The Ensign Group, Inc. (ENSG) 10-Q 1 Aug 19 2019 Q2 Quarterly report Financial data

Cover Page

Cover Page - shares	6 Months Ended
	Jun. 30, 2019	Jul. 31, 2019
Entity Information [Abstract]
Document Type	10-Q
Document Quarterly Report	true
Document Period End Date	Jun. 30, 2019
Document Transition Report	false
Entity File Number	001-33757
Entity Registrant Name	ENSIGN GROUP, INC
Entity Incorporation, State or Country Code	DE
Entity Tax Identification Number	33-0861263
Entity Address, Address Line One	29222 Rancho Viejo Road, Suite 127
Entity Address, City or Town	San Juan Capistrano
Entity Address, State or Province	CA
Entity Address, Postal Zip Code	92675
City Area Code	949
Local Phone Number	487-9500
Title of 12(b) Security	Common Stock, par value $0.001 per share
Trading Symbol	ENSG
Security Exchange Name	NASDAQ
Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Large Accelerated Filer
Entity Small Business	false
Entity Emerging Growth Company	false
Entity Shell Company	false
Entity Common Stock, Shares Outstanding		53,386,352
Entity Central Index Key	0001125376
Current Fiscal Year End Date	--12-31
Document Fiscal Year Focus	2019
Document Fiscal Period Focus	Q2
Amendment Flag	false

Consolidated Balance Sheets

Consolidated Balance Sheets - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Current assets:
Cash and cash equivalents	$ 39,042	$ 31,083
Accounts receivable—less allowance for doubtful accounts of $3,726 and $2,886 at June 30, 2019 and December 31, 2018, respectively	296,935	276,099
Investments—current	8,003	8,682
Prepaid income taxes	5,934	6,219
Prepaid expenses and other current assets	25,632	24,130
Assets held for sale - current	0	1,859
Total current assets	375,546	348,072
Property and equipment, net	674,892	618,874
Right-of-use assets (Note 17)	1,074,449	0
Insurance subsidiary deposits and investments	38,929	36,168
Escrow deposits	0	7,271
Deferred tax assets	8,603	11,650
Restricted and other assets (Note 17)	16,943	20,844
Intangible assets, net (Note 17)	3,829	31,000
Goodwill	97,408	80,477
Other indefinite-lived intangibles	30,922	27,602
Total assets	2,321,521	1,181,958
Current liabilities:
Accounts payable	44,694	44,236
Accrued wages and related liabilities	116,018	119,656
Lease liabilities—current (Note 17)	59,686	0
Accrued self-insurance liabilities—current	26,981	25,446
Other accrued liabilities	69,816	69,784
Current maturities of long-term debt	10,153	10,105
Total current liabilities	327,348	269,227
Long-term debt—less current maturities	268,179	233,135
Long-term lease liabilities—less current portion (Note 17)	988,145	0
Accrued self-insurance liabilities—less current portion	57,565	54,605
Other long-term liabilities	2,977	11,234
Deferred gain related to sale-leaseback (Note 17)	0	11,417
Total liabilities	1,644,214	579,618
Commitments and contingencies (Notes 15, 17 and 18)
Equity:
Common stock; $0.001 par value; 100,000 shares authorized; 55,809 and 53,272 shares issued and outstanding at June 30, 2019, respectively, and 55,089 and 52,584 shares issued and outstanding at December 31, 2018, respectively	55	55
Additional paid-in capital	298,891	284,384
Retained earnings	401,996	344,901
Common stock in treasury, at cost, 1,941 and 1,932 shares at June 30, 2019 and December 31, 2018, respectively	(38,890)	(38,405)
Total Ensign Group, Inc. stockholders' equity	662,052	590,935
Non-controlling interest	15,255	11,405
Total equity	677,307	602,340
Total liabilities and equity	$ 2,321,521	$ 1,181,958

Consolidated Balance Sheets Bal

Consolidated Balance Sheets Balance Sheet (Paranthetical) - USD ($) shares in Thousands, $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Current assets:
Allowance for doubtful accounts	$ 3,726	$ 2,886
Equity:
Common stock, par value	$ 0.001	$ 0.001
Common stock, shares authorized	100,000	75,000
Common stock, shares issued	55,809	55,089
Common stock, shares outstanding	53,272	52,584
Common stock in treasury, at cost	1,941	1,932

Consolidated Statements of Inco

Consolidated Statements of Income - USD ($) shares in Thousands, $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Revenue	$ 575,651	$ 496,386	$ 1,124,865	$ 988,520
Expense
Cost of services	457,000	396,132	887,002	786,375
Return of unclaimed class action settlement (Note 18)	0	0	0	(1,664)
Rent—cost of services (Note 17)	37,060	34,472	72,846	68,322
General and administrative expense	30,561	22,386	63,585	47,490
Depreciation and amortization	13,184	11,621	25,782	23,243
Total expenses	537,805	464,611	1,049,215	923,766
Income from operations	37,846	31,775	75,650	64,754
Other income (expense):
Interest expense	(3,941)	(3,869)	(7,613)	(7,482)
Interest income	572	562	1,147	1,010
Other expense, net	(3,369)	(3,307)	(6,466)	(6,472)
Income before provision for income taxes	34,477	28,468	69,184	58,282
Provision for income taxes	5,552	6,142	12,652	12,663
Net income	28,925	22,326	56,532	45,619
Less: net income attributable to noncontrolling interests	316	315	551	476
Net income attributable to The Ensign Group, Inc.	$ 28,609	$ 22,011	$ 55,981	$ 45,143
Basic:
Basic net income per common share attributable to The Ensign Group, Inc.	$ 0.54	$ 0.42	$ 1.05	$ 0.87
Diluted:
Diluted net income per common share attributable to The Ensign Group, Inc.	$ 0.51	$ 0.41	$ 1	$ 0.84
Weighted average common shares outstanding:
Basic	53,408	51,880	53,246	51,733
Diluted	56,078	54,251	55,896	53,909

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, 2017	$ 500,059	$ 53	$ 266,058	$ 264,691	$ (38,405)	$ 7,662
Balance - January 1 (in shares) at Dec. 31, 2017		51,360
Balance - January 1 (in treasury shares) at Dec. 31, 2017					1,932
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		404			0
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	2,920	$ 1	2,919		$ 0
Dividends declared	(2,346)			(2,346)
Employee stock award compensation	1,971		1,971
Noncontrolling interest attributable to subsidiary equity plan (Note 16)	338			(79)		417
Distribution to noncontrolling interest holder	(292)					(292)
Net income attributable to noncontrolling interest	161					161
Net Income (Loss) Attributable to the Ensign Group, Inc.	23,132			23,132
Balance - June 30, at Mar. 31, 2018	525,943	$ 54	270,948	285,398	$ (38,405)	7,948
Balance - June 30 (in shares) at Mar. 31, 2018		51,764
Balance - June 30 (in treasury shares) at Mar. 31, 2018					1,932
Balance - January 1, at Dec. 31, 2017	500,059	$ 53	266,058	264,691	$ (38,405)	7,662
Balance - January 1 (in shares) at Dec. 31, 2017		51,360
Balance - January 1 (in treasury shares) at Dec. 31, 2017					1,932
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Repurchase of shares of common stock to satisfy tax withholding obligations	0
Dividends declared	(2,367)
Employee stock award compensation	4,148
Net income attributable to noncontrolling interest	476
Net Income (Loss) Attributable to the Ensign Group, Inc.	45,143
Balance - June 30, at Jun. 30, 2018	550,279	$ 54	274,982	303,157	$ (38,405)	10,491
Balance - June 30 (in shares) at Jun. 30, 2018		52,033
Balance - June 30 (in treasury shares) at Jun. 30, 2018					1,932
Balance - January 1, at Mar. 31, 2018	525,943	$ 54	270,948	285,398	$ (38,405)	7,948
Balance - January 1 (in shares) at Mar. 31, 2018		51,764
Balance - January 1 (in treasury shares) at Mar. 31, 2018					1,932
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		269			0
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	1,857	$ 0	1,857		$ 0
Dividends declared	(2,367)			(2,367)
Employee stock award compensation	2,177		2,177
Noncontrolling interest attributable to subsidiary equity plan (Note 16)	343			(1,885)		2,228
Net income attributable to noncontrolling interest	315					315
Net Income (Loss) Attributable to the Ensign Group, Inc.	22,011			22,011
Balance - June 30, at Jun. 30, 2018	550,279	$ 54	274,982	303,157	$ (38,405)	10,491
Balance - June 30 (in shares) at Jun. 30, 2018		52,033
Balance - June 30 (in treasury shares) at Jun. 30, 2018					1,932
Balance - January 1, at Dec. 31, 2018	$ 602,340	$ 55	284,384	344,901	$ (38,405)	11,405
Balance - January 1 (in shares) at Dec. 31, 2018	52,584	52,584
Balance - January 1 (in treasury shares) at Dec. 31, 2018					1,932
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		371			0
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	$ 5,616	$ 0	5,616		$ 0
Dividends declared	(2,543)			(2,543)
Employee stock award compensation	2,612		2,612
Noncontrolling interest attributable to subsidiary equity plan (Note 16)	341			(317)		658
Net income attributable to noncontrolling interest	235					235
Net Income (Loss) Attributable to the Ensign Group, Inc.	27,372			27,372
Balance - June 30, at Mar. 31, 2019	645,003	$ 55	292,612	378,443	$ (38,405)	12,298
Balance - June 30 (in shares) at Mar. 31, 2019		52,955
Balance - June 30 (in treasury shares) at Mar. 31, 2019					1,932
Balance - January 1, at Dec. 31, 2018	$ 602,340	$ 55	284,384	344,901	$ (38,405)	11,405
Balance - January 1 (in shares) at Dec. 31, 2018	52,584	52,584
Balance - January 1 (in treasury shares) at Dec. 31, 2018					1,932
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Repurchase of shares of common stock to satisfy tax withholding obligations	$ (485)
Dividends declared	(2,559)
Employee stock award compensation	5,678
Net income attributable to noncontrolling interest	551
Net Income (Loss) Attributable to the Ensign Group, Inc.	55,981
Balance - June 30, at Jun. 30, 2019	$ 677,307	$ 55	298,891	401,996	$ (38,890)	15,255
Balance - June 30 (in shares) at Jun. 30, 2019	53,272	53,272
Balance - June 30 (in treasury shares) at Jun. 30, 2019					1,941
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Cumulative effect of new accounting change, net of tax	$ 9,030			9,030
Balance - January 1, at Mar. 31, 2019	645,003	$ 55	292,612	378,443	$ (38,405)	12,298
Balance - January 1 (in shares) at Mar. 31, 2019		52,955
Balance - January 1 (in treasury shares) at Mar. 31, 2019					1,932
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards (in shares)		326			0
Issuance of common stock to employees and directors resulting from the exercise of stock options and grant of stock awards	3,213	$ 0	3,213		$ 0
Share-based Payment Arrangement, Shares Withheld for Tax Withholding Obligation		(9)			9
Repurchase of shares of common stock to satisfy tax withholding obligations	(485)				$ (485)
Dividends declared	(2,559)			(2,559)
Employee stock award compensation	3,066		3,066
Noncontrolling interest attributable to subsidiary equity plan (Note 16)	236			(2,497)		2,733
Distribution to noncontrolling interest holder	(92)					(92)
Net income attributable to noncontrolling interest	316					316
Net Income (Loss) Attributable to the Ensign Group, Inc.	28,609			28,609
Balance - June 30, at Jun. 30, 2019	$ 677,307	$ 55	$ 298,891	$ 401,996	$ (38,890)	$ 15,255
Balance - June 30 (in shares) at Jun. 30, 2019	53,272	53,272
Balance - June 30 (in treasury shares) at Jun. 30, 2019					1,941

Consolidated Statement of Sto_2

Consolidated Statement of Stockholders' Equity (Parenthetical) - $ / shares	3 Months Ended
	Jun. 30, 2019	Jun. 30, 2018
Statement of Stockholders' Equity [Abstract]
Dividends Per Share	$ 0.0475	$ 0.0450

Consolidated Statements of Cash

Consolidated Statements of Cash Flows - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018
Cash flows from operating activities:
Net income	$ 56,532	$ 45,619
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation and amortization	25,782	23,243
Impairment of long-lived assets	0	860
Amortization of deferred financing fees	583	588
Amortization of deferred gain on sale-leaseback (Note 17)	0	(329)
Non-cash leasing arrangement (Note 17)	(688)	0
Provision for doubtful accounts	1,155	972
Share-based compensation	6,255	4,829
Cash received from insurance proceeds related to replacement properties and business interruptions	638	0
Income tax refund	0	11,000
Change in operating assets and liabilities
Accounts receivable	(22,716)	13,476
Prepaid income taxes	229	(129)
Prepaid expenses and other assets	3,332	(3,454)
Insurance subsidiary deposits	0	(2,571)
Operating lease obligations	(2,248)	0
Accounts payable	356	(74)
Accrued wages and related liabilities	(355)	(1,046)
Other accrued liabilities	(1,566)	2,531
Accrued self-insurance liabilities	3,717	5,349
Other long-term liability	1,272	376
Net cash provided by operating activities	72,278	101,240
Cash flows from investing activities:
Purchase of property and equipment	(35,762)	(24,295)
Cash payments for business acquisitions (Note 8)	(21,262)	0
Cash payments for asset acquisitions (Note 8)	(43,176)	(55,546)
Escrow deposits	0	(2,652)
Escrow deposits used to fund acquisitions	7,271	228
Cash proceeds from the sale of assets and insurance proceeds	2,575	1,610
Investments and change in other assets	(7,902)	(589)
Net cash used in investing activities	(98,256)	(81,244)
Cash flows from financing activities:
Proceeds from revolving credit facility and other debt (Note 15)	535,000	405,000
Payments on revolving credit facility and other debt (Note 15)	(500,965)	(439,922)
Issuance of common stock upon exercise of options	5,547	4,778
Repurchase of shares of common stock to satisfy tax withholding obligations	(485)	0
Proceeds from sale of subsidiary shares (Note 16)	2,293	0
Repurchase of shares of common stock and subsidiary shares (Note 16)	(2,293)	0
Dividends paid	(5,068)	(4,695)
Non-controlling interest distribution	(92)	(292)
Payments of deferred financing costs	0	(18)
Net cash provided by/(used in) financing activities	33,937	(35,149)
Net increase/(decrease) in cash and cash equivalents	7,959	(15,153)
Cash and cash equivalents beginning of period	31,083	42,337
Cash and cash equivalents end of period	39,042	27,184
Cash paid during the period for:
Interest	7,500	7,321
Income taxes	12,375	12,925
Lease liabilities	73,748	0
Non-cash financing and investing activity:
Accrued capital expenditures	3,600	3,600
Accrued dividends declared	2,559	2,367
Note receivable from sale of ancillary business	0	282
Right-of-Use Asset Obtained in Exchange for Operating Lease Liability	$ 47,748	$ 0

Description of Business

Description of Business	6 Months Ended
	Jun. 30, 2019
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 of June 30, 2019 , the Company operated 254 facilities, 62 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, senior living, home health, hospice, home care and other ancillary services. The Company's operating subsidiaries have a collective capacity of approximately 20,700 operational skilled nursing beds and 5,900 senior living units. As of June 30, 2019 , the Company owned 77 of its 254 affiliated facilities and leased an additional 177 facilities through long-term lease arrangements and had options to purchase 12 of those 177 facilities. 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. 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 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. Proposed Spin-Off Transaction — On May 6, 2019, the Company announced a proposed plan to separate its transitional and skilled nursing services, its home health and hospice operations and substantially all of its senior living operations into two separate, publicly traded companies. See Note 2, Proposed Spin-Off of Subsidiaries . Other Information — The accompanying condensed consolidated financial statements as of June 30, 2019 and for the three and six months ended June 30, 2019 and 2018 (collectively, the Interim Financial Statements) are unaudited. Certain information and note disclosures normally included in annual consolidated financial statements have been condensed or omitted, as permitted under applicable rules and regulations. Readers of the Interim Financial Statements should refer to the Company’s audited consolidated financial statements and notes thereto for the year ended December 31, 2018 which are included in the Company’s annual report on Form 10-K, File No. 001-33757 (the Annual Report) filed with the Securities and Exchange Commission (SEC). Management believes that the Interim Financial Statements reflect all adjustments which are of a normal and recurring nature necessary to present fairly the Company’s financial position and results of operations in all material respects. The results of operations presented in the Interim Financial Statements are not necessarily representative of operations for the entire year.

