Total income tax provision 19.8 % 41.1 % 38.4 %
Schedule of Deferred Tax Assets and Liabilities [Table Text Block]	The Company's deferred tax assets and liabilities as of December 31, 2018 and 2017 are summarized below. December 31, 2018 2017 Deferred tax assets (liabilities): Accrued expenses $ 22,756 $ 16,500 Allowance for doubtful accounts 12,312 11,090 Tax credits 3,201 3,334 Insurance 5,667 5,135 43,936 36,059 Valuation allowance (791 ) (530 ) Total deferred tax assets 43,145 35,529 State taxes (475 ) (911 ) Depreciation and amortization (28,496 ) (18,248 ) Prepaid expenses (2,524 ) (3,625 ) Total deferred tax liabilities (31,495 ) (22,784 ) Net deferred tax assets $ 11,650 $ 12,745

Debt (Tables)

Debt (Tables)	12 Months Ended
	Dec. 31, 2018
Debt Disclosure [Abstract]
Schedule of Long-term Debt Instruments [Table Text Block]	Long-term debt consists of the following: December 31, 2018 2017 Term loan with SunTrust $ 113,125 $ 140,625 Revolving credit facility with SunTrust 10,000 50,000 Mortgage loans and promissory note 122,955 125,394 246,080 316,019 Less: current maturities (10,105 ) (9,939 ) Less: debt issuance costs (2,840 ) (3,090 ) $ 233,135 $ 302,990
Schedule of Maturities of Long-term Debt [Table Text Block]	Future principal payments due under the long-term debt arrangements discussed above are as follows: Years Ending December 31, Amount 2019 10,105 2020 10,203 2021 110,926 2022 2,904 2023 3,016 Thereafter 108,926 $ 246,080

Options and Awards (Tables)

Options and Awards (Tables)	12 Months Ended
	Dec. 31, 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 years ended December 31, 2018, 2017 and 2016 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2018 640 2.8% 6.2 years 32.0% 0.5% 2017 481 2.0% 6.2 years 35.2% 0.8% 2016 497 1.4% 6.3 years 37.8% 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 years ended December 31, 2018, 2017 and 2016 , 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 640 $ 34.53 $ 12.05 2017 481 $ 20.31 $ 7.00 2016 497 $ 19.43 $ 7.00
Schedule of Common Stock Outstanding Roll Forward [Table Text Block]	The following table represents the employee stock option activity during the years ended December 31, 2018, 2017 and 2016 : Number of Options Outstanding Weighted Average Exercise Price Number of Options Vested Weighted Average Exercise Price of Options Vested January 1, 2016 5,448 $ 10.36 2,526 $ 6.35 Granted 497 19.43 Forfeited (127 ) 14.46 Exercised (642 ) 6.47 December 31, 2016 5,176 $ 11.62 2,704 $ 8.18 Granted 481 20.31 Forfeited (178 ) 15.82 Exercised (740 ) 6.93 December 31, 2017 4,739 $ 13.08 2,776 $ 10.07 Granted 640 34.53 Forfeited (120 ) 18.71 Exercised (1,071 ) 8.57 December 31, 2018 4,188 $ 17.35 2,431 $ 12.37
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 December 31, 2018 : Stock Options Outstanding Stock Options Vested Number Outstanding Black-Scholes Fair Value Remaining Contractual Life (Years) Vested and Exercisable Year of Grant Exercise Price 2009 4.06 - 4.56 194 $ 414 1 194 2010 4.77 - 4.96 81 196 2 81 2011 5.90 - 7.99 86 296 3 86 2012 6.56 - 7.96 257 952 4 257 2013 7.98 - 11.49 423 2,047 5 423 2014 10.55 - 18.94 1,201 6,816 6 885 2015 21.47 - 25.24 479 4,351 7 273 2016 18.79 - 19.89 403 2,810 8 151 2017 18.64 - 22.90 441 3,083 9 81 2018 26.53 - 38.59 623 7,523 10 — Total 4,188 $ 28,488 2,431
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 December 31, 2018 and changes during the years ended December 31, 2018, 2017 and 2016 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2016 425 $ 19.79 Granted 299 20.55 Vested (279 ) 19.58 Forfeited (16 ) 20.85 Nonvested at December 31, 2016 429 $ 20.42 Granted 173 20.21 Vested (195 ) 19.79 Forfeited (24 ) 20.34 Nonvested at December 31, 2017 383 $ 20.65 Granted 367 35.19 Vested (153 ) 22.68 Forfeited (24 ) 23.31 Nonvested at December 31, 2018 573 $ 29.31
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 years ended December 31, 2018, 2017 and 2016 was as follows: Year Ended December 31, 2018 2017 2016 Share-based compensation expense related to stock options $ 4,905 $ 4,773 $ 4,793 Share-based compensation expense related to restricted stock awards 3,159 2,322 2,371 Share-based compensation expense related to stock options and restricted stock awards to non-employee directors 895 1,236 612 Total $ 8,959 $ 8,331 $ 7,776
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 and for the years ended December 31, 2018, 2017 and 2016 is as follows: December 31, Options 2018 2017 2016 Outstanding $ 89,806 $ 44,060 $ 55,610 Vested 64,222 33,976 38,101 Expected to vest 22,963 9,311 15,983 Exercisable 27,646 10,481 9,199

Leases (Tables)

Leases (Tables)	12 Months Ended
	Dec. 31, 2018
Leases [Abstract]
Schedule of Future Minimum Rental Payments for Operating Leases [Table Text Block]	Future minimum lease payments for all leases as of December 31, 2018 are as follows: Year Amount 2019 142,497 2020 141,536 2021 140,524 2022 139,018 2023 137,349 Thereafter 967,027 $ 1,667,951

Self-Insurance Reserves (Tables

Self-Insurance Reserves (Tables)	12 Months Ended
	Dec. 31, 2018
Self-Insurance Reserves [Abstract]
Schedule of Liability for Future Policy Benefits, by Product Segment [Table Text Block]	The following table represents activity in our insurance reserves as of and for the years ended December 31, 2018 and 2017 : General and Professional Liability Workers' Compensation Health Total Balance January 1, 2017 $ 36,310 $ 23,402 $ 5,639 $ 65,351 Current year provisions 20,396 15,202 53,796 89,394 Claims paid and direct expenses (16,133 ) (12,455 ) (54,712 ) (83,300 ) Change in long-term insurance losses recoverable 361 930 — 1,291 Balance December 31, 2017 $ 40,934 $ 27,079 $ 4,723 $ 72,736 Current year provisions 23,113 14,970 49,988 88,071 Claims paid and direct expenses (19,476 ) (13,967 ) (48,888 ) (82,331 ) Change in long-term insurance losses recoverable 795 780 — 1,575 Balance December 31, 2018 $ 45,366 $ 28,862 $ 5,823 $ 80,051