Proposed Spin-Off of Subsidiari

Proposed Spin-Off of Subsidiaries	6 Months Ended
	Jun. 30, 2019
Proposed Spin-Off [Abstract]
Proposed Spin-Off [Text Block]	PROPOSED SPIN-OFF OF SUBSIDIARIES On May 6, 2019, the Company announced a proposed plan to separate its transitional and skilled nursing services, its home health and hospice operations and substantially all of its senior living operations into two separate, publicly traded companies: • Ensign, which will include transitional and skilled services, rehabilitative care services, healthcare campuses, post-acute-related new business ventures and real estate investments; and • The Pennant Group, Inc. ("Pennant"), which will be a holding company of operating subsidiaries that provide home health, hospice and senior living. The Company intends to accomplish the proposed separation through a spin-off (the Spin-Off), in which it expects to distribute shares of Pennant common stock to the Company’s stockholders, on a pro rata basis. The Company anticipates that at the time of the Spin-Off, Pennant, which is currently a wholly-owned subsidiary of the Company, will consists of 62 home health, hospice and home care agencies and 51 senior living communities as of June 30, 2019. Ensign affiliates will retain ownership of the real estate at 28 of the 51 senior living operations that are being contributed to Pennant. The Company anticipates that after the Spin-Off, all of these properties will be leased to Pennant on a triple-net basis, under which Pennant affiliates will be responsible for all costs at the properties, including property taxes, insurance and maintenance and repair costs. In accordance with Accounting Standards Codification (ASC) 505-60, Equity-Spinoffs and Reverse Spinoffs, the accounting for the separation of the Company follows its legal form, with Ensign as the legal and accounting spinnor and Pennant as the legal and accounting spinnee, due to the relative significance of Ensign’s healthcare business, the relative fair values of the respective companies, the retention of all senior management, and other relevant indicators. In connection with the adoption of the stockholder rights plan, the Company anticipates that the board of directors will declare a dividend of one share of Pennant common stock for every two shares of the Company's common stock held by stockholders as of the record date. Pennant is also anticipating that awards of equity of Pennant subsidiaries granted to certain individuals will be exchanged for Pennant common stock immediately prior to the distribution. The number of shares of Ensign common stock each stockholder owns and the related proportionate interest in Ensign will not change as a result of the proposed Spin-Off. Each Ensign stockholder will receive only whole shares of Pennant common stock in the distribution, as well as cash in lieu of any fractional shares. The proposed Spin-Off is subject to customary conditions, including receipt of a tax opinion from counsel, effectiveness of the registration statement filed with the Securities and Exchange Commission, execution of third-party agreements and final approval by Ensign’s board of directors.

Significant Accounting Policies

Significant Accounting Policies	6 Months Ended
	Jun. 30, 2019
Accounting Policies [Abstract]
Basis of Presentation and Significant Accounting Policies [Text Block]	SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Basis of Presentation — The accompanying Interim Financial Statements have been prepared in accordance with accounting principles generally accepted in the United States (GAAP). The Company is the sole member or stockholder of various consolidated limited liability companies and corporations established to operate various acquired skilled nursing and senior living operations, home health, hospice and home care operations, and related ancillary services. All intercompany transactions and balances have been eliminated in consolidation. The condensed consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest. The Company presents noncontrolling interests within the equity section of its condensed consolidated balance sheets. The Company presents the amount of consolidated net income that is attributable to The Ensign Group, Inc. and the noncontrolling interest in its condensed consolidated statements of income. The condensed 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, 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 three and six months ended June 30, 2019 and 2018 . The Company completed the sale of one of its senior living operations for a sale price of $1,838 during the first quarter of 2019. 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. The Company presented property and equipment assets of the senior living operation sold as held for sale in the consolidated balance sheet as of December 31, 2018. Estimates and Assumptions — The preparation of Interim Financial Statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the Interim Financial Statements and the reported amounts of revenue and expenses during the reporting periods. The most significant estimates in the Company’s Interim Financial Statements relate to revenue, intangible assets and goodwill, impairment of long-lived assets, general and professional liability, workers' compensation and healthcare claims included in accrued self-insurance liabilities, and income taxes. Actual results could differ from those estimates. Fair Value of Financial Instruments — The Company’s financial instruments consist principally of cash and cash equivalents, debt security investments, accounts receivable, insurance subsidiary deposits, accounts payable and borrowings. The Company believes all of the financial instruments’ recorded values approximate fair values because of their nature or respective short durations. Revenue Recognition — On January 1, 2018, the Company adopted Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (ASC 606) applying the modified retrospective method. 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 4, Revenue and Accounts Receivable . Accounts Receivable and Allowance for Doubtful Accounts — Accounts receivable consist primarily of amounts due from Medicare and Medicaid programs, other government programs, managed care health plans and private payor sources, net of estimates for variable consideration. The allowance for doubtful accounts reflects the Company’s best estimate of probable losses inherent in the accounts receivable balance. The Company determines the allowance based on known troubled accounts and other currently available evidence. See Note 4, Revenue and Accounts Receivable . Property and Equipment — Property and equipment are initially recorded at their historical cost. Repairs and maintenance are expensed as incurred. Depreciation is computed using the straight-line method over the estimated useful lives of the depreciable assets (ranging from three to 59 years ). Leasehold improvements are amortized on a straight-line basis over the shorter of their estimated useful lives or the remaining lease term. Impairment of Long-Lived Assets — The Company reviews the carrying value of long-lived assets that are held and used in the Company’s operating subsidiaries for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of these assets is determined based upon expected undiscounted future net cash flows from the operating subsidiaries to which the assets relate, utilizing management’s best estimate, appropriate assumptions, and projections at the time. If the carrying value is determined to be unrecoverable from future operating cash flows, the asset is deemed impaired and an impairment loss would be recognized to the extent the carrying value exceeded the estimated fair value of the asset. The Company estimates the fair value of assets based on the estimated future discounted cash flows of the asset. Management has evaluated its long-lived assets and recorded an impairment charge of $705 and $860 during the three and six months ended June 30, 2018 . The Company did no t record an impairment charge during the three and six months ended June 30, 2019 . Leases and Leasehold Improvements - The Company leases skilled nursing facilities, senior living facilities and commercial office space. On January 1, 2019, the Company adopted Accounting Standards Codification Topic 842, Leases (ASC 842), electing the transition method that allows it to apply the standard as of the adoption date and record a cumulative adjustment in retained earnings. The Company determines if an arrangement is a lease at the inception of each lease. At the inception of each lease, the Company performs an evaluation to determine whether the lease should be classified as an operating or finance lease. Operating leases are included in right-of-use assets, current lease liabilities and long-term lease liabilities on the Company's condensed consolidated balance sheet. As the Company's leases do not provide an implicit rate, the Company uses its incremental borrowing rate based on the information available at lease commencement date in determining the present value of future lease payments. The Company estimates this rate based on prevailing financial market conditions, comparable company and credit analysis, and management judgment. The Company records rent expense for operating leases on a straight-line basis over the term of the lease. The lease term used for straight-line rent expense is calculated from the date the Company is given control of the leased premises through the end of the lease term. The lease term excludes lease renewals as the renewal rents are not at a bargain, there are no economic penalties for the Company to renew the lease, and it is not reasonably assured that the Company will exercise the extension options. The lease term used for this evaluation also provides the basis for establishing depreciable lives for buildings subject to lease and leasehold improvements. The Company recognizes lease expense for leases with an initial term of 12 months or less on a straight-line basis over the lease term. These leases are not recorded on the condensed consolidated balance sheet. Certain of the Company's lease agreements include rental payments that are adjusted periodically for inflation. The lease agreements do not contain any material residual value guarantees or material restrictive covenants. The Company does not have material subleases. See further discussion at Note 17, Leases . Intangible Assets and Goodwill — Definite-lived intangible assets consist primarily of patient base, facility trade names and customer relationships. 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. The Company did no t identify any goodwill or intangible assets impairment during the three and six months ended June 30, 2019 and 2018 . See further discussion at Note 11, 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 condensed consolidated balance sheets. The Captive is subject to certain statutory requirements as an insurance provider. The Company’s policy is to accrue amounts equal to the actuarially estimated costs to settle open claims of insureds, as well as an estimate of the cost of insured claims that have been incurred but not reported. The Company develops information about the size of the ultimate claims based on historical experience, current industry information and actuarial analysis, and evaluates the estimates for claim loss exposure on a quarterly basis. Accrued general liability and professional malpractice liabilities on an undiscounted basis, net of anticipated insurance recoveries, were $45,106 and $42,635 as of June 30, 2019 and December 31, 2018 , respectively. The Company’s operating subsidiaries are self-insured for workers’ compensation in California. To protect itself against loss exposure in California with this policy, the Company has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington 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 benefit payments 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. Accrued workers’ compensation liabilities are recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets and were $25,317 and $24,624 as of June 30, 2019 and December 31, 2018 , respectively. In addition, the Company has recorded an asset and equal liability of $7,747 and $6,969 at June 30, 2019 and December 31, 2018 , 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 12, Restricted and Other Assets. The Company self-funds medical (including prescription drugs) and dental healthcare benefits to the majority of its employees. The Company is fully liable for all financial and legal aspects of these benefit plans. To protect itself against loss exposure with this policy, the Company has purchased individual stop-loss insurance coverage that insures individual claims that exceed $300 for each covered person with an additional one-time aggregate individual stop loss deductible of $75 . Beginning 2016, the Company's policy does not include the additional one-time aggregate individual stop loss deductible of $75 . The Company’s accrued liability under these plans recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets was $6,376 and $5,823 as of June 30, 2019 and December 31, 2018 , respectively. The Company believes that adequate provision has been made in the Interim Financial Statements for liabilities that may arise out of patient care, workers’ compensation, healthcare benefits and related services provided to date. The amount of the Company’s reserves was determined based on an estimation process that uses information obtained from both company-specific and industry data. This estimation process requires the Company to continuously monitor and evaluate the life cycle of the claims. Using data obtained from this monitoring and the Company’s assumptions about emerging trends, the Company, with the assistance of an independent actuary, develops information about the size of ultimate claims based on the Company’s historical experience and other available industry information. The most significant assumptions used in the estimation process include determining the trend in costs, the expected cost of claims incurred but not reported and the expected costs to settle or pay damage awards with respect to unpaid claims. The self-insured liabilities are based upon estimates, and while management believes that the estimates of loss are reasonable, the ultimate liability may be in excess of or less than the recorded amounts. Due to the inherent volatility of actuarially determined loss estimates, it is reasonably possible that the Company could experience changes in estimated losses that could be material to net income. If the Company’s actual liability exceeds its estimates of loss, its future earnings, cash flows and financial condition would be adversely affected. Income Taxes — Deferred tax assets and liabilities are established for temporary differences between the financial reporting basis and the tax basis of the Company’s assets and liabilities at tax rates in effect when such temporary differences are expected to reverse. The Company generally expects to fully utilize its deferred tax assets; however, when necessary, the Company records a valuation allowance to reduce its net deferred tax assets to the amount that is more likely than not to be realized. In determining the need for a valuation allowance or the need for and magnitude of liabilities for uncertain tax positions, the Company makes certain estimates and assumptions. These estimates and assumptions are based on, among other things, knowledge of operations, markets, historical trends and likely future changes and, when appropriate, the opinions of advisors with knowledge and expertise in certain fields. Due to certain risks associated with the Company’s estimates and assumptions, actual results could differ. Noncontrolling Interest — The noncontrolling interest in a subsidiary is initially recognized at estimated fair value on the acquisition date and is presented within total equity in the Company's condensed consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to The Ensign Group, Inc. in its condensed consolidated statements of income and net income per share is calculated based on net income attributable to The Ensign Group, Inc.'s stockholders. The carrying amount of the noncontrolling interest is adjusted based on an allocation of subsidiary earnings based on ownership interest. Share-Based Compensation — The Company measures and recognizes compensation expense for all share-based payment awards made to employees and directors including employee stock options based on estimated fair values, ratably over the requisite service period of the award. Net income has been reduced as a result of the recognition of the fair value of all stock options and restricted stock awards issued, the amount of which is contingent upon the number of future grants and other variables. Recent Accounting Pronouncements — Except for rules and interpretive releases of the Securities and Exchange Commission (SEC) under authority of federal securities laws and a limited number of grandfathered standards, the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) is the sole source of authoritative GAAP literature recognized by the FASB and applicable to the Company. For any new pronouncements announced, the Company considers whether the new pronouncements could alter previous generally accepted accounting principles and determines whether any new or modified principles will have a material impact on the Company's reported financial position or operations in the near term. The applicability of any standard is subject to the formal review of the Company's financial management and certain standards are under consideration. Recent Accounting Standards Adopted by the Company In 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, which among other things, allows the Company to carry forward the historical lease classification. The new standard also provides practical expedients for an entity’s ongoing accounting. The Company has made an accounting policy 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 right-of-use assets and lease liabilities of $1,051,148 and $1,029,240 , respectively, on its condensed consolidated balance sheets as of January 1, 2019. The Company recorded an adjustment, net of tax, of $9,030 to retained earnings, on the adoption date, related to a deferred gain on a previous sale-leaseback transaction, which resulted in an increase in rent expense of $658 annually, as we are no longer able to recognize the gain in our consolidated statement of income as a result of the new lease standard. In addition, initial direct costs associated with its lease agreements and favorable lease assets of $26,939 were classified into right-of-use assets on the adoption date. The standard does not materially affect the Company's consolidated net earnings or have a notable impact on liquidity or debt-covenant compliance under the current agreements. See further discussion at Note 17, Leases . Prior to the adoption of ASC 842, the Company recognized revenue related to its senior living residency agreements in accordance with the provisions of ASC 840, Leases ("ASC 840"). Subsequent to the adoption of ASU 2016-02, Leases , lessors are required to separately recognize and measure the lease component of a contract with a customer utilizing the provisions of ASC 842 and the non-lease components utilizing the provisions of ASC 606, Revenue from Contracts with Customers . To separately account for the components, the transaction price is allocated among the components based upon the estimated stand alone selling prices of the components. Additionally, certain components of a contract which were previously included within the lease element recognized in accordance with ASC 840 prior to the adoption of ASU 2016-02 (such as common area maintenance services, other basic services, and executory costs) are recognized as non-lease components subject to the provisions of ASC 606 subsequent to the adoption of ASU 2016-02. Entities are required to recognize a cumulative effect adjustment to beginning retained earnings as of the initial application date of ASU 2016-02 for changes to amounts recognized for these certain components for the transition from ASC 840 to ASC 606. However, entities are permitted to elect the practical expedient under ASU 2018-11, Leases , allowing lessors to not separate non-lease components from the associated lease components when certain criteria are met. Entities that elect to utilize the lease/non-lease component combination practical expedient under ASU 2018-11 upon initial application of ASC 842 are required to apply the practical expedient to all new and existing transactions within a class of underlying assets that qualify for the expedient as of the initial application date with a cumulative effect adjustment to beginning retained earnings as of the initial application date for any changes recognized related to existing transactions. Upon adoption of ASU 2016-02 and ASU 2018-11, the Company elected the lessor practical expedient within ASU 2018-11. The Company recognizes revenue under these resident agreements based upon the predominant component, either the lease or non-lease component, of the contracts rather than allocating the consideration and separately accounting for it under ASC Topic 842 and ASC Topic 606. The Company has concluded that the non-lease components of the agreements with respect to its senior living communities are the predominant component of the contract, therefore, the Company recognizes revenue for these residents agreements under ASC Topic 606. The timing and pattern of revenue recognition is substantially the same as that prior to the adoption of these standards. In June 2018, the FASB issued ASU 2018-07, which simplifies several aspects of the accounting for nonemployee share-based payment transactions resulting from expanding the scope of Topic 718, Compensation-Stock Compensation, to include share-based payment transactions for acquiring goods and services from nonemployees. The amendments specify that Topic 718 applies to all share-based payment transactions in which a grantor acquires goods or services to be used or consumed in a grantor’s own operations by issuing share-based payment awards. The amendments also clarify that Topic 718 does not apply to share-based payments used to effectively provide (1) financing to the issuer or (2) awards granted in conjunction with selling goods or services to customers as part of a contract accounted for under Topic 606, Revenue from Contracts with Customers. The Company adopted this guidance effective January 1, 2019. The adoption of this guidance did not have a material impact on its consolidated financial statements and related disclosures. 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 June 2016, the FASB issued Accounting Standards Update (ASU) 2016-13 “ Financial Instruments – Credit Losses (Topic 326): Measurement of credit Losses on Financial Instruments ”, which replaces the existing incurred loss impairment model with an expected credit loss model and requires a financial asset measured at amortized cost to be presented at the net amount expected to be collected. The guidance will be effective for fiscal year beginning after December 15, 2019, which will be the Company's fiscal year 2020, with early adoption is permitted. The Company has not yet determined the effect of the ASU on its results of operations, financial condition or cash flows.