Description of Business (Detail

Description of Business (Details)	Dec. 31, 2018businessBedsfacilities	Dec. 31, 2017facilities
Skilled nursing, assisted living and independent living facilities [Abstract]
Number of Real Estate Properties	72	63
Number of Real Estate Properties Leased	172	167
Number of Real Estate Properties Leased with an Option to Purchase	12	11
Number of Real Estate Properties Operated	244	230
Home Health, Hospice and Home Care Operations | business	54
Operational Skilled Nursing Beds | Beds	19,600
Operational Skilled Nursing, Assisted Living and Independent Living Beds [Abstract]
Operational Assisted Living and Independent Living Units | Beds	5,700

Significant Accounting Polici_3

Significant Accounting Policies Divestiture (Details)	12 Months Ended
	Dec. 31, 2018
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Long Lived Assets Held-for-sale, Description	1

Significant Accounting Polici_4

Significant Accounting Policies Revenue Recognition (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Jan. 01, 2018	Dec. 31, 2017
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Retained Earnings	$ 344,901		$ 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_5

Significant Accounting Policies Property and Equipment (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Property, Plant and Equipment [Line Items]
Impairment of Long-Lived Assets to be Disposed of	$ 5,492	$ 111	$ 137
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_6

Significant Accounting Policies Intangible Assets and Goodwill (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Finite-Lived Intangible Assets [Line Items]
Goodwill and intangible asset impairment	$ 3,653	$ 0	$ 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] $ in Thousands	Dec. 31, 2018USD ($)
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] $ in Thousands	Dec. 31, 2018USD ($)
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	Dec. 31, 2018	Dec. 31, 2017
Accounting Policies [Abstract]
Long-term insurance losses recoverable asset	$ 6,969	$ 5,394

Significant Accounting Polic_10

Significant Accounting Policies Self-Insurance Health Insurance (Details) - Health Liability Insurance [Member] $ in Thousands	Dec. 31, 2018USD ($)
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) $ in Thousands	Jan. 01, 2019USD ($)	Dec. 31, 2018USD ($)Operations	Dec. 31, 2017USD ($)	Dec. 31, 2016USD ($)
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Sale Leaseback Transaction, Deferred Gain		$ 658	$ 421	$ 0
Asset Acquisition [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Number of Businesses Acquired | Operations		17
Business Combination [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Number of Businesses Acquired | Operations		6
Accounting Standards Update 2016-02 [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Net Lease Assets	$ 1,050,000
Net of Lease Liability	1,030,000
Adjustment to Retained Earnings, before Tax	12,100
Sale Leaseback Transaction, Deferred Gain		$ 700
Favorable leases | Accounting Standards Update 2016-02 [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Net Lease Assets	$ 27,000

Revenue and Accounts Receivab_3

Revenue and Accounts Receivable Revenue from Medicare and Medicaid Programs (Details)	12 Months Ended
	Dec. 31, 2018Rate	Dec. 31, 2017Rate	Dec. 31, 2016Rate
Total Medicare and Medicaid
Disaggregation of Revenue [Line Items]
Revenue by payor as a percent of total revenue	68.50%	68.40%	67.80%

Revenue and Accounts Receivab_4

Revenue and Accounts Receivable Impact of New Revenue Guidance (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Total revenue	$ 2,040,659	$ 1,849,317	$ 1,654,864
Cost of services	1,627,672	1,497,703	1,341,814
Total Expense	1,912,171	1,768,032	1,563,017
Provision for Doubtful Accounts	$ 2,823	$ 31,023	$ 28,512
Bad Debt Expense as a Percent of Total Revenue	0.10%	1.70%	1.70%
Difference between Revenue Guidance in Effect before and after Topic 606 [Member]
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Total revenue	$ 32,810	$ 0	$ 0
Cost of services	32,810	0	0
Total Expense	32,810	0	0
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Revenue, Initial Application Period Cumulative Effect Transition [Line Items]
Total revenue	2,073,469	1,849,317	1,654,864
Cost of services	1,660,482	1,497,703	1,341,814
Total Expense	$ 1,944,981	$ 1,768,032	$ 1,563,017

Revenue and Accounts Receivab_5

Revenue and Accounts Receivable Revenue (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Disaggregation of Revenue [Line Items]
Total revenue	$ 2,040,659	$ 1,849,317	$ 1,654,864
Percentage of revenue	100.00%
Medicaid
Disaggregation of Revenue [Line Items]
Total revenue	$ 727,310
Percentage of revenue	35.60%
Medicare
Disaggregation of Revenue [Line Items]
Total revenue	$ 552,577
Percentage of revenue	27.10%
Medicaid — skilled
Disaggregation of Revenue [Line Items]
Total revenue	$ 117,686
Percentage of revenue	5.80%
Total Medicaid and Medicare
Disaggregation of Revenue [Line Items]
Total revenue	$ 1,397,573
Percentage of revenue	68.50%
Managed care
Disaggregation of Revenue [Line Items]
Total revenue	$ 326,325
Percentage of revenue	16.00%
Private Pay and Other
Disaggregation of Revenue [Line Items]
Total revenue	$ 316,761
Percentage of revenue	15.50%
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Disaggregation of Revenue [Line Items]
Total revenue	$ 2,073,469	$ 1,849,317	$ 1,654,864
Percentage of revenue	100.00%	100.00%	100.00%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid
Disaggregation of Revenue [Line Items]
Total revenue	$ 738,179	$ 644,803	$ 557,958
Percentage of revenue	35.60%	34.90%	33.70%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare
Disaggregation of Revenue [Line Items]
Total revenue	$ 556,159	$ 515,884	$ 477,019
Percentage of revenue	26.80%	27.90%	28.80%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid — skilled
Disaggregation of Revenue [Line Items]
Total revenue	$ 119,667	$ 102,875	$ 87,517
Percentage of revenue	5.80%	5.60%	5.30%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Total Medicaid and Medicare
Disaggregation of Revenue [Line Items]
Total revenue	$ 1,414,005	$ 1,263,562	$ 1,122,494
Percentage of revenue	68.20%	68.40%	67.80%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care
Disaggregation of Revenue [Line Items]
Total revenue	$ 333,197	$ 303,386	$ 265,508
Percentage of revenue	16.10%	16.40%	16.00%
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private Pay and Other
Disaggregation of Revenue [Line Items]
Total revenue	$ 326,267	$ 282,369	$ 266,862
Percentage of revenue	15.70%	15.20%	16.20%