Revenue and Accounts Receivable

Revenue and Accounts Receivable	6 Months Ended
	Jun. 30, 2019
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 net revenue only to the extent that it is probable that a significant reversal in the amount of the cumulative revenue recognized will not occur in a future period. If actual amounts of consideration ultimately received differ from the Company’s estimates, the Company adjusts these estimates, which would affect net revenue in the period such variances become known. Revenue from the Medicare and Medicaid programs accounted for 68.0% the Company's revenue for both the three and six months ended June 30, 2019 , respectively and 68.2% and 68.0% for the three and six months ended June 30, 2018 , respectively. Settlement with Medicare and Medicaid payors for retroactive adjustments due to audits and reviews are considered variable consideration and are included in the determination of the estimated transaction price. These settlements are estimated based on the terms of the payment agreement with the payor, correspondence from the payor and the Company’s historical settlement activity. Consistent with healthcare industry practices, any changes to these revenue estimates are recorded in the period the change or adjustment becomes known based on final settlement. The Company recorded adjustments to revenue which were not material to the Company's consolidated revenue or Interim Financial Statements for the three and six months ended June 30, 2019 and 2018 . 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 7, 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. Senior Living Revenue The Company's senior 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. The Company has elected the lessor practical expedient within ASC 842, Leases ("ASC 842") and recognizes, measures, presents, and discloses the revenue for services under the Company's senior living residency agreements based upon the predominant component, either the lease or nonlease component, of the contracts. The Company has determined that the services included under the Company’s senior living residency agreements have the same timing and pattern of transfer. The Company recognizes revenue under ASC 606, Revenue Recognition from Contracts with Customers ("ASC 606") for its senior residency agreements for which it has estimated that the nonlease components of such residency agreements are the predominant component of the contract. 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 the patient’s care was unusually costly; (b) a low utilization adjustment if the number of visits was fewer than five; (c) a partial payment if the patient transferred to another provider or transferred from another provider before completing the episode; (d) a payment adjustment based upon the level of covered therapy services; (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. 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 the Company’s 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, 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. The estimated payment rates are daily rates for each of the levels of care the Company delivers. The payment is adjusted for an inability to obtain appropriate billing documentation or authorizations acceptable to the payor and other reasons unrelated to credit risk. Additionally, as Medicare hospice revenue is subject to an inpatient cap 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. Revenue for the three and six months ended June 30, 2019 and 2018 is summarized in the following tables: Three Months Ended June 30, 2019 2018 Revenue % of Revenue Revenue % of Revenue Medicaid $ 206,811 35.9 % $ 173,169 34.9 % Medicare 153,187 26.6 136,813 27.6 Medicaid — skilled 31,792 5.5 28,298 5.7 Total Medicaid and Medicare 391,790 68.0 338,280 68.2 Managed care 93,690 16.3 80,150 16.1 Private and other payors (1) 90,171 15.7 77,956 15.7 Revenue $ 575,651 100.0 % $ 496,386 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended June 30, 2019 and 2018. Six Months Ended June 30, 2019 2018 Revenue % of Revenue % of Medicaid $ 401,814 35.7 % $ 340,794 34.5 % Medicare 300,907 26.8 276,127 27.9 Medicaid — skilled 62,243 5.5 55,340 5.6 Total Medicaid and Medicare 764,964 68.0 672,261 68.0 Managed care 183,538 16.3 163,866 16.6 Private and other payors (1) 176,363 15.7 152,393 15.4 Revenue $ 1,124,865 100.0 % $ 988,520 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the six months ended June 30, 2019 and 2018. Balance Sheet Impact Included in the Company’s condensed consolidated balance sheet are contract assets, comprised of billed accounts receivable and unbilled receivables, which are the result of the timing of revenue recognition, billings and cash collections, as well as, contract liabilities, which primarily represent payments the Company receives in advance of services provided. The Company had no material contract liabilities as of June 30, 2019 and December 31, 2018 , or activity during the three and six months ended June 30, 2019 and 2018. Accounts receivable as of June 30, 2019 and December 31, 2018 is summarized in the following table: June 30, 2019 December 31, 2018 Medicaid $ 128,069 $ 117,984 Managed care 62,605 54,682 Medicare 53,232 50,994 Private and other payors 56,755 55,325 300,661 278,985 Less: allowance for doubtful accounts (3,726 ) (2,886 ) Accounts receivable, net $ 296,935 $ 276,099 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

Computation of Net Income Per C

Computation of Net Income Per Common Share	6 Months Ended
	Jun. 30, 2019
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 stockholders of The Ensign Group, Inc. by the weighted average number of outstanding common shares for the period. The computation of diluted net income per share is similar to the computation of basic net income per share except that the denominator is increased to include the number of additional common shares that would have been outstanding if the dilutive potential common shares had been issued. A reconciliation of the numerator and denominator used in the calculation of basic net income per common share follows: Three Months Ended June 30, Six Months Ended June 30, 2019 2018 2019 2018 Numerator: Net income $ 28,925 $ 22,326 $ 56,532 $ 45,619 Less: net income attributable to noncontrolling interests 316 315 551 476 Net income attributable to The Ensign Group, Inc. $ 28,609 $ 22,011 $ 55,981 $ 45,143 Denominator: Weighted average shares outstanding for basic net income per share 53,408 51,880 53,246 51,733 Basic net income per common share attributable to The Ensign Group, Inc. $ 0.54 $ 0.42 $ 1.05 $ 0.87 A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows: Three Months Ended June 30, Six Months Ended June 30, 2019 2018 2019 2018 Numerator: Net income $ 28,925 $ 22,326 $ 56,532 $ 45,619 Less: net income attributable to noncontrolling interests 316 315 551 476 Net income attributable to The Ensign Group, Inc. $ 28,609 $ 22,011 $ 55,981 $ 45,143 Denominator: Weighted average common shares outstanding 53,408 51,880 53,246 51,733 Plus: incremental shares from assumed conversion (1) 2,670 2,371 2,650 2,176 Adjusted weighted average common shares outstanding 56,078 54,251 55,896 53,909 Diluted net income per common share attributable to The Ensign Group, Inc. $ 0.51 $ 0.41 $ 1.00 $ 0.84 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 173 and 322 for the three and six months ended June 30, 2019 , respectively, and 196 and 398 for the three and six months ended June 30, 2018

Fair Value Measurements

Fair Value Measurements	6 Months Ended
	Jun. 30, 2019
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 June 30, 2019 and December 31, 2018 : June 30, 2019 December 31, 2018 Level 1 Level 2 Level 3 Level 1 Level 2 Level 3 Cash and cash equivalents $ 39,042 $ — $ — $ 31,083 $ — $ — The Company's non-financial assets, which includes 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 3, Summary of Significant Accounting Policies for further discussion of the Company's significant accounting policies. Debt Security Investments - Held to Maturity At June 30, 2019 and December 31, 2018 , the Company had approximately $46,932 and $44,850 , 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 June 30, 2019 , the debt security investments were held in AA, A and BBB rated debt securities.

Business Segments

Business Segments	6 Months Ended
	Jun. 30, 2019
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) senior 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 June 30, 2019 , transitional and skilled services included 171 wholly-owned affiliated skilled nursing operations and 27 campuses that provide skilled nursing and rehabilitative care services and senior living services. The Company provided room and board and social services through 56 wholly-owned affiliated senior living operations and 27 campuses as mentioned above. Home health, hospice and home care services were provided to patients through 62 affiliated agencies. As of June 30, 2019 , 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 3 , Summary of Significant Accounting Policies. The Company's CODM does not review assets by segment in his resource allocation and therefore assets by segment are not disclosed below. Segment revenues by major payor source were as follows: Three Months Ended June 30, 2019 Transitional and Skilled Services Senior Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 192,545 $ 10,333 $ 3,933 $ — $ 206,811 35.9 % Medicare 118,807 — 34,380 — 153,187 26.6 Medicaid-skilled 31,792 — — — 31,792 5.5 Subtotal 343,144 10,333 38,313 — 391,790 68.0 Managed care 86,491 — 7,199 — 93,690 16.3 Private and other 39,603 31,713 4,696 14,159 (1) 90,171 15.7 Total revenue $ 469,238 $ 42,046 $ 50,208 $ 14,159 $ 575,651 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended June 30, 2019. Three Months Ended June 30, 2018 Transitional and Skilled Services Senior Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 161,584 $ 8,677 $ 2,908 $ — $ 173,169 34.9 % Medicare 108,237 — 28,576 — 136,813 27.6 Medicaid-skilled 28,298 — — — 28,298 5.7 Subtotal 298,119 8,677 31,484 — 338,280 68.2 Managed care 74,168 — 5,982 — 80,150 16.1 Private and other 36,231 28,487 3,783 9,455 (1) 77,956 15.7 Total revenue $ 408,518 $ 37,164 $ 41,249 $ 9,455 $ 496,386 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended June 30, 2018. Six Months Ended June 30, 2019 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 373,839 $ 20,135 $ 7,840 $ — $ 401,814 35.7 % Medicare 235,508 — 65,399 — 300,907 26.8 Medicaid-skilled 62,243 — — — 62,243 5.5 Subtotal 671,590 20,135 73,239 — 764,964 68.0 Managed care 169,663 — 13,875 — 183,538 16.3 Private and other 77,243 62,605 9,211 27,304 (1) 176,363 15.7 Total revenue $ 918,496 $ 82,740 $ 96,325 $ 27,304 $ 1,124,865 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the six months ended June 30, 2019. Six Months Ended June 30, 2018 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 318,095 $ 16,941 $ 5,758 $ — $ 340,794 34.5 % Medicare 220,190 — 55,937 — 276,127 27.9 Medicaid-skilled 55,340 — — — 55,340 5.6 Subtotal 593,625 16,941 61,695 — 672,261 68.0 Managed care 151,968 — 11,898 — 163,866 16.6 Private and other 69,941 56,336 7,414 18,702 (1) 152,393 15.4 Total revenue $ 815,534 $ 73,277 $ 81,007 $ 18,702 $ 988,520 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the six months ended June 30, 2018. The following table sets forth selected financial data consolidated by business segment: Three Months Ended June 30, 2019 Transitional and Skilled Services (4) Senior Living Services (4) Home Health and Hospice Services All Other (3) Elimination Total Revenue from external customers $ 469,238 $ 42,046 $ 50,208 $ 14,159 $ — $ 575,651 Intersegment revenue (1) 780 — — 2,149 (2,929 ) — Total revenue $ 470,018 $ 42,046 $ 50,208 $ 16,308 $ (2,929 ) $ 575,651 Segment income (loss) (2) $ 56,652 $ 4,821 $ 7,306 $ (30,933 ) $ — $ 37,846 Interest expense, net of interest income $ (3,369 ) Income before provision for income taxes $ 34,477 Depreciation and amortization $ 8,938 $ 2,019 $ 320 $ 1,907 $ — $ 13,184 (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, senior 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 $780 . Including these expenses, home health and hospice services segment income would be $6,526 . Transitional and skilled services, senior living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines that are included in the "All Other" category of $2,149 . (3) General and administrative expense are included in the "All Other" category. (4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment. Three Months Ended June 30, 2018 Transitional and Skilled Services (4) Senior Living Services (4) Home Health and Hospice Services All Other (3) Elimination Total Revenue from external customers $ 408,518 $ 37,164 $ 41,249 $ 9,455 $ — $ 496,386 Intersegment revenue (1) 645 — — 1,112 (1,757 ) — Total revenue $ 409,163 $ 37,164 $ 41,249 $ 10,567 $ (1,757 ) $ 496,386 Segment income (loss) (2) $ 43,210 $ 4,966 $ 6,268 $ (22,669 ) $ — $ 31,775 Interest expense, net of interest income $ (3,307 ) Income before provision for income taxes $ 28,468 Depreciation and amortization $ 7,708 $ 1,863 $ 281 $ 1,769 $ — $ 11,621 (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, senior 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 $645 . Including these expenses, home health and hospice services segment income would be $5,623 . Transitional and skilled services, senior living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines that are included in the "All Other" category of $1,112 . (3) General and administrative expense is included in the "All Other" category. (4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment. Six Months Ended June 30, 2019 Transitional and Skilled Services (4) Senior Living Services (4) Home Health and Hospice Services All Other (3) Elimination Total Revenue from external customers $ 918,496 $ 82,740 $ 96,325 $ 27,304 $ — $ 1,124,865 Intersegment revenue (1) 1,495 — — 3,861 (5,356 ) — Total revenue $ 919,991 $ 82,740 $ 96,325 $ 31,165 $ (5,356 ) $ 1,124,865 Segment income (loss) (2) $ 115,416 $ 9,859 $ 14,174 $ (63,799 ) $ — $ 75,650 Interest expense, net of interest income $ (6,466 ) Income before provision for income taxes $ 69,184 Depreciation and amortization $ 17,552 $ 3,919 $ 580 $ 3,731 $ — $ 25,782 (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, senior 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 $1,495 . Including these expenses, home health and hospice services segment income would be $12,679 . Transitional and skilled services, senior 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 $3,861 . (3) General and administrative expense is included in the "All Other" category. (4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment. Six Months Ended June 30, 2018 Transitional and Skilled Services (4) Senior Living Services (4) Home Health and Hospice Services All Other (3) Elimination Total Revenue from external customers $ 815,534 $ 73,277 $ 81,007 $ 18,702 $ — $ 988,520 Intersegment revenue (1) 1,334 — — 2,194 (3,528 ) — Total revenue $ 816,868 $ 73,277 $ 81,007 $ 20,896 $ (3,528 ) $ 988,520 Segment income (loss) (2) $ 89,405 $ 9,629 $ 12,326 $ (46,606 ) $ — $ 64,754 Interest expense, net of interest income $ (6,472 ) Income before provision for income taxes $ 58,282 Depreciation and amortization $ 15,510 $ 3,460 $ 526 $ 3,747 $ — $ 23,243 (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, senior 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 $1,334 . Including these expenses, home health and hospice services segment income would be $10,992 . Transitional and skilled services, senior living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines that are included in the "All Other" category of $2,194 . (3) General and administrative expense is included in the "All Other" category. (4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment. The Company completed the sale of one of its senior living operations for an aggregate sale price of $1,838

Acquisitions

Acquisitions	6 Months Ended
	Jun. 30, 2019
Business Combinations [Abstract]
Business Combination Disclosure [Text Block]	ACQUISITIONS The acquisition focus of the subsidiaries is to purchase or lease operations that are complementary to the current affiliated operations, accretive to the business or otherwise advance the Company's strategy. The results of all operating subsidiaries are included in the accompanying Interim Financial Statements subsequent to the date of acquisition. Acquisitions are accounted for using the acquisition method of accounting. The Company's affiliated operations also enter into long-term leases that may include options to purchase the facilities. As a result, from time to time, the affiliated operations will acquire facilities that have been operating under third-party leases. During the six months ended June 30, 2019 , the Company expanded its operations through a combination of a long-term lease and real estate purchases, with the addition of seven stand-alone skilled nursing operations, one stand-alone senior living operation, three campus operations, two home health agencies, four 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 1,088 operational skilled nursing beds and 364 operational senior living units to be operated by the Company's affiliated operating subsidiaries. The Company also invested in new ancillary services that are complementary to its existing businesses. The Company entered into a separate operations transfer agreement with the prior operator as part of each transaction. The aggregate purchase price for these acquisitions during the six months ended June 30, 2019 was $65,362 . The fair value of assets for eleven of the acquisitions was concentrated in property and equipment and as such, these transactions were classified as asset acquisitions in accordance with Accounting Standards Codification Topic 805, Clarifying the Definition of a Business (ASC 805). The purchase price for the eleven asset acquisitions was $43,176 , which mainly consisted of building and improvements of $33,900 and land of $7,660 . The fair value of assets for the remaining nine 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 nine business combinations was $22,186 , which mainly consisted of goodwill and indefinite-lived intangible assets of $20,251 . The Company also entered into a note payable with the seller of $924 , which was subsequently paid off in the second quarter of 2019 and included in the payments on revolving credit facility and other debt line item in the consolidated statement of cash flow. As of the date of this filing, the preliminary allocation of the purchase price for the acquisitions in the second quarter was not finalized as necessary valuation information was not yet available. During the second quarter of 2018, all of the fair value of the assets acquired were concentrated in property and equipment and as such, the transactions were classified as asset acquisitions in accordance with ASC 805. During the six months ended June 30, 2018 , the aggregate purchase price for those acquisitions was $55,546 , of which $31,500 was related to an office building acquisition to accommodate its growing Service Center team. The Company’s acquisition strategy has been focused on identifying both opportunistic and strategic acquisitions within its target markets that offer strong opportunities for return. The 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 six months ended June 30, 2019 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 June 30, 2019 condensed consolidated balance sheets of the Company, and the operating results have been included in the condensed consolidated statements of operations of the Company since the dates the Company gained effective control. Subsequent to June 30, 2019 , the Company expanded its operations through long-term leases, with the addition of one stand-alone skilled nursing operation and one stand-alone senior living operation. 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 27 operational skilled nursing beds and 91

Property and Equipment

Property and Equipment	6 Months Ended
	Jun. 30, 2019
Property, Plant and Equipment [Abstract]
Property, Plant and Equipment Disclosure [Text Block]	PROPERTY AND EQUIPMENT— Net Property and equipment, net consist of the following: June 30, 2019 December 31, 2018 Land $ 68,081 $ 60,420 Buildings and improvements 449,763 411,096 Equipment 220,402 202,346 Furniture and fixtures 5,465 5,079 Leasehold improvements 127,345 112,935 Construction in progress 10,195 9,729 881,251 801,605 Less: accumulated depreciation (206,359 ) (182,731 ) Property and equipment, net $ 674,892 $ 618,874 See also Note 8, Acquisitions for information on acquisitions during the six months ended June 30, 2019 and 2018.