Revenue and Accounts Receivab_6

Revenue and Accounts Receivable Contract Balances (Details)	Dec. 31, 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	Dec. 31, 2018	Dec. 31, 2017
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	$ 278,985
Less: allowance for doubtful accounts	(2,886)	$ (43,961)
Accounts receivable, net	276,099
Medicaid
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	117,984
Managed care
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	54,682
Medicare
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	50,994
Private Pay and Other
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	55,325
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	324,956	309,029
Less: allowance for doubtful accounts	(48,857)	(43,961)
Accounts receivable, net	276,099	265,068
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	130,476	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	67,238	68,930
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable, Gross	57,580	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	$ 69,662	$ 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	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Numerator:
Net income	$ 92,528	$ 40,833	$ 52,843
Less: net income attributable to noncontrolling interests	164	358	2,853
Net income attributable to The Ensign Group, Inc.	$ 92,364	$ 40,475	$ 49,990
Denominator:
Weighted average shares outstanding for basic net income per share	52,016	50,932	50,555
Adjusted weighted average common shares outstanding	54,397	52,829	52,133
Basic net income (loss) per common share:
Basic net income per common share attributable to The Ensign Group, Inc.	$ 1.78	$ 0.79	$ 0.99
Diluted net (loss) income per common share:
Diluted net income per common share attributable to The Ensign Group, Inc.	$ 1.70	$ 0.77	$ 0.96
Common Class A [Member]
Denominator:
Weighted average shares outstanding for basic net income per share	52,016	50,932	50,555
Plus: incremental shares from assumed conversion (1)	2,381	1,897	1,578

Computation of Net Income Per_4

Computation of Net Income Per Common Share Antidilutive Shares (Details) - shares shares in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Earnings Per Share, Diluted, Other Disclosures [Abstract]
Antidilutive Securities Excluded from Computation of Earnings Per Share, Amount	220	1,252	838

Fair Value Measurements (Detail

Fair Value Measurements (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Disposal Group, Including Discontinued Operation, Property, Plant and Equipment	$ 1,859
Long Lived Assets Held-for-sale, Description	1
Cash and cash equivalents | Level 1
Cash and cash equivalents	$ 31,083	$ 42,337
Cash and cash equivalents | Level 2
Cash and cash equivalents	0	0
Disposal Group, Including Discontinued Operation, Property, Plant and Equipment	1,859
Cash and cash equivalents | Level 3
Cash and cash equivalents	$ 0	$ 0

Fair Value Measurements Investm

Fair Value Measurements Investments (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Debt Security, Corporate, US [Member]
Schedule of Held-to-maturity Securities [Line Items]
Debt Securities, Held-to-maturity	$ 44,850	$ 41,777

Business Segments (Details)

Business Segments (Details) $ in Thousands	3 Months Ended	12 Months Ended
	Jun. 30, 2017USD ($)	Dec. 31, 2018USD ($)businessSegmentsfacilities	Dec. 31, 2017USD ($)	Dec. 31, 2016USD ($)
Segment Reporting Information [Line Items]
Number of Reportable Segments | Segments		3
Transitional and Skilled Service Facilities | facilities		164
Transitional and Skilled Services and Assistant and Independent Living Campuses | facilities		24
Assisted and Independent Living Facilities | facilities		56
Home Health, Hospice and Home Care Operations | business		54
Business Exit Costs	$ (1,286)	$ 0	$ 2,321	$ (11,225)
Gain (Loss) on Contract Termination			2,715	6,512
Impairment of Long-Lived Assets to be Disposed of		5,492	111	137
Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Impairment of Long-Lived Assets to be Disposed of		$ 4,632
Contract Termination and Facility Closing [Member]
Segment Reporting Information [Line Items]
Business Exit Costs			4,017
Facility Closing [Member]
Segment Reporting Information [Line Items]
Business Exit Costs			$ 2,830	$ 7,935

Business Segments Revenue by Se

Business Segments Revenue by Segment (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 2,040,659	$ 1,849,317	$ 1,654,864
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	100.00%
Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 1,679,012
Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	151,797
Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	169,037
All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	40,813
Medicaid
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 727,310
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	35.60%
Medicaid | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 678,749
Medicaid | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	36,152
Medicaid | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	12,409
Medicaid | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 552,577
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	27.10%
Medicare | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 436,580
Medicare | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Medicare | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	115,997
Medicare | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Medicaid — skilled
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 117,686
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	5.80%
Medicaid — skilled | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 117,686
Medicaid — skilled | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Medicaid — skilled | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Medicaid — skilled | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Total Medicaid and Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 1,397,573
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	68.50%
Total Medicaid and Medicare | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 1,233,015
Total Medicaid and Medicare | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	36,152
Total Medicaid and Medicare | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	128,406
Total Medicaid and Medicare | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Managed care
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 326,325
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	16.00%
Managed care | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 301,866
Managed care | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Managed care | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	24,459
Managed care | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0
Private and other payors(1)
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 316,761
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	15.50%
Private and other payors(1) | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 144,131
Private and other payors(1) | Assisted and Independent Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	115,645
Private and other payors(1) | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	16,172
Private and other payors(1) | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	40,813
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 2,073,469	$ 1,849,317	$ 1,654,864
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	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	$ 1,709,988	$ 1,545,210	$ 1,374,803
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	151,797	136,646	123,636
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	170,871	142,403	115,813
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	40,813	25,058	40,612
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 738,179	$ 644,803	$ 557,958
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	35.60%	34.90%	33.70%
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	$ 689,225	$ 603,104	$ 521,063
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	36,152	30,469	26,397
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	12,802	11,230	10,498
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
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 556,159	$ 515,884	$ 477,019
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	26.80%	27.90%	28.80%
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	$ 439,433	$ 417,870	$ 396,519
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
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	116,726	98,014	80,500
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
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Medicaid — skilled
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 119,667	$ 102,875	$ 87,517
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	5.80%	5.60%	5.30%
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	$ 119,667	$ 102,875	$ 87,517
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
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
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
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Total Medicaid and Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 1,414,005	$ 1,263,562	$ 1,122,494
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	68.20%	68.40%	67.80%
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	$ 1,248,325	$ 1,123,849	$ 1,005,099
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	36,152	30,469	26,397
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	129,528	109,244	90,998
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
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Managed care
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 333,197	$ 303,386	$ 265,508
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	16.10%	16.40%	16.00%
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	$ 308,148	$ 281,563	$ 247,844
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
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	25,049	21,823	17,664
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
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Private and other payors(1)
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 326,267	$ 282,369	$ 266,862
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	15.70%	15.20%	16.20%
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	$ 153,515	$ 139,798	$ 121,860
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	115,645	106,177	97,239
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	16,294	11,336	7,151
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	$ 40,813	$ 25,058	$ 40,612

Business Segments Schedule of S

Business Segments Schedule of Segment Reporting Information, by Segment (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Segment Reporting Information [Line Items]
Revenue from external customers	$ 2,040,659	$ 1,849,317	$ 1,654,864
Intersegment revenue (1)	0
Total revenue	2,040,659
Segment income (loss) (2)	128,488	81,285	91,847
Interest expense, net of interest income	(13,119)	(12,007)	(6,029)
Income before provision for income taxes	115,369	69,278	85,818
Depreciation and amortization	47,344	44,472	38,682
Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	1,679,012
Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	151,797
Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	169,037
All Other
Segment Reporting Information [Line Items]
Revenue from external customers	40,813
Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	2,073,469	1,849,317	1,654,864
Intersegment revenue (1)	0	0	0
Total revenue	2,073,469	1,849,317	1,654,864
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	1,709,988	1,545,210	1,374,803
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	151,797	136,646	123,636
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	170,871	142,403	115,813
Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	40,813	25,058	40,612
Health Care, Patient Service [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	1,888,862	1,712,670	1,531,228
Health Care, Patient Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	1,921,672	1,712,671	1,531,228
Health Care, Resident Service [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	151,797	136,647	123,636
Health Care, Resident Service [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member]
Segment Reporting Information [Line Items]
Revenue from external customers	151,797	136,646	123,636
Operating Segments [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	1,679,012	1,545,210	1,374,803
Total revenue	1,682,008	1,548,233	1,377,732
Segment income (loss) (2)	190,924	140,272	118,118
Depreciation and amortization	31,931	29,928	26,298
Operating Segments [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	151,797	136,646	123,636
Total revenue	151,797	136,646	123,636
Segment income (loss) (2)	15,426	16,736	11,701
Depreciation and amortization	7,282	6,334	4,157
Operating Segments [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	169,037	142,403	115,813
Total revenue	169,037	142,403	115,813
Segment income (loss) (2)	26,117	19,717	16,571
Depreciation and amortization	1,045	945	924
Operating Segments [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	40,813	25,058	40,612
Total revenue	45,112	28,093	42,796
Segment income (loss) (2)	(103,979)	(95,440)	(54,543)
Depreciation and amortization	7,086	7,265	7,303
Operating Segments [Member] | Elimination
Segment Reporting Information [Line Items]
Total revenue	(7,295)	(6,058)	(5,113)
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	1,709,988
Total revenue	1,712,984
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	151,797
Total revenue	151,797
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	170,871
Total revenue	170,871
Operating Segments [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	40,813
Total revenue	45,112
Operating Segments [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Elimination
Segment Reporting Information [Line Items]
Total revenue	(7,295)
Operating Segments [Member] | Health Care, Patient Service [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	1,679,012	1,545,210	1,374,803
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
Operating Segments [Member] | Health Care, Patient Service [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	169,037	142,403	115,813
Operating Segments [Member] | Health Care, Patient Service [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	40,813	25,058	40,612
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	1,709,988
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
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	170,871
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	40,813
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
Operating Segments [Member] | Health Care, Resident Service [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	151,797	136,646	123,636
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
Operating Segments [Member] | Health Care, Resident Service [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	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
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	151,797
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
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
Consolidation, Eliminations [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Intersegment revenue (1)	2,996	3,023	2,929
Consolidation, Eliminations [Member] | Assisted and Independent Living Services Segment
Segment Reporting Information [Line Items]
Intersegment revenue (1)	0	0	0
Consolidation, Eliminations [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Intersegment revenue (1)	0	0	0
Intersegment Expense	2,996
Consolidation, Eliminations [Member] | Transitional and skilled services, assisted and independent living services and home health and hospice services segments [Member]
Segment Reporting Information [Line Items]
Intersegment Expense	4,299
Consolidation, Eliminations [Member] | All Other
Segment Reporting Information [Line Items]
Intersegment revenue (1)	4,299	3,035	2,184
Consolidation, Eliminations [Member] | Elimination
Segment Reporting Information [Line Items]
Intersegment revenue (1)	(7,295)	(6,058)	(5,113)
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)	2,996
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
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
Intersegment Expense	2,996	3,023	2,929
Consolidation, Eliminations [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Transitional and skilled services, assisted and independent living services and home health and hospice services segments [Member]
Segment Reporting Information [Line Items]
Intersegment Expense	4,299	$ 3,035	$ 2,184
Consolidation, Eliminations [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | All Other
Segment Reporting Information [Line Items]
Intersegment revenue (1)	4,299
Consolidation, Eliminations [Member] | Calculated under Revenue Guidance in Effect before Topic 606 [Member] | Elimination
Segment Reporting Information [Line Items]
Intersegment revenue (1)	$ (7,295)

Acquisitions Summary (Details)

Acquisitions Summary (Details) $ in Thousands	Jan. 01, 2019OperationsBeds	Jun. 01, 2018USD ($)	Feb. 01, 2019USD ($)	Dec. 31, 2018USD ($)OperationsBeds	Dec. 31, 2017USD ($)OperationsBeds	Dec. 31, 2016USD ($)OperationsBeds
Business Acquisition [Line Items]
Payments to Acquire Asset Acquisitions | $				$ 85,314	$ 195	$ 120,935
Payments to Acquire Business and Asset Acquisitions | $				$ 90,039	$ 89,683	$ 64,521
Operational Skilled Nursing Beds | Beds				19,600
Operational Assisted Living and Independent Living Units | Beds				5,700
621610 Home Health Care Services [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired				4	3	2
Hospice Agencies [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired				3	3	5
Home Care Agency [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired				2	1
8051 Services, Skilled Nursing Care Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired				4	8	18
Operational Skilled Nursing Beds | Beds				744	905	2,336
Transitional and Skilled Services and Assisted and Independent Campuses [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired				3	1	1
Assisted Living Facility [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired				7	9
Operational Assisted Living and Independent Living Units | Beds				650	594	10
Wholly Owned Properties [Member] | 8051 Services, Skilled Nursing Care Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired						2
Wholly Owned Properties [Member] | 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						15
Payments to Acquire Asset Acquisitions | $						$ 127,348
Transitional and Skilled Services and Assisted and Independent Campuses [Member] | Transitional and Skilled Services and Assisted and Independent Campuses [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired						6
8051 Services, Skilled Nursing Care Facilities [Member] | 8051 Services, Skilled Nursing Care Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired					4	16
Operational Skilled Nursing Beds | Beds					455	463
Operational Assisted Living and Independent Living Units | Beds						142
Subsequent Event [Member] | 8051 Services, Skilled Nursing Care Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired	1
Operational Skilled Nursing Beds | Beds	120
Office Building [Member]
Business Acquisition [Line Items]
Payments to Acquire Asset Acquisitions | $		$ 30,959
Skilled Nursing Facility and Other Ancillary Business [Member] | Subsequent Event [Member]
Business Acquisition [Line Items]
Payments to Acquire Asset Acquisitions | $			$ 12,250

Acquisitions (Details)