Intangible Assets - Net

Intangible Assets - Net	6 Months Ended
	Jun. 30, 2019
Intangible Assets, Net (Excluding Goodwill) [Abstract]
Intangible Assets Disclosure [Text Block]	INTANGIBLE ASSETS — Net Weighted Average Life (Years) June 30, 2019 December 31, 2018 Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Lease acquisition costs 1.7 $ 360 $ (240 ) 120 $ 843 $ (251 ) $ 592 Favorable leases 2.1 534 (316 ) 218 35,650 (8,724 ) 26,926 Assembled occupancy 0.4 3,180 (3,056 ) 124 2,936 (2,870 ) 66 Facility trade name 30.0 733 (330 ) 403 733 (317 ) 416 Customer relationships 16.7 5,110 (2,146 ) 2,964 4,670 (1,670 ) 3,000 Total $ 9,917 $ (6,088 ) $ 3,829 $ 44,832 $ (13,832 ) $ 31,000 Amortization expense was $1,012 and $1,905 for the three and six months ended June 30, 2019 , respectively, and $691 and $1,306 for the three and six months ended June 30, 2018 , respectively. Favorable leases and lease acquisition costs of $26,939 were reclassed to right-of-use assets as of January 1, 2019, as a part of the adoption of ASC 842. See Note 17, Leases . Estimated amortization expense for each of the years ending December 31 is as follows: Year Amount 2019 (remainder) $ 567 2020 345 2021 249 2022 249 2023 237 2024 234 Thereafter 1,948 $ 3,829

Goodwill and Other Indefinite-L

Goodwill and Other Indefinite-Lived Intangible Assets	6 Months Ended
	Jun. 30, 2019
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 anticipates that the majority of total goodwill recognized will be fully deductible for tax purposes as of June 30, 2019 . See further discussion of goodwill acquired at Note 8, Acquisitions . The following table represents activity in goodwill by segment as of and for the six months ended June 30, 2019 : Goodwill Transitional and Skilled Services Senior Living Services Home Health and Hospice Services All Other Total January 1, 2019 $ 45,486 $ 3,958 $ 27,250 $ 3,783 $ 80,477 Additions — — 11,500 5,431 16,931 June 30, 2019 $ 45,486 $ 3,958 $ 38,750 $ 9,214 $ 97,408 Other indefinite-lived intangible assets consists of the following: June 30, 2019 December 31, 2018 Trade name $ 1,373 $ 1,217 Medicare and Medicaid licenses 29,549 26,385 $ 30,922 $ 27,602 As of the date of this filing, the preliminary allocation of the purchase price for the acquisitions in the second quarter, mentioned in Note 8, Acquisitions

Restricted and Other Assets

Restricted and Other Assets	6 Months Ended
	Jun. 30, 2019
Other Assets [Abstract]
Other Assets Disclosure [Text Block]	RESTRICTED AND OTHER ASSETS Restricted and other assets consist of the following: June 30, 2019 December 31, 2018 Debt issuance costs, net $ 1,442 $ 1,892 Long-term insurance losses recoverable asset 7,747 6,969 Deposits with landlords 4,148 8,694 Capital improvement reserves with landlords and lenders 3,535 3,196 Note receivable from sale of ancillary business 71 93 Restricted and other assets $ 16,943 $ 20,844 Included in restricted and other assets as of June 30, 2019 and December 31, 2018 are anticipated insurance recoveries related to the Company's workers' compensation, general and professional liability claims that are recorded on a gross rather than net basis in accordance with an Accounting Standards Update issued by the FASB. Prepaid rent of $5,220 , previously included in deposits with landlords above, were reclassed to right-of-use assets as of January 1, 2019, as part of the adoption of ASC 842. See Note 17, Leases .

Other Accrued Liabilities

Other Accrued Liabilities	6 Months Ended
	Jun. 30, 2019
Accrued Liabilities [Abstract]
Other Liabilities Disclosure [Text Block]	OTHER ACCRUED LIABILITIES Other accrued liabilities consist of the following: June 30, 2019 December 31, 2018 Quality assurance fee $ 5,639 $ 5,375 Refunds payable 27,477 25,118 Resident advances 4,607 8,495 Cash held in trust for patients 2,842 2,824 Resident deposits 7,753 6,665 Dividends payable 2,559 2,525 Property taxes 7,669 9,426 Other 11,270 9,356 Other accrued liabilities $ 69,816 $ 69,784

Income Taxes

Income Taxes	6 Months Ended
	Jun. 30, 2019
Income Tax Disclosure [Abstract]
Income Tax Disclosure [Text Block]	INCOME TAXES The Company recorded income tax expense of $12,652 and $12,663 during the six months ended June 30, 2019 and 2018 , respectively, or 18.3% of earnings before income taxes for the six months ended June 30, 2019 , compared to 21.7% for the six months ended June 30, 2018 . The effective tax rate for both six month periods include excess tax benefits from stock-based compensation which were offset by non-deductible expenses including non-deductible compensation. The Company is not currently under examination by any major income tax jurisdiction. During 2019, the statutes of limitations will lapse on the Company's 2015 Federal tax year and certain 2014 and 2015 state tax years. The Company does not believe the Federal or state statute lapses or any other event will significantly impact the balance of unrecognized tax benefits in the next twelve months. The net balance of unrecognized tax benefits was not material to the Interim Financial Statements for the six months ended June 30, 2019 and 2018 . The Company implemented ASC 842 as described in the Summary of Significant Accounting Policies. The new lease standard reduced net deferred assets by $3,044

Debt

Debt	6 Months Ended
	Jun. 30, 2019
Debt Disclosure [Abstract]
Debt Disclosure [Text Block]	DEBT Long-term debt consists of the following: June 30, 2019 December 31, 2018 Term loan with SunTrust $ 109,375 $ 113,125 Revolving credit facility with SunTrust 50,000 10,000 Mortgage loans and promissory note 121,664 122,955 281,039 246,080 Less: current maturities (10,153 ) (10,105 ) Less: debt issuance costs (2,707 ) (2,840 ) $ 268,179 $ 233,135 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 . 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 pays 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 5.00% 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 June 30, 2019 , the Company's operating subsidiaries had $159,375 outstanding under the Credit Facility. The outstanding balance on the term loan was $109,375 , of which $7,500 is classified as short-term and the remaining $101,875 is classified as long-term. The outstanding balance on the revolving Credit Facility was $50,000 , which is classified as long-term. The Company was in compliance with all loan covenants as of June 30, 2019 . As of July 30, 2019 , there was approximately $111,250 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 June 30, 2019 , the Company's operating subsidiaries had $121,664 outstanding under the mortgage loans and note, of which $2,653 is classified as short-term and the remaining $119,011 is classified as long-term. The Company was in compliance with all loan covenants as of June 30, 2019 . Based on Level 2, the carrying value of the Company's long-term debt is considered to approximate the fair value of such debt for all periods presented based upon the interest rates that the Company believes it can currently obtain for similar debt. Off-Balance Sheet Arrangements During the six months ended June 30, 2019 , the Company increased its outstanding letters of credit by $560 . As of June 30, 2019 , the Company had approximately $5,342

Options and Awards

Options and Awards	6 Months Ended
	Jun. 30, 2019
Options and Awards [Abstract]
Share-based Payment Arrangement [Text Block]	OPTIONS AND AWARDS Stock-based compensation expense consists of share-based payment awards made to employees and directors, including employee stock options and restricted stock awards, based on estimated fair values. As stock-based compensation expense recognized in the Company’s condensed consolidated statements of income for the three and six months ended June 30, 2019 and 2018 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. Stock Options 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 three 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 June 30, 2019 , there were 3,908 unissued shares of common stock available for issuance under this plan. The Company uses the Black-Scholes option-pricing model to recognize the value of stock-based compensation expense for all share-based payment awards. Determining the appropriate fair-value model and calculating the fair value of stock-based awards at the grant date requires considerable judgment, including estimating stock price volatility, expected option life and forfeiture rates. The Company develops estimates based on historical data and market information, which can change significantly over time. The Company granted 399 options and 194 restricted stock awards from the 2017 Plan during the six months ended June 30, 2019 . The Company used the following assumptions for stock options granted during the three months ended June 30, 2019 and 2018 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2019 258 2.1% 6.3 years 34.0% 0.4% 2018 227 2.7% 6.2 years 32.0% 0.5% The Company used the following assumptions for stock options granted during the six months ended June 30, 2019 and 2018 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2019 399 2.2% 6.3 years 33.9% 0.3% 2018 395 2.7% 6.2 years 32.0% 0.6% For the six months ended June 30, 2019 and 2018 , 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 2019 399 $ 53.67 $ 19.35 2018 395 $ 32.33 $ 11.15 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 June 30, 2019 and 2018 and therefore, the intrinsic value was $0 at the date of grant. The following table represents the employee stock option activity during the six months ended June 30, 2019 : Number of Options Outstanding Weighted Average Exercise Price Number of Options Vested Weighted Average Exercise Price of Options Vested January 1, 2019 4,188 $ 17.35 2,431 $ 12.37 Granted 399 53.67 Forfeited (27 ) 26.16 Exercised (531 ) 10.45 June 30, 2019 4,029 $ 21.80 2,407 $ 13.88 The following summary information reflects stock options outstanding, vested and related details as of June 30, 2019 : 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 40 $ 83 0 40 2010 4.77 - 4.96 50 122 1 50 2011 5.90 - 7.99 80 274 2 80 2012 6.56 - 7.96 217 797 3 217 2013 7.98 - 11.49 355 1,712 4 355 2014 10.55 - 18.94 1,049 5,953 5 1,025 2015 21.47 - 25.24 431 3,926 6 272 2016 18.79 - 19.89 381 2,652 7 180 2017 18.64 - 22.90 420 2,931 8 118 2018 26.53 - 38.59 607 7,346 9 70 2019 $53.50 - $53.99 399 7,724 10 — Total 4,029 $ 33,520 2,407 Restricted Stock Awards The Company granted 89 and 194 restricted stock awards during the three and six months ended June 30, 2019 , respectively. The Company granted 217 and 274 restricted stock awards during the three and six months ended June 30, 2018 , 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 six months ended June 30, 2019 and 2018 ranged from $41.68 to $53.99 and $23.61 to $36.61 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 June 30, 2019 and changes during the six months ended June 30, 2019 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2019 573 $ 29.31 Granted 194 52.16 Vested (166 ) 38.79 Forfeited (5 ) 28.67 Nonvested at June 30, 2019 596 $ 34.13 During the three and six months ended June 30, 2019 , the Company granted 8 and 14 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 $41.68 to $51.78 based on the market price on the grant date. Share-based compensation expense recognized for the Company's equity incentive plans for the three and six months ended June 30, 2019 and 2018 was as follows: Three Months Ended June 30, Six Months Ended June 30, 2019 2018 2019 2018 Share-based compensation expense related to stock options $ 1,479 $ 1,292 $ 2,822 $ 2,508 Share-based compensation expense related to restricted stock awards 1,199 675 2,197 1,253 Share-based compensation expense related to stock options and restricted stock awards to non-employee directors 388 210 659 387 Total $ 3,066 $ 2,177 $ 5,678 $ 4,148 In future periods, the Company expects to recognize approximately $17,760 and $18,860 in share-based compensation expense for unvested options and unvested restricted stock awards, respectively, that were outstanding as of June 30, 2019 . Future share-based compensation expense will be recognized over 3.9 weighted average years for both unvested options and restricted stock awards. There were 1,622 unvested and outstanding options at June 30, 2019 , of which 1,517 are expected to vest. The weighted average contractual life for options outstanding, vested and expected to vest at June 30, 2019 was 6.1 years. The aggregate intrinsic value of options outstanding, vested, expected to vest and exercised as of June 30, 2019 and December 31, 2018 is as follows: Options June 30, 2019 December 31, 2018 Outstanding $ 141,531 $ 89,806 Vested 103,589 64,222 Expected to vest 32,597 22,963 Exercisable 21,118 27,646 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 did no t grant any new restricted shares during the six months ended June 30, 2019 and 2018 . These awards generally vest over a period of three to five years , or upon the occurrence of certain prescribed events. During both the six months ended June 30, 2019 and 2018 , 976 restricted stock awards vested. The Company granted 221 stock options during the six months ended June 30, 2018 . The Company did no t grant any new stock options during the six months ended June 30, 2019 . The value of the stock options and restricted stock awards is tied to the value of the common stock of the subsidiary. The awards can be put to the Company at various prescribed dates, which in no event is earlier than six months after vesting of the restricted awards or exercise of the stock options. The Company can also call the awards, generally upon employee termination. The grant-date fair value of the awards is recognized as compensation expense over the relevant vesting periods, with a corresponding adjustment to noncontrolling interests. The grant value was determined based on an independent valuation of the subsidiary shares. For the three and six months ended June 30, 2019 , the Company expensed $236 and $577 , respectively, in share-based compensation related to the Subsidiary Equity Plan. For the three and six months ended June 30, 2018 , the Company expensed $343 and $681 , 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 June 30, 2019 and 2018 is 328 and 235 , respectively. During the second quarter of 2019, the Company repurchased 469 shares of common stock under the Subsidiary Equity Plan for $2,293 . The Company subsequently sold the shares and received net proceeds of $2,293 .