Acquisitions (Details) $ in Thousands	12 Months Ended
	Dec. 31, 2018USD ($)Operations	Dec. 31, 2017USD ($)	Dec. 31, 2016USD ($)
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross	$ 4,725
Business Combination, Recognized Identifiable Assets Acquired and Liabilities Assumed, Net		$ 92	$ 6
Payments to Acquire Asset Acquisitions	85,314	195	120,935
Assembled occupancy
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		762	1,299
Other Intangible Assets [Member]
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross			363
Favorable leases
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross			393
Goodwill & Indefinite-lived Intangible Assets [Member]
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross	$ 4,709
Goodwill
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		13,962	30,343
Other indefinite-lived intangible assets
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		7,018	1,741
Land
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		9,732	1,054
Building and improvements
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		53,735	21,057
Equipment, furniture, and fixtures
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross		$ 4,382	$ 8,265
Asset Acquisition [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired | Operations	17
Business Combination [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired | Operations	6

Property and Equipment (Details

Property and Equipment (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Property, Plant and Equipment [Line Items]
Property and equipment	$ 801,605	$ 681,177
Less: accumulated depreciation	(182,731)	(144,093)
Property and equipment, net	618,874	537,084
Land
Property, Plant and Equipment [Line Items]
Property and equipment	60,420	49,081
Building and improvements
Property, Plant and Equipment [Line Items]
Property and equipment	411,096	342,641
Equipment
Property, Plant and Equipment [Line Items]
Property and equipment	202,346	181,530
Furniture and fixtures
Property, Plant and Equipment [Line Items]
Property and equipment	5,079	5,244
Leasehold improvements
Property, Plant and Equipment [Line Items]
Property and equipment	112,935	97,221
Construction in progress
Property, Plant and Equipment [Line Items]
Property and equipment	$ 9,729	$ 5,460

Property and Equipment Addition

Property and Equipment Additional Disclosures (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016	Jun. 01, 2017
Property, Plant and Equipment [Abstract]
Disposal Group, Including Discontinued Operation, Property, Plant and Equipment	$ 1,859
Long Lived Assets Held-for-sale, Description	1
Impairment of Long-Lived Assets to be Disposed of	$ 5,492	$ 111	$ 137
Sale Leaseback Transaction, Historical Cost				$ 24,847

Intangible Assets - Net (Detail

Intangible Assets - Net (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Acquired Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Assets, Gross	$ 44,832	$ 43,924
Accumulated Amortization	(13,832)	(11,121)
Intangible assets, net	$ 31,000	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	(251)	(99)
Intangible assets, net	$ 592	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	(8,724)	(6,568)
Intangible assets, net	$ 26,926	28,548
Assembled occupancy
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	4 months 30 days
Finite-Lived Intangible Assets, Gross	$ 2,936	2,659
Accumulated Amortization	(2,870)	(2,631)
Intangible assets, net	$ 66	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	(317)	(293)
Intangible assets, net	$ 416	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	(1,670)	(1,530)
Intangible assets, net	$ 3,000	$ 3,403

Intangible Assets - Net Additio

Intangible Assets - Net Additional Disclosures (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Finite-Lived Intangible Assets [Line Items]
Amortization of Intangible Assets	$ 2,837	$ 3,035	$ 4,634

Intangible Assets - Net Future

Intangible Assets - Net Future Amortization (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Finite-Lived Intangible Assets, Net, Amortization Expense, Fiscal Year Maturity [Abstract]
2,019	$ 2,777
2,020	1,616
2,021	1,454
2,022	1,450
2,023	1,391
Thereafter	22,312
Intangible assets, net	$ 31,000	$ 32,803

Goodwill and Other Indefinite_3

Goodwill and Other Indefinite-Lived Intangible Assets Goodwill Rollforward (Details) $ in Thousands	12 Months Ended			228 Months Ended
	Dec. 31, 2018USD ($)Operations	Dec. 31, 2017USD ($)	Dec. 31, 2016USD ($)	Dec. 31, 2018USD ($)
Goodwill [Line Items]
Number of Operations Impaired | Operations	1
January 1	$ 81,062	$ 67,100	$ 40,886
Additions	2,872	13,962	30,343
Less: Dispositions			4,103
Purchase price adjustment	56		(26)
Impairments	(3,513)			$ (6,912)
December 31	80,477	81,062	67,100	80,477
Transitional and Skilled Services Segment
Goodwill [Line Items]
January 1	45,486	40,636	14,221
Additions	0	4,850	26,415
Less: Dispositions			0
Purchase price adjustment	0		0
Impairments	0
December 31	45,486	45,486	40,636	45,486
Assisted and Independent Living Services Segment
Goodwill [Line Items]
January 1	3,958	3,538	3,538
Additions	0	420	0
Less: Dispositions			0
Purchase price adjustment	0		0
Impairments	0
December 31	3,958	3,958	3,538	3,958
Home Health and Hospice Services
Goodwill [Line Items]
January 1	24,322	17,901	16,102
Additions	2,872	6,421	1,799
Less: Dispositions			0
Purchase price adjustment	56		0
Impairments	0
December 31	27,250	24,322	17,901	27,250
All Other
Goodwill [Line Items]
January 1	7,296	5,025	7,025
Additions	0	2,271	2,129
Less: Dispositions			4,103
Purchase price adjustment	0		(26)
Impairments	(3,513)
December 31	$ 3,783	$ 7,296	5,025	$ 3,783
Disposal Group, Disposed of by Sale, Not Discontinued Operations [Member] | All Other
Goodwill [Line Items]
Less: Dispositions			$ (4,103)

Goodwill and Other Indefinite_4

Goodwill and Other Indefinite-Lived Intangible Assets Indefinite-lived intangble assets (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Indefinite-lived Intangible Assets [Line Items]
Impairment of Intangible Assets, Indefinite-lived (Excluding Goodwill)	$ 140
Other indefinite-lived intangibles	27,602	$ 25,249
Medicare and Medicaid licenses
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	2,317
Home Health and Hospice Services | Trade name
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	1,217	1,181
Home Health and Hospice Services | Medicare and Medicaid licenses
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 26,385	$ 24,068

Restricted and Other Assets (De

Restricted and Other Assets (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Other Assets [Abstract]
Debt issuance costs, net	$ 1,892	$ 2,799
Long-term insurance losses recoverable asset	6,969	5,394
Deposits with landlords	8,694	5,981
Capital improvement reserves with landlords and lenders	3,196	2,327
Note receivable from sale of ancillary business	93	0
Restricted and other assets	$ 20,844	$ 16,501

Other Accrued Liabilities (Deta

Other Accrued Liabilities (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Accrued Liabilities [Abstract]
Quality assurance fee	$ 5,375	$ 4,864
Refunds payable	25,118	21,661
Contract liabilities	8,495	7,066
Cash held in trust for patients	2,824	2,609
Resident deposits	6,665	6,574
Dividends payable	2,525	2,328
Property taxes	9,426	10,088
Other	9,356	8,625
Other accrued liabilities	$ 69,784	$ 63,815

Income Taxes Expense (Details)

Income Taxes Expense (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Income Tax Disclosure [Abstract]
Current Federal	$ 16,158	$ 15,141	$ 30,043
Current State	5,588	2,975	5,183
Current Total	21,746	18,116	35,226
Deferred Federal	1,778	5,428	(1,034)
Deferred State	(683)	986	(1,217)
Deferred Total	1,095	6,414	(2,251)
Adjustment to deferred taxes for tax rate change	0	3,915	0
Total	$ 22,841	$ 28,445	$ 32,975

Income Taxes Rate Reconciliatio

Income Taxes Rate Reconciliation (Details)	12 Months Ended
	Dec. 31, 2018Rate	Dec. 31, 2017Rate	Dec. 31, 2016Rate
Income tax expense at statutory rate	21.00%	35.00%	35.00%
State income taxes - net of federal benefit	3.10%	3.10%	3.00%
Non-deductible expenses	0.80%	1.70%	0.90%
Non-deductible compensation	1.80%	0.00%	0.00%
Equity compensation	(4.80%)	(4.50%)	0.00%
Revaluation of deferred	(1.10%)	5.70%	0.00%
Other adjustments	(1.00%)	0.10%	(0.50%)
Total income tax provision	19.80%	41.10%	38.40%

Income Taxes Deferred (Details)

Income Taxes Deferred (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Income Tax Disclosure [Abstract]
Accrued expenses	$ 22,756	$ 16,500
Allowance for doubtful accounts	12,312	11,090
Tax credits	3,201	3,334
Insurance	5,667	5,135
Deferred Tax Assets, Gross	43,936	36,059
Valuation allowance	(791)	(530)
Total deferred tax assets	43,145	35,529
State taxes	(475)	(911)
Depreciation and amortization	(28,496)	(18,248)
Prepaid expenses	(2,524)	(3,625)
Total deferred tax liabilities	(31,495)	(22,784)
Net deferred tax assets	$ 11,650	$ 12,745

Income Taxes Other Disclosures

Income Taxes Other Disclosures (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Operating Loss Carryforwards [Line Items]
Tax credits	$ 3,201	$ 3,334
Valuation Allowance, Deferred Tax Asset, Increase (Decrease), Amount		$ 1,000
Internal Revenue Service (IRS) [Member]
Operating Loss Carryforwards [Line Items]
Effective Income Tax Rate Reconciliation, Change in Enacted Tax Rate, Amount	$ 1,233

Debt (Details)

Debt (Details) - USD ($) $ in Thousands	Dec. 31, 2018	Dec. 31, 2017
Debt Instrument [Line Items]
Long-term Debt, Gross	$ 246,080	$ 316,019
Current maturities of long-term debt	(10,105)	(9,939)
Long Term Debt, net of Current Maturities and Debt Discount	233,135	302,990
SunTrust Bank [Member] | Revolving Credit Facility [Member]
Debt Instrument [Line Items]
Revolving credit facility with SunTrust	10,000	50,000
Second Amended Credit Facility [Member] | SunTrust Bank [Member] | Revolving Credit Facility [Member]
Debt Instrument [Line Items]
Term loan with SunTrust	113,125	140,625
Less: debt issuance costs	(2,840)	(3,090)
Collateralized Debt Obligations [Member] | Notes Payable, Other Payables [Member]
Debt Instrument [Line Items]
Mortgage loans and promissory note	$ 122,955	$ 125,394

Debt Additional Disclosures (De

Debt Additional Disclosures (Details) $ in Thousands	Feb. 05, 2016USD ($)Rate	Feb. 04, 2019USD ($)	Dec. 31, 2018USD ($)	Dec. 31, 2017USD ($)	Jul. 19, 2016USD ($)Rate	May 30, 2014USD ($)
Secured Debt [Member] | Senior Debt Obligations [Member]
Long-Term Debt Additional Disclosures [Line Items]
Decrease in Letters of Credit			$ 1,522
Pledged Financial Instruments, Not Separately Reported, Securities for Letter of Credit Facilities			4,782
SunTrust Bank [Member] | Revolving Credit Facility [Member]
Long-Term Debt Additional Disclosures [Line Items]
Revolving credit facility with SunTrust			10,000	$ 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			105,625
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 and Line of Credit Facility, Amount Outstanding			123,125
Term loan with SunTrust			$ 113,125	$ 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		$ 123,125
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%
Line of Credit Facility, Interest Rate, LIBOR | Rate	1.75%
Line of Credit Facility, Unused Capacity, Commitment Fee Percentage | Rate	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%
Line of Credit Facility, Interest Rate, LIBOR | Rate	2.75%
Line of Credit Facility, Unused Capacity, Commitment Fee Percentage | Rate	0.50%

Debt Other Additional Disclosur

Debt Other Additional Disclosures (Details) - Collateralized Debt Obligations [Member] $ in Thousands	Dec. 31, 2014	Dec. 27, 2017USD ($)facilitiesRate	Dec. 31, 2018USD ($)	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 | $			$ 122,955	$ 125,394
Notes Payable, Current | $			2,605
Notes Payable, Noncurrent | $			$ 120,350
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%

Debt Future Principal Obligatio

Debt Future Principal Obligations (Details) $ in Thousands	Dec. 31, 2018USD ($)
Debt Disclosure [Abstract]
2,019	$ 10,105
2,020	10,203
2,021	110,926
2,022	2,904
2,023	3,016
Thereafter	108,926
Long-term Debt	$ 246,080

Options and Awards Lead Paragra

Options and Awards Lead Paragraphs (Details) shares in Thousands	May 25, 2017shares	Dec. 31, 2018AgreementsRateshares	Dec. 31, 2017shares	Dec. 31, 2016shares
Stock Options granted [Line Items]
Number of Option Plans | Agreements		1
Stock Issued or Granted During Period, Share-based Compensation [Abstract]
Share-based Compensation Arrangement by Share-Based Payment Award, Options, Fair Value Assumptions, Forfeiture Rate | Rate		9.63%
Award Vesting Period		5 years
Options Granted		640	481	497
Nonvested Restricted Awards, Granted		367	173	299
2017 Plan [Member]
Stock Issued or Granted During Period, Share-based Compensation [Abstract]
Number of Shares Available for Grant		4,770
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	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Options and Awards [Abstract]
Options Granted	640	481	497
Fair Value Assumptions and Methodology
Weighted Average Risk-Free Rate	2.80%	2.00%	1.40%
Expected Life	6 years 2 months	6 years 2 months	6 years 4 months
Weighted Average Volatility	32.00%	35.20%	37.80%
Weighted Average Dividend Yield	0.50%	0.80%	0.80%