Leases

Leases	6 Months Ended
	Jun. 30, 2019
Leases [Abstract]
Lessee, Operating Leases [Text Block]	LEASES The Company leases from CareTrust REIT, Inc. (CareTrust) real property associated with 93 affiliated skilled nursing, senior 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 $15,057 and $29,896 for the three and six months ended June 30, 2019 , respectively, and $14,538 and $28,956 for the three and six months ended June 30, 2018 , 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 June 30, 2019 . 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 $37,211 and $73,181 for the three and six months ended June 30, 2019 , respectively, and $34,476 and $68,640 for the three and six months ended June 30, 2018 , respectively. Thirty-nine of the Company’s affiliated facilities, excluding the facilities that are operated under the Master Leases with CareTrust, are operated under seven 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. Impact of New Leases Guidance As described further in Note 3, Summary of Significant Accounting Policies , the Company adopted Topic 842, Leases , as of January 1, 2019. Prior period amounts have not been adjusted and continue to be reported in accordance with our historic accounting under Topic 840. All of the Company's leases are classified as operating leases. The components of lease assets and liabilities are included in the condensed consolidated balance sheets. The following tables summarize the impact of the adoption of the new lease accounting guidance on the Company’s condensed consolidated balance sheet as of June 30, 2019 and the condensed consolidated statement of income for the three and six months ended June 30, 2019 , as if the previous accounting guidance was in effect for comparison purposes. There was no impact to the condensed consolidated statement of cash flows for the six months ended June 30, 2019 . The following table summarizes the impact of the adoption of the new lease accounting guidance on the Company’s condensed consolidated balance sheet as of January 1, 2019 . Balance at December 31, 2018 Adjustments due to new lease guidance January 1, 2019 Balance at June 30, 2019 Total assets (1) $ 1,181,958 $ 1,015,937 $ 2,197,895 $ 2,321,521 Total liabilities (2) 579,618 1,006,907 1,586,525 1,644,214 Total equity 602,340 9,030 611,370 677,307 (1) Adjustment in assets includes the reclassification of intangible assets, prepaid rent and deferred rent into right-of-use assets and the decrease in deferred tax assets due to the removal of deferred gain related to sale-leaseback as of January 1, 2019. (2) Adjustment in liabilities includes the reclassification of other liabilities into lease liabilities and the removal of deferred gain related to sale-lease back as of January 1, 2019. The components of operating lease expense (1) , are as follows: Three Months Ended June 30, Six Months Ended June 30, 2019 2018 2019 2018 Rent - cost of services (2) $ 37,060 $ 34,472 $ 72,846 $ 68,322 General and administrative expense 151 168 335 318 Depreciation and amortization (3) 495 495 990 990 $ 37,706 $ 35,135 $ 74,171 $ 69,630 (1) Operating lease expenses include short-term leases and variable lease costs, which are immaterial. (2) Rent- cost of services includes the amortization of deferred rent of $434 and $688 for the three and six months ended June 30, 2019 , respectively. (3) Depreciation and amortization is related to the amortization of favorable and direct lease costs. Future minimum lease payments for all leases as of June 30, 2019 are as follows: Year Amount 2019 (remainder) $ 74,865 2020 149,083 2021 148,086 2022 146,540 2023 144,852 2024 142,880 Thereafter 912,928 Total lease payments 1,719,234 Less: present value adjustment (646,138 ) Less: variable rent (25,265 ) Present value of total lease liabilities 1,047,831 Less: current lease liabilities (59,686 ) Long-term operating lease liabilities $ 988,145 Future minimum lease payments for all leases as of December 31, 2018 were as follows: Year Amount 2019 $ 142,497 2020 141,536 2021 140,524 2022 139,018 2023 137,349 Thereafter 967,027 Total lease payments $ 1,667,951 Operating lease liabilities are based on the net present value of the remaining lease payments over the remaining lease term. In determining the present value of lease payments, the Company used its incremental borrowing rate based on the information available at the lease commencement date. As of June 30, 2019 , the weighted average remaining lease term is 12 years and the weighted average discount rate used to determine the operating lease liability is 8.66% .

Commitments and Contingencies

Commitments and Contingencies	6 Months Ended
	Jun. 30, 2019
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. As of June 30, 2019, this matter has been resolved. 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 condensed consolidated balance sheets for any of the periods presented. U.S. Department of Justice Civil Investigative Demand - On May 31, 2018, the Company received a Civil Investigative Demand (CID) from the U.S. Department of Justice stating that it is investigating 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 operated skilled nursing facilities and persons who served as medical directors, advisory board participants or other potential 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 the requirements 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. For example, the Company has been subjected to, and is currently involved in, class action litigation alleging violations of state and federal wage and hour law as related to the alleged failure to pay wages and to timely provide and authorize meal and rest breaks. The Company does not believe that the ultimate resolution of these actions will have a material adverse effect on the Company’s business, cash flows, financial condition or results of operations. A significant increase in the number of these claims or an increase in amounts owing should plaintiffs be successful in their prosecution of these claims, could materially adversely affect the Company’s business, financial condition, results of operations and cash flows. 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 back $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, its independent operating entities, and other post-acute care providers. 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 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 June 30, 2019 , ten 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 June 30, 2019 , 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 and its independent operating entities 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 and its independent operating entities have denied engaging in any illegal conduct and 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 and its independent operating entities entered into a five-year corporate integrity agreement (the CIA) with the Office of Inspector General-HHS. CMS acknowledged 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 required that the Company and its independent operating entities 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. In the first quarter of 2019, the Company received notice from the OIG that the Company’s five-year CIA with the OIG has been completed. Upon receipt of the Company’s fifth and final annual report, the OIG confirmed that the term of the CIA is concluded. 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 60.3% and 60.6% of its total accounts receivable as of June 30, 2019 and December 31, 2018 , respectively. Revenue from reimbursement under the Medicare and Medicaid programs accounted for 68.0% of the Company's revenue for both the three and six months ended June 30, 2019 , respectively, and 68.2% and 68.0% of the Company's revenue for the three and six months ended June 30, 2018 , 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 July 30, 2019 , the Company had approximately $1,066 in uninsured cash deposits. All uninsured bank deposits are held at high quality credit institutions.

Common Stock

Common Stock	6 Months Ended
	Jun. 30, 2019
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 expired on February 20, 2019 . The Company did not purchase any shares pursuant to this stock repurchase program.

Significant Accounting Polici_2

Significant Accounting Policies Level 2 (Policies)	6 Months Ended
	Jun. 30, 2019
Accounting Policies [Abstract]
Basis of Presentation	Basis of Presentation — The accompanying Interim Financial Statements have been prepared in accordance with accounting principles generally accepted in the United States (GAAP). The Company is the sole member or stockholder of various consolidated limited liability companies and corporations established to operate various acquired skilled nursing and senior living operations, home health, hospice and home care operations, and related ancillary services. All intercompany transactions and balances have been eliminated in consolidation. The condensed consolidated financial statements include the accounts of all entities controlled by the Company through its ownership of a majority voting interest. The Company presents noncontrolling interests within the equity section of its condensed consolidated balance sheets. The Company presents the amount of consolidated net income that is attributable to The Ensign Group, Inc. and the noncontrolling interest in its condensed consolidated statements of income. The condensed 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, 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 three and six months ended June 30, 2019 and 2018 . The Company completed the sale of one of its senior living operations for a sale price of $1,838 during the first quarter of 2019. 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. The Company presented property and equipment assets of the senior living operation sold as held for sale in the consolidated balance sheet as of December 31, 2018.
Estimates and Assumptions	Estimates and Assumptions — The preparation of Interim Financial Statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the Interim Financial Statements and the reported amounts of revenue and expenses during the reporting periods. The most significant estimates in the Company’s Interim Financial Statements relate to revenue, intangible assets and goodwill, impairment of long-lived assets, general and professional liability, workers' compensation and healthcare claims included in accrued self-insurance liabilities, and income taxes. Actual results could differ from those estimates.
Fair Value of Financial Instruments	Fair Value of Financial Instruments — The Company’s financial instruments consist principally of cash and cash equivalents, debt security investments, accounts receivable, insurance subsidiary deposits, accounts payable and borrowings. The Company believes all of the financial instruments’ recorded values approximate fair values because of their nature or respective short durations.
Revenue Recognition	Revenue Recognition — On January 1, 2018, the Company adopted Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (ASC 606) applying the modified retrospective method. 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 4, 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 4, Revenue and Accounts Receivable .
Property and Equipment	Property and Equipment — Property and equipment are initially recorded at their historical cost. Repairs and maintenance are expensed as incurred. Depreciation is computed using the straight-line method over the estimated useful lives of the depreciable assets (ranging from three to 59 years ). Leasehold improvements are amortized on a straight-line basis over the shorter of their estimated useful lives or the remaining lease term. Impairment of Long-Lived Assets — 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 $705 and $860 during the three and six months ended June 30, 2018 . The Company did no t record an impairment charge during the three and six months ended June 30, 2019 .
Leases and Leasehold Improvements	Leases and Leasehold Improvements - The Company leases skilled nursing facilities, senior living facilities and commercial office space. On January 1, 2019, the Company adopted Accounting Standards Codification Topic 842, Leases (ASC 842), electing the transition method that allows it to apply the standard as of the adoption date and record a cumulative adjustment in retained earnings. The Company determines if an arrangement is a lease at the inception of each lease. At the inception of each lease, the Company performs an evaluation to determine whether the lease should be classified as an operating or finance lease. Operating leases are included in right-of-use assets, current lease liabilities and long-term lease liabilities on the Company's condensed consolidated balance sheet. As the Company's leases do not provide an implicit rate, the Company uses its incremental borrowing rate based on the information available at lease commencement date in determining the present value of future lease payments. The Company estimates this rate based on prevailing financial market conditions, comparable company and credit analysis, and management judgment. The Company records rent expense for operating leases on a straight-line basis over the term of the lease. The lease term used for straight-line rent expense is calculated from the date the Company is given control of the leased premises through the end of the lease term. The lease term excludes lease renewals as the renewal rents are not at a bargain, there are no economic penalties for the Company to renew the lease, and it is not reasonably assured that the Company will exercise the extension options. The lease term used for this evaluation also provides the basis for establishing depreciable lives for buildings subject to lease and leasehold improvements. The Company recognizes lease expense for leases with an initial term of 12 months or less on a straight-line basis over the lease term. These leases are not recorded on the condensed consolidated balance sheet. Certain of the Company's lease agreements include rental payments that are adjusted periodically for inflation. The lease agreements do not contain any material residual value guarantees or material restrictive covenants. The Company does not have material subleases. See further discussion at Note 17, Leases .
Intangible Assets and Goodwill	Intangible Assets and Goodwill — Definite-lived intangible assets consist primarily of patient base, facility trade names and customer relationships. 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. The Company did no t identify any goodwill or intangible assets impairment during the three and six months ended June 30, 2019 and 2018 . See further discussion at Note 11, 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 condensed consolidated balance sheets. The Captive is subject to certain statutory requirements as an insurance provider. The Company’s policy is to accrue amounts equal to the actuarially estimated costs to settle open claims of insureds, as well as an estimate of the cost of insured claims that have been incurred but not reported. The Company develops information about the size of the ultimate claims based on historical experience, current industry information and actuarial analysis, and evaluates the estimates for claim loss exposure on a quarterly basis. Accrued general liability and professional malpractice liabilities on an undiscounted basis, net of anticipated insurance recoveries, were $45,106 and $42,635 as of June 30, 2019 and December 31, 2018 , respectively. The Company’s operating subsidiaries are self-insured for workers’ compensation in California. To protect itself against loss exposure in California with this policy, the Company has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington 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 benefit payments 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. Accrued workers’ compensation liabilities are recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets and were $25,317 and $24,624 as of June 30, 2019 and December 31, 2018 , respectively. In addition, the Company has recorded an asset and equal liability of $7,747 and $6,969 at June 30, 2019 and December 31, 2018 , 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 12, Restricted and Other Assets. The Company self-funds medical (including prescription drugs) and dental healthcare benefits to the majority of its employees. The Company is fully liable for all financial and legal aspects of these benefit plans. To protect itself against loss exposure with this policy, the Company has purchased individual stop-loss insurance coverage that insures individual claims that exceed $300 for each covered person with an additional one-time aggregate individual stop loss deductible of $75 . Beginning 2016, the Company's policy does not include the additional one-time aggregate individual stop loss deductible of $75 . The Company’s accrued liability under these plans recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets was $6,376 and $5,823 as of June 30, 2019 and December 31, 2018 , respectively. The Company believes that adequate provision has been made in the Interim Financial Statements for liabilities that may arise out of patient care, workers’ compensation, healthcare benefits and related services provided to date. The amount of the Company’s reserves was determined based on an estimation process that uses information obtained from both company-specific and industry data. This estimation process requires the Company to continuously monitor and evaluate the life cycle of the claims. Using data obtained from this monitoring and the Company’s assumptions about emerging trends, the Company, with the assistance of an independent actuary, develops information about the size of ultimate claims based on the Company’s historical experience and other available industry information. The most significant assumptions used in the estimation process include determining the trend in costs, the expected cost of claims incurred but not reported and the expected costs to settle or pay damage awards with respect to unpaid claims. The self-insured liabilities are based upon estimates, and while management believes that the estimates of loss are reasonable, the ultimate liability may be in excess of or less than the recorded amounts. Due to the inherent volatility of actuarially determined loss estimates, it is reasonably possible that the Company could experience changes in estimated losses that could be material to net income. If the Company’s actual liability exceeds its estimates of loss, its future earnings, cash flows and financial condition would be adversely affected.
Income Taxes	Income Taxes — Deferred tax assets and liabilities are established for temporary differences between the financial reporting basis and the tax basis of the Company’s assets and liabilities at tax rates in effect when such temporary differences are expected to reverse. The Company generally expects to fully utilize its deferred tax assets; however, when necessary, the Company records a valuation allowance to reduce its net deferred tax assets to the amount that is more likely than not to be realized. In determining the need for a valuation allowance or the need for and magnitude of liabilities for uncertain tax positions, the Company makes certain estimates and assumptions. These estimates and assumptions are based on, among other things, knowledge of operations, markets, historical trends and likely future changes and, when appropriate, the opinions of advisors with knowledge and expertise in certain fields. Due to certain risks associated with the Company’s estimates and assumptions, actual results could differ.
Noncontrolling Interest	Noncontrolling Interest — The noncontrolling interest in a subsidiary is initially recognized at estimated fair value on the acquisition date and is presented within total equity in the Company's condensed consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to The Ensign Group, Inc. in its condensed consolidated statements of income and net income per share is calculated based on net income attributable to The Ensign Group, Inc.'s stockholders. The carrying amount of the noncontrolling interest is adjusted based on an allocation of subsidiary earnings based on ownership interest.
Share-Based Compensation	Share-Based Compensation — The Company measures and recognizes compensation expense for all share-based payment awards made to employees and directors including employee stock options based on estimated fair values, ratably over the requisite service period of the award. Net income has been reduced as a result of the recognition of the fair value of all stock options and restricted stock awards issued, the amount of which is contingent upon the number of future grants and other variables.
Recent Accounting Pronouncements	Recent Accounting Pronouncements — Except for rules and interpretive releases of the Securities and Exchange Commission (SEC) under authority of federal securities laws and a limited number of grandfathered standards, the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) is the sole source of authoritative GAAP literature recognized by the FASB and applicable to the Company. For any new pronouncements announced, the Company considers whether the new pronouncements could alter previous generally accepted accounting principles and determines whether any new or modified principles will have a material impact on the Company's reported financial position or operations in the near term. The applicability of any standard is subject to the formal review of the Company's financial management and certain standards are under consideration. Recent Accounting Standards Adopted by the Company In 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, which among other things, allows the Company to carry forward the historical lease classification. The new standard also provides practical expedients for an entity’s ongoing accounting. The Company has made an accounting policy 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 right-of-use assets and lease liabilities of $1,051,148 and $1,029,240 , respectively, on its condensed consolidated balance sheets as of January 1, 2019. The Company recorded an adjustment, net of tax, of $9,030 to retained earnings, on the adoption date, related to a deferred gain on a previous sale-leaseback transaction, which resulted in an increase in rent expense of $658 annually, as we are no longer able to recognize the gain in our consolidated statement of income as a result of the new lease standard. In addition, initial direct costs associated with its lease agreements and favorable lease assets of $26,939 were classified into right-of-use assets on the adoption date. The standard does not materially affect the Company's consolidated net earnings or have a notable impact on liquidity or debt-covenant compliance under the current agreements. See further discussion at Note 17, Leases . Prior to the adoption of ASC 842, the Company recognized revenue related to its senior living residency agreements in accordance with the provisions of ASC 840, Leases ("ASC 840"). Subsequent to the adoption of ASU 2016-02, Leases , lessors are required to separately recognize and measure the lease component of a contract with a customer utilizing the provisions of ASC 842 and the non-lease components utilizing the provisions of ASC 606, Revenue from Contracts with Customers . To separately account for the components, the transaction price is allocated among the components based upon the estimated stand alone selling prices of the components. Additionally, certain components of a contract which were previously included within the lease element recognized in accordance with ASC 840 prior to the adoption of ASU 2016-02 (such as common area maintenance services, other basic services, and executory costs) are recognized as non-lease components subject to the provisions of ASC 606 subsequent to the adoption of ASU 2016-02. Entities are required to recognize a cumulative effect adjustment to beginning retained earnings as of the initial application date of ASU 2016-02 for changes to amounts recognized for these certain components for the transition from ASC 840 to ASC 606. However, entities are permitted to elect the practical expedient under ASU 2018-11, Leases , allowing lessors to not separate non-lease components from the associated lease components when certain criteria are met. Entities that elect to utilize the lease/non-lease component combination practical expedient under ASU 2018-11 upon initial application of ASC 842 are required to apply the practical expedient to all new and existing transactions within a class of underlying assets that qualify for the expedient as of the initial application date with a cumulative effect adjustment to beginning retained earnings as of the initial application date for any changes recognized related to existing transactions. Upon adoption of ASU 2016-02 and ASU 2018-11, the Company elected the lessor practical expedient within ASU 2018-11. The Company recognizes revenue under these resident agreements based upon the predominant component, either the lease or non-lease component, of the contracts rather than allocating the consideration and separately accounting for it under ASC Topic 842 and ASC Topic 606. The Company has concluded that the non-lease components of the agreements with respect to its senior living communities are the predominant component of the contract, therefore, the Company recognizes revenue for these residents agreements under ASC Topic 606. The timing and pattern of revenue recognition is substantially the same as that prior to the adoption of these standards. In June 2018, the FASB issued ASU 2018-07, which simplifies several aspects of the accounting for nonemployee share-based payment transactions resulting from expanding the scope of Topic 718, Compensation-Stock Compensation, to include share-based payment transactions for acquiring goods and services from nonemployees. The amendments specify that Topic 718 applies to all share-based payment transactions in which a grantor acquires goods or services to be used or consumed in a grantor’s own operations by issuing share-based payment awards. The amendments also clarify that Topic 718 does not apply to share-based payments used to effectively provide (1) financing to the issuer or (2) awards granted in conjunction with selling goods or services to customers as part of a contract accounted for under Topic 606, Revenue from Contracts with Customers. The Company adopted this guidance effective January 1, 2019. The adoption of this guidance did not have a material impact on its consolidated financial statements and related disclosures. 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 June 2016, the FASB issued Accounting Standards Update (ASU) 2016-13 “ Financial Instruments – Credit Losses (Topic 326): Measurement of credit Losses on Financial Instruments ”, which replaces the existing incurred loss impairment model with an expected credit loss model and requires a financial asset measured at amortized cost to be presented at the net amount expected to be collected. The guidance will be effective for fiscal year beginning after December 15, 2019, which will be the Company's fiscal year 2020, with early adoption is permitted. The Company has not yet determined the effect of the ASU on its results of operations, financial condition or cash flows.