Options and Awards Exercise Pri

Options and Awards Exercise Price and Fair Value (Details) - $ / shares shares in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Share-based Compensation Arrangement by Share-based Payment Award, Options, Grants in Period, Net of Forfeitures [Abstract]
Options Granted	640	481	497
Weighted Average Exercise Price	$ 34.53	$ 20.31	$ 19.43
Weighted Average Fair Value of Options	12.05	7	7
Intrinsic Value of Options Granted on Grant Date [Abstract]
Grant Date Intrinsic Value	$ 0	$ 0	$ 0

Options and Awards Options Outs

Options and Awards Options Outstanding Rollforward (Details) - $ / shares shares in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Options outstanding January 1,	4,739	5,176	5,448
Weighted average exercise price January 1,	$ 13.08	$ 11.62	$ 10.36
Options vested January 1,	2,776	2,704	2,526
Weighted Average Exercise Price of Options Vested January 1,	$ 10.07	$ 8.18	$ 6.35
Options Granted	640	481	497
Weighted Average Exercise Price, Options Granted	$ 34.53	$ 20.31	$ 19.43
Options Forfeited in Period	(120)	(178)	(127)
Weighted Average Exercise Price, Options Forfeited in Period	$ 18.71	$ 15.82	$ 14.46
Options Exercised in Period	(1,071)	(740)	(642)
Weighted Average Exercise Price, Options Exercised in Period	$ 8.57	$ 6.93	$ 6.47
Options outstanding December 31,	4,188	4,739	5,176
Weighted average exercise price December 31,	$ 17.35	$ 13.08	$ 11.62
Options vested December 31,	2,431	2,776	2,704
Weighted Average Exercise Price of Options Vested December 31,	$ 12.37	$ 10.07	$ 8.18

Options and Awards Options Ou_2

Options and Awards Options Outstanding by Exercise Price (Details) $ / shares in Units, shares in Thousands, $ in Thousands	12 Months Ended
	Dec. 31, 2018USD ($)$ / sharesshares
Share-based Compensation, Shares Authorized under Stock Option Plans, Exercise Price Range [Line Items]
Number of Outstanding Options	4,188
Black-Scholes Fair Value | $	$ 28,488
Stock Options Vested and Exercisable	2,431
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	194
Black-Scholes Fair Value | $	$ 414
Remaining Contractual Life (Years)	1 year
Stock Options Vested and Exercisable	194
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	81
Black-Scholes Fair Value | $	$ 196
Remaining Contractual Life (Years)	2 years
Stock Options Vested and Exercisable	81
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	86
Black-Scholes Fair Value | $	$ 296
Remaining Contractual Life (Years)	3 years
Stock Options Vested and Exercisable	86
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	257
Black-Scholes Fair Value | $	$ 952
Remaining Contractual Life (Years)	4 years
Stock Options Vested and Exercisable	257
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	423
Black-Scholes Fair Value | $	$ 2,047
Remaining Contractual Life (Years)	5 years
Stock Options Vested and Exercisable	423
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	1,201
Black-Scholes Fair Value | $	$ 6,816
Remaining Contractual Life (Years)	6 years
Stock Options Vested and Exercisable	885
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	479
Black-Scholes Fair Value | $	$ 4,351
Remaining Contractual Life (Years)	7 years
Stock Options Vested and Exercisable	273
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	403
Black-Scholes Fair Value | $	$ 2,810
Remaining Contractual Life (Years)	8 years
Stock Options Vested and Exercisable	151
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	441
Black-Scholes Fair Value | $	$ 3,083
Remaining Contractual Life (Years)	9 years
Stock Options Vested and Exercisable	81
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	623
Black-Scholes Fair Value | $	$ 7,523
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	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Restricted awards granted [Line Items]
Restricted Awards Grant Date Fair Value Range, Minimum	$ 23.61	$ 18.47	$ 18.79
Restricted Awards Grant Date Fair Value Range, Maximum	$ 38.59	$ 22.90	$ 23.23
Share-based Compensation, Restricted Awards, Exercise Price	$ 0
Issuance of restricted stock to employees (in shares)	367	173	299
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	$ 37.78
Options Granted to Non-employee Directors	29

Options and Awards Restricted_2

Options and Awards Restricted Award Rollforward (Details) - $ / shares shares in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Restricted Stock Rollforward [Line Items]
Nonvested Restricted Awards, Nonvested at January 1,	383	429	425
Weighted Average Grant Date Fair Value, Nonvested at January 1,	$ 20.65	$ 20.42	$ 19.79
Nonvested Restricted Awards, Granted	367	173	299
Weighted Average Grant Date Fair Value, Restricted Awards Granted in the Period	$ 35.19	$ 20.21	$ 20.55
Nonvested Restricted Awards, Vested in the Period	(153)	(195)	(279)
Weighted Average Grant Date Fair Value, Restricted Awards Vested in the Period	$ 22.68	$ 19.79	$ 19.58
Nonvested Restricted Awards, Forfeited in the Period	(24)	(24)	(16)
Weighted Average Grant Date Fair Value, Restricted Awards Forfeited in the Period	$ 23.31	$ 20.34	$ 20.85
Nonvested Restricted Awards, Nonvested at December 31,	573	383	429
Weighted Average Grant Date Fair Value, Nonvested at December 31,	$ 29.31	$ 20.65	$ 20.42

Options and Awards Compensation

Options and Awards Compensation Expense (Details) - USD ($) shares in Thousands, $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 8,959	$ 8,331	$ 7,776
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 11 months
Stock Options
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 4,905	4,773	4,793
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	$ 13,105
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized, Period for Recognition	3 years 6 months
Employee Service Share-based Compensation, Nonvested Awards	1,757
Share-based Compensation Arrangement by Share-based Payment Award, Options, Expected to Vest, Number	1,653
Restricted Stock Awards
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 3,159	2,322	2,371
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	$ 15,022
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized, Period for Recognition	3 years 11 months
Stock awards
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 895	$ 1,236	$ 612

Options and Awards Intrinsic Va

Options and Awards Intrinsic Values (Details) - Stock Options - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Outstanding	$ 89,806	$ 44,060	$ 55,610
Vested	64,222	33,976	38,101
Expected to Vest	22,963	9,311	15,983
Exercised	$ 27,646	$ 10,481	$ 9,199

Options and Awards Subsidiary C

Options and Awards Subsidiary Common Stock Shares and Restricted Stock (Details) - $ / shares shares in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Class of Stock [Line Items]
Nonvested Restricted Awards, Granted	367	173	299
Weighted Average Grant Date Fair Value, Restricted Awards Granted in the Period	$ 35.19	$ 20.21	$ 20.55
Nonvested Restricted Awards, Vested in the Period	(153)	(195)	(279)
Award Vesting Period	5 years
Options Granted	640	481	497
Subsidiaries Stock awards [Member] | Subsidiaries [Member]
Class of Stock [Line Items]
Nonvested Restricted Awards, Granted	0	0	3,323
Weighted Average Grant Date Fair Value, Restricted Awards Granted in the Period			$ 1.37
Nonvested Restricted Awards, Vested in the Period	976	976	375
Options Granted	221	174	120
Common Stock Required to Settle Subsidiary Shares	217	264	212
Minimum [Member] | Subsidiaries Stock awards [Member] | Subsidiaries [Member]
Class of Stock [Line Items]
Award Vesting Period	3 years
Maximum [Member] | Subsidiaries Stock awards [Member] | Subsidiaries [Member]
Class of Stock [Line Items]
Award Vesting Period	5 years