Revenue and Accounts Receivab_2

Revenue and Accounts Receivable (Tables)	6 Months Ended
	Jun. 30, 2019
REVENUE AND ACCOUNTS RECEIVABLE [Abstract]
Disaggregation of Revenue [Table Text Block]	Revenue for the three and six months ended June 30, 2019 and 2018 is summarized in the following tables: Three Months Ended June 30, 2019 2018 Revenue % of Revenue Revenue % of Revenue Medicaid $ 206,811 35.9 % $ 173,169 34.9 % Medicare 153,187 26.6 136,813 27.6 Medicaid — skilled 31,792 5.5 28,298 5.7 Total Medicaid and Medicare 391,790 68.0 338,280 68.2 Managed care 93,690 16.3 80,150 16.1 Private and other payors (1) 90,171 15.7 77,956 15.7 Revenue $ 575,651 100.0 % $ 496,386 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended June 30, 2019 and 2018. Six Months Ended June 30, 2019 2018 Revenue % of Revenue % of Medicaid $ 401,814 35.7 % $ 340,794 34.5 % Medicare 300,907 26.8 276,127 27.9 Medicaid — skilled 62,243 5.5 55,340 5.6 Total Medicaid and Medicare 764,964 68.0 672,261 68.0 Managed care 183,538 16.3 163,866 16.6 Private and other payors (1) 176,363 15.7 152,393 15.4 Revenue $ 1,124,865 100.0 % $ 988,520 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the six months ended June 30, 2019 and 2018.
Schedule of Accounts, Notes, Loans and Financing Receivable [Table Text Block]	Accounts receivable as of June 30, 2019 and December 31, 2018 is summarized in the following table: June 30, 2019 December 31, 2018 Medicaid $ 128,069 $ 117,984 Managed care 62,605 54,682 Medicare 53,232 50,994 Private and other payors 56,755 55,325 300,661 278,985 Less: allowance for doubtful accounts (3,726 ) (2,886 ) Accounts receivable, net $ 296,935 $ 276,099

Computation of Net Income Per_2

Computation of Net Income Per Common Share (Tables)	6 Months Ended
	Jun. 30, 2019
COMPUTATION OF NET INCOME PER COMMON SHARE [Abstract]
Schedule of Earnings Per Share, Basic, by Common Class, Including Two Class Method [Table Text Block]	A reconciliation of the numerator and denominator used in the calculation of basic net income per common share follows: Three Months Ended June 30, Six Months Ended June 30, 2019 2018 2019 2018 Numerator: Net income $ 28,925 $ 22,326 $ 56,532 $ 45,619 Less: net income attributable to noncontrolling interests 316 315 551 476 Net income attributable to The Ensign Group, Inc. $ 28,609 $ 22,011 $ 55,981 $ 45,143 Denominator: Weighted average shares outstanding for basic net income per share 53,408 51,880 53,246 51,733 Basic net income per common share attributable to The Ensign Group, Inc. $ 0.54 $ 0.42 $ 1.05 $ 0.87
Schedule of Earnings Per Share, Diluted, by Common Class, Including Two Class Method [Table Text Block]	A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows: Three Months Ended June 30, Six Months Ended June 30, 2019 2018 2019 2018 Numerator: Net income $ 28,925 $ 22,326 $ 56,532 $ 45,619 Less: net income attributable to noncontrolling interests 316 315 551 476 Net income attributable to The Ensign Group, Inc. $ 28,609 $ 22,011 $ 55,981 $ 45,143 Denominator: Weighted average common shares outstanding 53,408 51,880 53,246 51,733 Plus: incremental shares from assumed conversion (1) 2,670 2,371 2,650 2,176 Adjusted weighted average common shares outstanding 56,078 54,251 55,896 53,909 Diluted net income per common share attributable to The Ensign Group, Inc. $ 0.51 $ 0.41 $ 1.00 $ 0.84 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 173 and 322 for the three and six months ended June 30, 2019 , respectively, and 196 and 398 for the three and six months ended June 30, 2018

Fair Value Measurements (Tables

Fair Value Measurements (Tables)	6 Months Ended
	Jun. 30, 2019
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 June 30, 2019 and December 31, 2018 : June 30, 2019 December 31, 2018 Level 1 Level 2 Level 3 Level 1 Level 2 Level 3 Cash and cash equivalents $ 39,042 $ — $ — $ 31,083 $ — $ —

Business Segments (Tables)

Business Segments (Tables)	6 Months Ended
	Jun. 30, 2019
Segment Reporting [Abstract]
Reconciliation of Revenue from Segments to Consolidated [Table Text Block]	Segment revenues by major payor source were as follows: Three Months Ended June 30, 2019 Transitional and Skilled Services Senior Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 192,545 $ 10,333 $ 3,933 $ — $ 206,811 35.9 % Medicare 118,807 — 34,380 — 153,187 26.6 Medicaid-skilled 31,792 — — — 31,792 5.5 Subtotal 343,144 10,333 38,313 — 391,790 68.0 Managed care 86,491 — 7,199 — 93,690 16.3 Private and other 39,603 31,713 4,696 14,159 (1) 90,171 15.7 Total revenue $ 469,238 $ 42,046 $ 50,208 $ 14,159 $ 575,651 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended June 30, 2019. Three Months Ended June 30, 2018 Transitional and Skilled Services Senior Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 161,584 $ 8,677 $ 2,908 $ — $ 173,169 34.9 % Medicare 108,237 — 28,576 — 136,813 27.6 Medicaid-skilled 28,298 — — — 28,298 5.7 Subtotal 298,119 8,677 31,484 — 338,280 68.2 Managed care 74,168 — 5,982 — 80,150 16.1 Private and other 36,231 28,487 3,783 9,455 (1) 77,956 15.7 Total revenue $ 408,518 $ 37,164 $ 41,249 $ 9,455 $ 496,386 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the three months ended June 30, 2018. Six Months Ended June 30, 2019 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 373,839 $ 20,135 $ 7,840 $ — $ 401,814 35.7 % Medicare 235,508 — 65,399 — 300,907 26.8 Medicaid-skilled 62,243 — — — 62,243 5.5 Subtotal 671,590 20,135 73,239 — 764,964 68.0 Managed care 169,663 — 13,875 — 183,538 16.3 Private and other 77,243 62,605 9,211 27,304 (1) 176,363 15.7 Total revenue $ 918,496 $ 82,740 $ 96,325 $ 27,304 $ 1,124,865 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the six months ended June 30, 2019. Six Months Ended June 30, 2018 Transitional and Skilled Services Assisted and Independent Living Services Home Health and Hospice Services All Other Total Revenue Revenue % Medicaid $ 318,095 $ 16,941 $ 5,758 $ — $ 340,794 34.5 % Medicare 220,190 — 55,937 — 276,127 27.9 Medicaid-skilled 55,340 — — — 55,340 5.6 Subtotal 593,625 16,941 61,695 — 672,261 68.0 Managed care 151,968 — 11,898 — 163,866 16.6 Private and other 69,941 56,336 7,414 18,702 (1) 152,393 15.4 Total revenue $ 815,534 $ 73,277 $ 81,007 $ 18,702 $ 988,520 100.0 % (1) Private and other payors also includes revenue from all payors generated in other ancillary services for the six months ended June 30, 2018.
Schedule of Segment Reporting Information, by Segment [Table Text Block]	The following table sets forth selected financial data consolidated by business segment: Three Months Ended June 30, 2019 Transitional and Skilled Services (4) Senior Living Services (4) Home Health and Hospice Services All Other (3) Elimination Total Revenue from external customers $ 469,238 $ 42,046 $ 50,208 $ 14,159 $ — $ 575,651 Intersegment revenue (1) 780 — — 2,149 (2,929 ) — Total revenue $ 470,018 $ 42,046 $ 50,208 $ 16,308 $ (2,929 ) $ 575,651 Segment income (loss) (2) $ 56,652 $ 4,821 $ 7,306 $ (30,933 ) $ — $ 37,846 Interest expense, net of interest income $ (3,369 ) Income before provision for income taxes $ 34,477 Depreciation and amortization $ 8,938 $ 2,019 $ 320 $ 1,907 $ — $ 13,184 (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, senior 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 $780 . Including these expenses, home health and hospice services segment income would be $6,526 . Transitional and skilled services, senior living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines that are included in the "All Other" category of $2,149 . (3) General and administrative expense are included in the "All Other" category. (4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment. Three Months Ended June 30, 2018 Transitional and Skilled Services (4) Senior Living Services (4) Home Health and Hospice Services All Other (3) Elimination Total Revenue from external customers $ 408,518 $ 37,164 $ 41,249 $ 9,455 $ — $ 496,386 Intersegment revenue (1) 645 — — 1,112 (1,757 ) — Total revenue $ 409,163 $ 37,164 $ 41,249 $ 10,567 $ (1,757 ) $ 496,386 Segment income (loss) (2) $ 43,210 $ 4,966 $ 6,268 $ (22,669 ) $ — $ 31,775 Interest expense, net of interest income $ (3,307 ) Income before provision for income taxes $ 28,468 Depreciation and amortization $ 7,708 $ 1,863 $ 281 $ 1,769 $ — $ 11,621 (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, senior 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 $645 . Including these expenses, home health and hospice services segment income would be $5,623 . Transitional and skilled services, senior living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines that are included in the "All Other" category of $1,112 . (3) General and administrative expense is included in the "All Other" category. (4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment. Six Months Ended June 30, 2019 Transitional and Skilled Services (4) Senior Living Services (4) Home Health and Hospice Services All Other (3) Elimination Total Revenue from external customers $ 918,496 $ 82,740 $ 96,325 $ 27,304 $ — $ 1,124,865 Intersegment revenue (1) 1,495 — — 3,861 (5,356 ) — Total revenue $ 919,991 $ 82,740 $ 96,325 $ 31,165 $ (5,356 ) $ 1,124,865 Segment income (loss) (2) $ 115,416 $ 9,859 $ 14,174 $ (63,799 ) $ — $ 75,650 Interest expense, net of interest income $ (6,466 ) Income before provision for income taxes $ 69,184 Depreciation and amortization $ 17,552 $ 3,919 $ 580 $ 3,731 $ — $ 25,782 (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, senior 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 $1,495 . Including these expenses, home health and hospice services segment income would be $12,679 . Transitional and skilled services, senior 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 $3,861 . (3) General and administrative expense is included in the "All Other" category. (4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment. Six Months Ended June 30, 2018 Transitional and Skilled Services (4) Senior Living Services (4) Home Health and Hospice Services All Other (3) Elimination Total Revenue from external customers $ 815,534 $ 73,277 $ 81,007 $ 18,702 $ — $ 988,520 Intersegment revenue (1) 1,334 — — 2,194 (3,528 ) — Total revenue $ 816,868 $ 73,277 $ 81,007 $ 20,896 $ (3,528 ) $ 988,520 Segment income (loss) (2) $ 89,405 $ 9,629 $ 12,326 $ (46,606 ) $ — $ 64,754 Interest expense, net of interest income $ (6,472 ) Income before provision for income taxes $ 58,282 Depreciation and amortization $ 15,510 $ 3,460 $ 526 $ 3,747 $ — $ 23,243 (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, senior 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 $1,334 . Including these expenses, home health and hospice services segment income would be $10,992 . Transitional and skilled services, senior living services and home health and hospice services segment income excludes intercompany expenses for services provided by the business lines that are included in the "All Other" category of $2,194 . (3) General and administrative expense is included in the "All Other" category. (4) The Company's campuses represent facilities that offer both skilled nursing and senior living services. Revenue and expenses related to skilled nursing and senior living services have been allocated and recorded in the respective reportable segment.

Property and Equipment (Tables)

Property and Equipment (Tables)	6 Months Ended
	Jun. 30, 2019
Property, Plant and Equipment [Abstract]
Property, Plant and Equipment [Table Text Block]	Property and equipment, net consist of the following: June 30, 2019 December 31, 2018 Land $ 68,081 $ 60,420 Buildings and improvements 449,763 411,096 Equipment 220,402 202,346 Furniture and fixtures 5,465 5,079 Leasehold improvements 127,345 112,935 Construction in progress 10,195 9,729 881,251 801,605 Less: accumulated depreciation (206,359 ) (182,731 ) Property and equipment, net $ 674,892 $ 618,874

Intangible Assets - Net (Tables

Intangible Assets - Net (Tables)	6 Months Ended
	Jun. 30, 2019
Intangible Assets, Net (Excluding Goodwill) [Abstract]
Schedule of Finite-Lived Intangible Assets [Table Text Block]	Weighted Average Life (Years) June 30, 2019 December 31, 2018 Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Lease acquisition costs 1.7 $ 360 $ (240 ) 120 $ 843 $ (251 ) $ 592 Favorable leases 2.1 534 (316 ) 218 35,650 (8,724 ) 26,926 Assembled occupancy 0.4 3,180 (3,056 ) 124 2,936 (2,870 ) 66 Facility trade name 30.0 733 (330 ) 403 733 (317 ) 416 Customer relationships 16.7 5,110 (2,146 ) 2,964 4,670 (1,670 ) 3,000 Total $ 9,917 $ (6,088 ) $ 3,829 $ 44,832 $ (13,832 ) $ 31,000
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 (remainder) $ 567 2020 345 2021 249 2022 249 2023 237 2024 234 Thereafter 1,948 $ 3,829

Goodwill and Other Indefinite_2

Goodwill and Other Indefinite-Lived Intangible Assets (Tables)	6 Months Ended
	Jun. 30, 2019
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 six months ended June 30, 2019 : Goodwill Transitional and Skilled Services Senior Living Services Home Health and Hospice Services All Other Total January 1, 2019 $ 45,486 $ 3,958 $ 27,250 $ 3,783 $ 80,477 Additions — — 11,500 5,431 16,931 June 30, 2019 $ 45,486 $ 3,958 $ 38,750 $ 9,214 $ 97,408
Schedule of Acquired Indefinite-lived Intangible Assets by Major Class [Table Text Block]	Other indefinite-lived intangible assets consists of the following: June 30, 2019 December 31, 2018 Trade name $ 1,373 $ 1,217 Medicare and Medicaid licenses 29,549 26,385 $ 30,922 $ 27,602

Restricted and Other Assets (Ta

Restricted and Other Assets (Tables)	6 Months Ended
	Jun. 30, 2019
Other Assets [Abstract]
Schedule of Other Assets [Table Text Block]	Restricted and other assets consist of the following: June 30, 2019 December 31, 2018 Debt issuance costs, net $ 1,442 $ 1,892 Long-term insurance losses recoverable asset 7,747 6,969 Deposits with landlords 4,148 8,694 Capital improvement reserves with landlords and lenders 3,535 3,196 Note receivable from sale of ancillary business 71 93 Restricted and other assets $ 16,943 $ 20,844

Other Accrued Liabilities (Tabl

Other Accrued Liabilities (Tables)	6 Months Ended
	Jun. 30, 2019
Accrued Liabilities [Abstract]
Schedule of Accrued Liabilities [Table Text Block]	Other accrued liabilities consist of the following: June 30, 2019 December 31, 2018 Quality assurance fee $ 5,639 $ 5,375 Refunds payable 27,477 25,118 Resident advances 4,607 8,495 Cash held in trust for patients 2,842 2,824 Resident deposits 7,753 6,665 Dividends payable 2,559 2,525 Property taxes 7,669 9,426 Other 11,270 9,356 Other accrued liabilities $ 69,816 $ 69,784

Debt (Tables)

Debt (Tables)	6 Months Ended
	Jun. 30, 2019
Debt Disclosure [Abstract]
Schedule of Long-term Debt Instruments [Table Text Block]	Long-term debt consists of the following: June 30, 2019 December 31, 2018 Term loan with SunTrust $ 109,375 $ 113,125 Revolving credit facility with SunTrust 50,000 10,000 Mortgage loans and promissory note 121,664 122,955 281,039 246,080 Less: current maturities (10,153 ) (10,105 ) Less: debt issuance costs (2,707 ) (2,840 ) $ 268,179 $ 233,135

Options and Awards (Tables)

Options and Awards (Tables)	6 Months Ended
	Jun. 30, 2019
Options and Awards [Abstract]
Schedule of Share-based Payment Award, Stock Options, Valuation Assumptions [Table Text Block]	The Company used the following assumptions for stock options granted during the three months ended June 30, 2019 and 2018 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2019 258 2.1% 6.3 years 34.0% 0.4% 2018 227 2.7% 6.2 years 32.0% 0.5% The Company used the following assumptions for stock options granted during the six months ended June 30, 2019 and 2018 : Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2019 399 2.2% 6.3 years 33.9% 0.3% 2018 395 2.7% 6.2 years 32.0% 0.6%
Share-based Compensation Arrangement by Share-based Payment Award, Options, Grants in Period, Weighted Average Grant Date Fair Value [Table Text Block]	For the six months ended June 30, 2019 and 2018 , 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 2019 399 $ 53.67 $ 19.35 2018 395 $ 32.33 $ 11.15
Schedule of Common Stock Outstanding Roll Forward [Table Text Block]	The following table represents the employee stock option activity during the six months ended June 30, 2019 : Number of Options Outstanding Weighted Average Exercise Price Number of Options Vested Weighted Average Exercise Price of Options Vested January 1, 2019 4,188 $ 17.35 2,431 $ 12.37 Granted 399 53.67 Forfeited (27 ) 26.16 Exercised (531 ) 10.45 June 30, 2019 4,029 $ 21.80 2,407 $ 13.88
Share-based Payment Arrangement, Option, Exercise Price Range [Table Text Block]	The following summary information reflects stock options outstanding, vested and related details as of June 30, 2019 : 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 40 $ 83 0 40 2010 4.77 - 4.96 50 122 1 50 2011 5.90 - 7.99 80 274 2 80 2012 6.56 - 7.96 217 797 3 217 2013 7.98 - 11.49 355 1,712 4 355 2014 10.55 - 18.94 1,049 5,953 5 1,025 2015 21.47 - 25.24 431 3,926 6 272 2016 18.79 - 19.89 381 2,652 7 180 2017 18.64 - 22.90 420 2,931 8 118 2018 26.53 - 38.59 607 7,346 9 70 2019 $53.50 - $53.99 399 7,724 10 — Total 4,029 $ 33,520 2,407
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 June 30, 2019 and changes during the six months ended June 30, 2019 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2019 573 $ 29.31 Granted 194 52.16 Vested (166 ) 38.79 Forfeited (5 ) 28.67 Nonvested at June 30, 2019 596 $ 34.13
Share-based Payment Arrangement, Expensed and Capitalized, Amount [Table Text Block]	Share-based compensation expense recognized for the Company's equity incentive plans for the three and six months ended June 30, 2019 and 2018 was as follows: Three Months Ended June 30, Six Months Ended June 30, 2019 2018 2019 2018 Share-based compensation expense related to stock options $ 1,479 $ 1,292 $ 2,822 $ 2,508 Share-based compensation expense related to restricted stock awards 1,199 675 2,197 1,253 Share-based compensation expense related to stock options and restricted stock awards to non-employee directors 388 210 659 387 Total $ 3,066 $ 2,177 $ 5,678 $ 4,148
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 June 30, 2019 and December 31, 2018 is as follows: Options June 30, 2019 December 31, 2018 Outstanding $ 141,531 $ 89,806 Vested 103,589 64,222 Expected to vest 32,597 22,963 Exercisable 21,118 27,646

Leases (Tables)

Leases (Tables)	6 Months Ended
	Jun. 30, 2019
Leases [Abstract]
Schedule of New Accounting Pronouncements and Changes in Accounting Principles [Table Text Block]	The following table summarizes the impact of the adoption of the new lease accounting guidance on the Company’s condensed consolidated balance sheet as of January 1, 2019 . Balance at December 31, 2018 Adjustments due to new lease guidance January 1, 2019 Balance at June 30, 2019 Total assets (1) $ 1,181,958 $ 1,015,937 $ 2,197,895 $ 2,321,521 Total liabilities (2) 579,618 1,006,907 1,586,525 1,644,214 Total equity 602,340 9,030 611,370 677,307 (1) Adjustment in assets includes the reclassification of intangible assets, prepaid rent and deferred rent into right-of-use assets and the decrease in deferred tax assets due to the removal of deferred gain related to sale-leaseback as of January 1, 2019. (2) Adjustment in liabilities includes the reclassification of other liabilities into lease liabilities and the removal of deferred gain related to sale-lease back as of January 1, 2019.
Lease, Cost [Table Text Block]	The components of operating lease expense (1) , are as follows: Three Months Ended June 30, Six Months Ended June 30, 2019 2018 2019 2018 Rent - cost of services (2) $ 37,060 $ 34,472 $ 72,846 $ 68,322 General and administrative expense 151 168 335 318 Depreciation and amortization (3) 495 495 990 990 $ 37,706 $ 35,135 $ 74,171 $ 69,630 (1) Operating lease expenses include short-term leases and variable lease costs, which are immaterial. (2) Rent- cost of services includes the amortization of deferred rent of $434 and $688 for the three and six months ended June 30, 2019 , respectively. (3) Depreciation and amortization is related to the amortization of favorable and direct lease costs.
Lessee, Operating Lease, Liability, Maturity [Table Text Block]	Future minimum lease payments for all leases as of June 30, 2019 are as follows: Year Amount 2019 (remainder) $ 74,865 2020 149,083 2021 148,086 2022 146,540 2023 144,852 2024 142,880 Thereafter 912,928 Total lease payments 1,719,234 Less: present value adjustment (646,138 ) Less: variable rent (25,265 ) Present value of total lease liabilities 1,047,831 Less: current lease liabilities (59,686 ) Long-term operating lease liabilities $ 988,145 Future minimum lease payments for all leases as of December 31, 2018 were as follows: Year Amount 2019 $ 142,497 2020 141,536 2021 140,524 2022 139,018 2023 137,349 Thereafter 967,027 Total lease payments $ 1,667,951

Description of Business (Detail

Description of Business (Details)	Jun. 30, 2019businessBedsfacilities	Dec. 31, 2018facilities
Skilled nursing, assisted living and independent living facilities [Abstract]
Number of Real Estate Properties	77	72
Number of Real Estate Properties Leased	177	172
Number of Real Estate Properties Leased with an Option to Purchase	12	12
Number of Real Estate Properties Operated	254	244
Home Health, Hospice and Home Care Operations | business	62
Operational Skilled Nursing Beds | Beds	20,700
Operational Skilled Nursing, Assisted Living and Independent Living Beds [Abstract]
Operational Senior Living Units | Beds	5,900

Description of Business Propose

Description of Business Proposed Spin-Off Transaction (Details)	May 06, 2019business
Spinoff [Member]
Restructuring Cost and Reserve [Line Items]
Public Companies Created	2

Proposed Spin-Off of Subsidia_2

Proposed Spin-Off of Subsidiaries (Details)	May 06, 2019businessfacilities	Jun. 30, 2019businessfacilities
Restructuring Cost and Reserve [Line Items]
Home Health, Hospice and Home Care Operations | business		62
Senior Living Facilities | facilities		56
Spinoff [Member]
Restructuring Cost and Reserve [Line Items]
Public Companies Created | business	2
Spin-Off Transaction Company [Member] | Spinoff [Member]
Restructuring Cost and Reserve [Line Items]
Home Health, Hospice and Home Care Operations | business	62
Senior Living Facilities | facilities	51
Remaining Company [Member] | Spinoff [Member]
Restructuring Cost and Reserve [Line Items]
Senior Living Facilities | facilities	28
Common Stock [Member] | Spin-Off Transaction Company [Member] | Spinoff [Member]
Restructuring Cost and Reserve [Line Items]
Stockholders' Equity Note, Stock Split, Conversion Ratio	1
Common Stock [Member] | Remaining Company [Member] | Spinoff [Member]
Restructuring Cost and Reserve [Line Items]
Stockholders' Equity Note, Stock Split, Conversion Ratio	2

Significant Accounting Polici_3

Significant Accounting Policies Divestiture (Details) $ in Thousands	6 Months Ended
	Jun. 30, 2019USD ($)facilities
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Sale Price from Divestiture of Businesses | $	$ 1,838
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]
Senior Living Facility | facilities	1

Significant Accounting Polici_4

Significant Accounting Policies Property and Equipment (Details)	6 Months Ended
	Jun. 30, 2019
Minimum [Member]
Property, Plant and Equipment [Line Items]
Property, Plant and Equipment, Useful Life	3 years
Maximum [Member]
Property, Plant and Equipment [Line Items]
Property, Plant and Equipment, Useful Life	59 years

Significant Accounting Polici_5

Significant Accounting Policies Impairment (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Accounting Policies [Abstract]
Impairment of Long-Lived Assets to be Disposed of	$ 0	$ 705	$ 0	$ 860

Significant Accounting Polici_6

Significant Accounting Policies Intangible Assets and Goodwill (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Finite-Lived Intangible Assets [Line Items]
Goodwill and intangible asset impairment	$ 0	$ 0	$ 0	$ 0
Minimum [Member]
Finite-Lived Intangible Assets [Line Items]
Property, Plant and Equipment, Useful Life			3 years
Maximum [Member]
Finite-Lived Intangible Assets [Line Items]
Property, Plant and Equipment, Useful Life			59 years
Trade name
Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Asset, Useful Life			30 years
Customer relationships
Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Asset, Useful Life			20 years

Significant Accounting Polici_7

Significant Accounting Policies Self-Insurance General and Professional (Details) - General and Professional Liability Insurance [Member] - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 45,106	$ 42,635
Self-insurance retention per claim [Member] | Parent Company [Member]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	500
Aggregate Deductible [Member] | Parent Company [Member] | CALIFORNIA
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	750
Aggregate Deductible [Member] | Parent Company [Member] | Non-California [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	1,000
Blanket Aggregate [Member] | Third-Party Payor [Member] | All States Except Colorado [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	5,000
Per Facility [Member] | Third-Party Payor [Member] | All States Except Colorado [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	3,000
Per Facility [Member] | Third-Party Payor [Member] | COLORADO
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	3,000
Per Occurence [Member] | Third-Party Payor [Member] | All States Except Colorado [Domain]
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	1,000
Per Occurence [Member] | Third-Party Payor [Member] | COLORADO
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 1,000

Significant Accounting Polici_8

Significant Accounting Policies Self-Insurance Workers' Compensation (Details) - Workers' Compensation [Member] - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 25,317	$ 24,624
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	Jun. 30, 2019	Dec. 31, 2018
Accounting Policies [Abstract]
Long-term insurance losses recoverable asset	$ 7,747	$ 6,969

Significant Accounting Polic_10

Significant Accounting Policies Self-Insurance Health Insurance (Details) - Health Liability Insurance [Member] - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Liability for Claims and Claims Adjustment Expense [Line Items]
Self Insurance Reserve	$ 6,376	$ 5,823
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) - USD ($) $ in Thousands	Jan. 01, 2019	Jun. 30, 2019	Jun. 30, 2018	Dec. 31, 2018
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Right-of-use assets		$ 1,074,449		$ 0
Net of Lease Liability		1,047,831
Sale Leaseback Transaction, Deferred Gain		$ 0	$ 329
Accounting Standards Update 2016-02 [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Right-of-use assets	$ 1,051,148
Net of Lease Liability	1,029,240
Cumulative Effect on Retained Earnings, Net of Tax	9,030
Sale Leaseback Transaction, Deferred Gain	658
Favorable leases | Accounting Standards Update 2016-02 [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Right-of-use assets	$ 26,939

Revenue and Accounts Receivab_3

Revenue and Accounts Receivable Revenue from Medicare and Medicaid Programs (Details)	3 Months Ended		6 Months Ended
	Jun. 30, 2019Rate	Jun. 30, 2018Rate	Jun. 30, 2019Rate	Jun. 30, 2018Rate
Total Medicare and Medicaid
Disaggregation of Revenue [Line Items]
Revenue by payor as a percent of total revenue	68.00%	68.20%	68.00%	68.00%

Revenue and Accounts Receivab_4

Revenue and Accounts Receivable Revenue (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Disaggregation of Revenue [Line Items]
Revenue	$ 575,651	$ 496,386	$ 1,124,865	$ 988,520
Percentage of revenue	100.00%	100.00%	100.00%	100.00%
Medicaid
Disaggregation of Revenue [Line Items]
Revenue	$ 206,811	$ 173,169	$ 401,814	$ 340,794
Percentage of revenue	35.90%	34.90%	35.70%	34.50%
Medicare
Disaggregation of Revenue [Line Items]
Revenue	$ 153,187	$ 136,813	$ 300,907	$ 276,127
Percentage of revenue	26.60%	27.60%	26.80%	27.90%
Medicaid — skilled
Disaggregation of Revenue [Line Items]
Revenue	$ 31,792	$ 28,298	$ 62,243	$ 55,340
Percentage of revenue	5.50%	5.70%	5.50%	5.60%
Total Medicaid and Medicare
Disaggregation of Revenue [Line Items]
Revenue	$ 391,790	$ 338,280	$ 764,964	$ 672,261
Percentage of revenue	68.00%	68.20%	68.00%	68.00%
Managed care
Disaggregation of Revenue [Line Items]
Revenue	$ 93,690	$ 80,150	$ 183,538	$ 163,866
Percentage of revenue	16.30%	16.10%	16.30%	16.60%
Private Pay and Other
Disaggregation of Revenue [Line Items]
Revenue	$ 90,171	$ 77,956	$ 176,363	$ 152,393
Percentage of revenue	15.70%	15.70%	15.70%	15.40%

Revenue and Accounts Receivab_5

Revenue and Accounts Receivable Accounts Receivable (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable	$ 300,661	$ 278,985
Less: allowance for doubtful accounts	(3,726)	(2,886)
Accounts receivable, net	296,935	276,099
Medicaid
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable	128,069	117,984
Managed care
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable	62,605	54,682
Medicare
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable	53,232	50,994
Private Pay and Other
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts Receivable	$ 56,755	$ 55,325

Computation of Net Income Per_3

Computation of Net Income Per Common Share (Details) - USD ($) $ / shares in Units, shares in Thousands, $ in Thousands	3 Months Ended				6 Months Ended
	Jun. 30, 2019	Mar. 31, 2019	Jun. 30, 2018	Mar. 31, 2018	Jun. 30, 2019	Jun. 30, 2018
Numerator:
Net income	$ 28,925		$ 22,326		$ 56,532	$ 45,619
Less: net income attributable to noncontrolling interests	316	$ 235	315	$ 161	551	476
Net income attributable to The Ensign Group, Inc.	$ 28,609	$ 27,372	$ 22,011	$ 23,132	$ 55,981	$ 45,143
Denominator:
Weighted average shares outstanding for basic net income per share	53,408		51,880		53,246	51,733
Adjusted weighted average common shares outstanding	56,078		54,251		55,896	53,909
Basic net income (loss) per common share:
Basic net income per common share attributable to The Ensign Group, Inc.	$ 0.54		$ 0.42		$ 1.05	$ 0.87
Diluted net (loss) income per common share:
Diluted net income per common share attributable to The Ensign Group, Inc.	$ 0.51		$ 0.41		$ 1	$ 0.84
Common Class A [Member]
Denominator:
Weighted average shares outstanding for basic net income per share	53,408		51,880		53,246	51,733
Plus: incremental shares from assumed conversion (1)	2,670		2,371		2,650	2,176