Options and Awards Subsidiary E

Options and Awards Subsidiary Equity Plan Share-based Payments (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Employee stock award compensation	$ 8,959	$ 8,331	$ 7,776
Subsidiaries [Member] | Subsidiaries Stock awards [Member]
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Employee stock award compensation	$ 1,378	$ 1,364	$ 1,325

Options and Awards Sale of Stoc

Options and Awards Sale of Stock by Subsidiary (Details) - USD ($) shares in Thousands, $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Subsidiary, Sale of Stock [Line Items]
Payments for Repurchase of Common Stock	$ 1,972	$ 7,288	$ 30,000
Proceeds from sale of subsidiary shares (Note 15)	$ 1,972	$ 0	$ 0
Subsidiaries [Member] | Subsidiaries Stock awards [Member]
Subsidiary, Sale of Stock [Line Items]
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	Dec. 31, 2018USD ($)facilitiesRenewals	Dec. 31, 2017USD ($)	Dec. 31, 2016USD ($)
Operating Leased Assets [Line Items]
Rent | $		$ 138,512	$ 131,919	$ 124,581
Facilities under Master Lease Arrangement		35
Master Lease Agreements		6
Various Landlords [Member] [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract		15 years
Lessee Leasing Arrangements, Operating Leases, Number of Renewal Terms | Renewals		2
Lessee, Operating Lease, Renewal Term		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 | $		$ 58,513	57,169	56,271
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
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
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	20 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 | $		$ 139,149	$ 132,932	$ 125,221

Leases Additional Disclosures (

Leases Additional Disclosures (Details) $ in Thousands	3 Months Ended	12 Months Ended
	Jun. 30, 2017USD ($)	Dec. 31, 2018USD ($)	Dec. 31, 2017USD ($)facilities	Dec. 31, 2016USD ($)facilities
Operating Leased Assets [Line Items]
Gain (Loss) on Contract Termination			$ 2,715	$ 6,512
Business Exit Costs	$ (1,286)	$ 0	$ 2,321	$ (11,225)
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	1
Facility Closing [Member]
Operating Leased Assets [Line Items]
Business Exit Costs			$ 2,830	$ 7,935
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	Dec. 31, 2018USD ($)
Leases [Abstract]
2,019	$ 142,497
2,020	141,536
2,021	140,524
2,022	139,018
2,023	137,349
Thereafter	967,027
Operating Leases, Future Minimum Payments Due	$ 1,667,951

Self-Insurance Reserves (Detail

Self-Insurance Reserves (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017
Schedule of Self-Insurance Reserves [Line Items]
Balance January 1,	$ 72,736	$ 65,351
Current year provisions	88,071	89,394
Claims paid and direct expenses	(82,331)	(83,300)
Change in long-term insurance losses recoverable	1,575	1,291
Balance December 31,	80,051	72,736
Professional Malpractice Liability Insurance [Member]
Schedule of Self-Insurance Reserves [Line Items]
Balance January 1,	40,934	36,310
Current year provisions	23,113	20,396
Claims paid and direct expenses	(19,476)	(16,133)
Change in long-term insurance losses recoverable	795	361
Balance December 31,	45,366	40,934
Workers' Compensation [Member]
Schedule of Self-Insurance Reserves [Line Items]
Balance January 1,	27,079	23,402
Current year provisions	14,970	15,202
Claims paid and direct expenses	(13,967)	(12,455)
Change in long-term insurance losses recoverable	780	930
Balance December 31,	28,862	27,079
Health Insurance Product Line [Member]
Schedule of Self-Insurance Reserves [Line Items]
Balance January 1,	4,723	5,639
Current year provisions	49,988	53,796
Claims paid and direct expenses	(48,888)	(54,712)
Change in long-term insurance losses recoverable	0	0
Balance December 31,	$ 5,823	$ 4,723

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)	Dec. 31, 2018facilities
Probe Reviews [Abstract]
Facilities under Medicare Probe Reviews	16

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	12 Months Ended
	Dec. 31, 2018Rate	Dec. 31, 2017Rate	Dec. 31, 2016Rate
Concentration Risk [Line Items]
Accounts receivable by payor as a percent of total accounts receivable	60.60%	56.70%
% of Revenue	68.50%	68.40%	67.80%

Commitments and Contingencies_2

Commitments and Contingencies Cash in Excess of FDIC Limits (Details) - USD ($) $ in Thousands	Feb. 04, 2019	Dec. 31, 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	$ 593

Defined Contribution Plan (Deta

Defined Contribution Plan (Details) - USD ($) $ in Thousands	12 Months Ended
	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016	Dec. 31, 2006
Defined Contribution Plan [Abstract]
Defined Contribution Plan, Maximum Annual Contributions Per Employee, Percent	15.00%			90.00%
Defined Contribution Plan, Employer Discretionary Contribution Amount	$ 1,283	$ 1,028	$ 862

Common Stock (Details)

Common Stock (Details) - USD ($) shares in Thousands, $ in Thousands	Apr. 03, 2018	Feb. 08, 2017	Feb. 09, 2016	Dec. 31, 2018	Dec. 31, 2017	Dec. 31, 2016
Common Stock Transactions [Line Items]
Stock Repurchase Program, Period in Force	11 months	12 months	12 months
Stock Repurchase Program Expiration Date	Feb. 20, 2019	Feb. 8, 2018
Payments for Repurchase of Common Stock				$ 1,972	$ 7,288	$ 30,000
Common Stock [Member]
Common Stock Transactions [Line Items]
Stock Repurchase Program, Authorized Amount	$ 30,000	$ 30,000	$ 15,000
Stock Repurchased During Period, Shares					412	746
Payments for Repurchase of Common Stock					$ 7,288	$ 15,000

Divestitures (Details)

Divestitures (Details) $ in Thousands	12 Months Ended
	Dec. 31, 2018USD ($)	Dec. 31, 2017USD ($)	Dec. 31, 2016USD ($)Centers
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Gain (Loss) on Disposition of Business	$ 0	$ 0	$ 19,160
Disposal Group, Disposed of by Sale, Not Discontinued Operations [Member]
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Urgent Care Centers Operated | Centers			17
Sale Price from Divestiture of Businesses			$ 41,492
Gain (Loss) on Disposition of Business			$ 19,160