Computation of Net Income Per_4

Computation of Net Income Per Common Share Antidilutive Shares (Details) - shares shares in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Earnings Per Share, Diluted, Other Disclosures [Abstract]
Antidilutive Securities Excluded from Computation of Earnings Per Share, Amount	173	196	322	398

Fair Value Measurements (Detail

Fair Value Measurements (Details) - Cash and cash equivalents - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Level 1
Cash and cash equivalents	$ 39,042	$ 31,083
Level 2
Cash and cash equivalents	0	0
Level 3
Cash and cash equivalents	$ 0	$ 0

Fair Value Measurements Investm

Fair Value Measurements Investments (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Debt Security, Corporate, US [Member]
Schedule of Held-to-maturity Securities [Line Items]
Debt Securities, Held-to-maturity	$ 46,932	$ 44,850

Business Segments (Details)

Business Segments (Details) $ in Thousands	6 Months Ended
	Jun. 30, 2019USD ($)Segmentsbusinessfacilities
Segment Reporting Information [Line Items]
Number of Reportable Segments | Segments	3
Transitional and Skilled Service Facilities	171
Transitional and Skilled Services and Senior Living Campuses	27
Senior Living Facilities	56
Home Health, Hospice and Home Care Operations | business	62
Sale Price from Divestiture of Businesses | $	$ 1,838
Disposal Group, Disposed of by Sale, Not Discontinued Operations [Member]
Segment Reporting Information [Line Items]
Senior Living Facility	1

Business Segments Revenue by Se

Business Segments Revenue by Segment (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 575,651	$ 496,386	$ 1,124,865	$ 988,520
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	100.00%	100.00%	100.00%	100.00%
Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 469,238	$ 408,518	$ 918,496	$ 815,534
Senior Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	42,046	37,164	82,740	73,277
Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	50,208	41,249	96,325	81,007
All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	14,159	9,455	27,304	18,702
Medicaid
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 206,811	$ 173,169	$ 401,814	$ 340,794
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	35.90%	34.90%	35.70%	34.50%
Medicaid | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 192,545	$ 161,584	$ 373,839	$ 318,095
Medicaid | Senior Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	10,333	8,677	20,135	16,941
Medicaid | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	3,933	2,908	7,840	5,758
Medicaid | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 153,187	$ 136,813	$ 300,907	$ 276,127
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	26.60%	27.60%	26.80%	27.90%
Medicare | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 118,807	$ 108,237	$ 235,508	$ 220,190
Medicare | Senior Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Medicare | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	34,380	28,576	65,399	55,937
Medicare | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Medicaid — skilled
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 31,792	$ 28,298	$ 62,243	$ 55,340
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	5.50%	5.70%	5.50%	5.60%
Medicaid — skilled | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 31,792	$ 28,298	$ 62,243	$ 55,340
Medicaid — skilled | Senior Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Medicaid — skilled | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Medicaid — skilled | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Total Medicaid and Medicare
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 391,790	$ 338,280	$ 764,964	$ 672,261
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	68.00%	68.20%	68.00%	68.00%
Total Medicaid and Medicare | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 343,144	$ 298,119	$ 671,590	$ 593,625
Total Medicaid and Medicare | Senior Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	10,333	8,677	20,135	16,941
Total Medicaid and Medicare | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	38,313	31,484	73,239	61,695
Total Medicaid and Medicare | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Managed care
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 93,690	$ 80,150	$ 183,538	$ 163,866
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	16.30%	16.10%	16.30%	16.60%
Managed care | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 86,491	$ 74,168	$ 169,663	$ 151,968
Managed care | Senior Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Managed care | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	7,199	5,982	13,875	11,898
Managed care | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	0	0	0	0
Private and other payors(1)
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 90,171	$ 77,956	$ 176,363	$ 152,393
Revenue from Contract with Customer by Payor as a Percent of Total Revenue	15.70%	15.70%	15.70%	15.40%
Private and other payors(1) | Transitional and Skilled Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 39,603	$ 36,231	$ 77,243	$ 69,941
Private and other payors(1) | Senior Living Services Segment
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	31,713	28,487	62,605	56,336
Private and other payors(1) | Home Health and Hospice Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	4,696	3,783	9,211	7,414
Private and other payors(1) | All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Revenue	$ 14,159	$ 9,455	$ 27,304	$ 18,702

Business Segments Schedule of S

Business Segments Schedule of Segment Reporting Information, by Segment (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Segment Reporting Information [Line Items]
Revenue from external customers	$ 575,651	$ 496,386	$ 1,124,865	$ 988,520
Intersegment revenue (1)	0	0	0	0
Total revenue	575,651	496,386	1,124,865	988,520
Segment Income (Loss)	37,846	31,775	75,650	64,754
Interest expense, net of interest income	(3,369)	(3,307)	(6,466)	(6,472)
Income before provision for income taxes	34,477	28,468	69,184	58,282
Depreciation and amortization	13,184	11,621	25,782	23,243
Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	469,238	408,518	918,496	815,534
Senior Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	42,046	37,164	82,740	73,277
Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	50,208	41,249	96,325	81,007
All Other
Segment Reporting Information [Line Items]
Revenue from external customers	14,159	9,455	27,304	18,702
Operating Segments [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	469,238	408,518	918,496	815,534
Total revenue	470,018	409,163	919,991	816,868
Segment Income (Loss)	56,652	43,210	115,416	89,405
Depreciation and amortization	8,938	7,708	17,552	15,510
Operating Segments [Member] | Senior Living Services Segment
Segment Reporting Information [Line Items]
Revenue from external customers	42,046	37,164	82,740	73,277
Total revenue	42,046	37,164	82,740	73,277
Segment Income (Loss)	4,821	4,966	9,859	9,629
Depreciation and amortization	2,019	1,863	3,919	3,460
Operating Segments [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Revenue from external customers	50,208	41,249	96,325	81,007
Operating Income & Intersegment Expense	6,526	5,623	12,679	10,992
Total revenue	50,208	41,249	96,325	81,007
Segment Income (Loss)	7,306	6,268	14,174	12,326
Depreciation and amortization	320	281	580	526
Operating Segments [Member] | All Other
Segment Reporting Information [Line Items]
Revenue from external customers	14,159	9,455	27,304	18,702
Total revenue	16,308	10,567	31,165	20,896
Segment Income (Loss)	(30,933)	(22,669)	(63,799)	(46,606)
Depreciation and amortization	1,907	1,769	3,731	3,747
Operating Segments [Member] | Elimination
Segment Reporting Information [Line Items]
Total revenue	(2,929)	(1,757)	(5,356)	(3,528)
Segment Income (Loss)	0	0	0	0
Depreciation and amortization	0	0	0	0
Consolidation, Eliminations [Member] | Transitional and Skilled Services Segment
Segment Reporting Information [Line Items]
Intersegment revenue (1)	780	645	1,495	1,334
Consolidation, Eliminations [Member] | Senior Living Services Segment
Segment Reporting Information [Line Items]
Intersegment revenue (1)	0	0	0	0
Consolidation, Eliminations [Member] | Home Health and Hospice Services
Segment Reporting Information [Line Items]
Intersegment revenue (1)	0	0	0	0
Intersegment Expense	780	645	1,495	1,334
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	2,149	1,112	3,861	2,194
Consolidation, Eliminations [Member] | All Other
Segment Reporting Information [Line Items]
Intersegment revenue (1)	2,149	1,112	3,861	2,194
Consolidation, Eliminations [Member] | Elimination
Segment Reporting Information [Line Items]
Revenue from external customers	0	0	0	0
Intersegment revenue (1)	$ (2,929)	$ (1,757)	$ (5,356)	$ (3,528)

Acquisitions Summary (Details)

Acquisitions Summary (Details) $ in Thousands	1 Months Ended	6 Months Ended
	Jul. 31, 2019Operations	Jun. 30, 2019USD ($)BedsOperations	Jun. 30, 2018USD ($)	Jul. 01, 2019Beds
Business Acquisition [Line Items]
Cash payments for asset acquisitions (Note 8) | $		$ (43,176)	$ (55,546)
Payments to Acquire Business and Asset Acquisitions | $		$ 65,362
Operational Skilled Nursing Beds | Beds		20,700
Operational Senior Living Units | Beds		5,900
Transitional and Skilled Services and Senior Living Campuses [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired		3
Senior Living Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired		1
Operational Senior Living Units | Beds		364
621610 Home Health Care Services [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired		2
Hospice Agencies [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired		4
8051 Services, Skilled Nursing Care Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired		7
Operational Skilled Nursing Beds | Beds		1,088
Home Care Agency [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired		2
Subsequent Event [Member] | Senior Living Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired	1
Operational Senior Living Units | Beds				91
Subsequent Event [Member] | 8051 Services, Skilled Nursing Care Facilities [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired	1
Operational Skilled Nursing Beds | Beds				27

Acquisitions (Details)

Acquisitions (Details) $ in Thousands	6 Months Ended
	Jun. 30, 2019USD ($)Operations	Jun. 30, 2018USD ($)
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross	$ 22,186
Payments to Acquire Asset Acquisitions	43,176	$ 55,546
Note payable due to seller from business acquisition	924
Goodwill & Indefinite-lived Intangible Assets [Member]
Business Acquisition [Line Items]
Payments to Acquire Businesses, Gross	20,251
Building and improvements
Business Acquisition [Line Items]
Payments to Acquire Asset Acquisitions	33,900
Land
Business Acquisition [Line Items]
Payments to Acquire Asset Acquisitions	$ 7,660
Asset Acquisition [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired | Operations	11
Business Combination [Member]
Business Acquisition [Line Items]
Number of Businesses Acquired | Operations	9
Office Building [Member]
Business Acquisition [Line Items]
Payments to Acquire Asset Acquisitions		$ 31,500

Property and Equipment (Details

Property and Equipment (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Property, Plant and Equipment [Line Items]
Property and equipment	$ 881,251	$ 801,605
Less: accumulated depreciation	(206,359)	(182,731)
Property and equipment, net	674,892	618,874
Land
Property, Plant and Equipment [Line Items]
Property and equipment	68,081	60,420
Building and improvements
Property, Plant and Equipment [Line Items]
Property and equipment	449,763	411,096
Equipment
Property, Plant and Equipment [Line Items]
Property and equipment	220,402	202,346
Furniture and fixtures
Property, Plant and Equipment [Line Items]
Property and equipment	5,465	5,079
Leasehold improvements
Property, Plant and Equipment [Line Items]
Property and equipment	127,345	112,935
Construction in progress
Property, Plant and Equipment [Line Items]
Property and equipment	$ 10,195	$ 9,729

Intangible Assets - Net (Detail

Intangible Assets - Net (Details) - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2019	Dec. 31, 2018
Acquired Finite-Lived Intangible Assets [Line Items]
Finite-Lived Intangible Assets, Gross	$ 9,917	$ 44,832
Accumulated Amortization	(6,088)	(13,832)
Intangible assets, net	$ 3,829	31,000
Lease acquisition costs
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	1 year 8 months 12 days
Finite-Lived Intangible Assets, Gross	$ 360	843
Accumulated Amortization	(240)	(251)
Intangible assets, net	$ 120	592
Favorable leases
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	2 years 1 month 6 days
Finite-Lived Intangible Assets, Gross	$ 534	35,650
Accumulated Amortization	(316)	(8,724)
Intangible assets, net	$ 218	26,926
Assembled occupancy
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	12 days
Finite-Lived Intangible Assets, Gross	$ 3,180	2,936
Accumulated Amortization	(3,056)	(2,870)
Intangible assets, net	$ 124	66
Trade name
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	30 years
Finite-Lived Intangible Assets, Gross	$ 733	733
Accumulated Amortization	(330)	(317)
Intangible assets, net	$ 403	416
Customer relationships
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	16 years 8 months 12 days
Finite-Lived Intangible Assets, Gross	$ 5,110	4,670
Accumulated Amortization	(2,146)	(1,670)
Intangible assets, net	$ 2,964	$ 3,000

Intangible Assets - Net Additio

Intangible Assets - Net Additional Disclosures (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018	Jan. 01, 2019	Dec. 31, 2018
Finite-Lived Intangible Assets [Line Items]
Amortization of Intangible Assets	$ 1,012	$ 691	$ 1,905	$ 1,306
Right-of-use assets (Note 17)	$ 1,074,449		$ 1,074,449			$ 0
Accounting Standards Update 2016-02 [Member]
Finite-Lived Intangible Assets [Line Items]
Right-of-use assets (Note 17)					$ 1,051,148
Accounting Standards Update 2016-02 [Member] | Favorable leases
Finite-Lived Intangible Assets [Line Items]
Right-of-use assets (Note 17)					$ 26,939

Intangible Assets - Net Future

Intangible Assets - Net Future Amortization (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Finite-Lived Intangible Assets, Net, Amortization Expense, Fiscal Year Maturity [Abstract]
2019 (remainder)	$ 567
2020	345
2021	249
2022	249
2023	237
2024	234
Thereafter	1,948
Intangible assets, net	$ 3,829	$ 31,000

Goodwill and Other Indefinite_3

Goodwill and Other Indefinite-Lived Intangible Assets Goodwill Rollforward (Details) $ in Thousands	6 Months Ended
	Jun. 30, 2019USD ($)
Goodwill [Line Items]
January 1,	$ 80,477
Additions	16,931
June 30,	97,408
Transitional and Skilled Services Segment
Goodwill [Line Items]
January 1,	45,486
Additions	0
June 30,	45,486
Senior Living Services Segment
Goodwill [Line Items]
January 1,	3,958
Additions	0
June 30,	3,958
Home Health and Hospice Services
Goodwill [Line Items]
January 1,	27,250
Additions	11,500
June 30,	38,750
All Other
Goodwill [Line Items]
January 1,	3,783
Additions	5,431
June 30,	$ 9,214

Goodwill and Other Indefinite_4

Goodwill and Other Indefinite-Lived Intangible Assets Indefinite-lived intangble assets (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 30,922	$ 27,602
Trade name
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	1,373	1,217
Medicare and Medicaid licenses
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 29,549	$ 26,385

Restricted and Other Assets (De

Restricted and Other Assets (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Other Assets [Abstract]
Debt issuance costs, net	$ 1,442	$ 1,892
Long-term insurance losses recoverable asset	7,747	6,969
Deposits with landlords	4,148	8,694
Capital improvement reserves with landlords and lenders	3,535	3,196
Note receivable from sale of ancillary business	71	93
Restricted and other assets	$ 16,943	$ 20,844

Restricted and Other Assets Add

Restricted and Other Assets Additional (Details) - Accounting Standards Update 2016-02 [Member] - USD ($) $ in Thousands	Jan. 01, 2019	Dec. 31, 2018
Right-of-Use Asset [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Prepaid Rent	$ 5,220
Deposits with Landlords [Member]
New Accounting Pronouncements or Change in Accounting Principle [Line Items]
Prepaid Rent		$ 5,220

Other Accrued Liabilities (Deta

Other Accrued Liabilities (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Accrued Liabilities [Abstract]
Quality assurance fee	$ 5,639	$ 5,375
Refunds payable	27,477	25,118
Resident advances	4,607	8,495
Cash held in trust for patients	2,842	2,824
Resident deposits	7,753	6,665
Dividends payable	2,559	2,525
Property taxes	7,669	9,426
Other	11,270	9,356
Other accrued liabilities	$ 69,816	$ 69,784

Income Taxes Expense (Details)

Income Taxes Expense (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Income Tax Disclosure [Abstract]
Provision for income taxes	$ 5,552	$ 6,142	$ 12,652	$ 12,663
Effective Income Tax Rate Reconciliation, Percent			18.30%	21.70%

Income Taxes Other Disclosures

Income Taxes Other Disclosures (Details) $ in Thousands	3 Months Ended
	Mar. 31, 2019USD ($)
Accounting Standards Update 2016-02 [Member]
Operating Loss Carryforwards [Line Items]
Cumulative Effect on Retained Earnings, Tax	$ 3,044

Debt (Details)

Debt (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Debt Instrument [Line Items]
Long-term Debt, Gross	$ 281,039	$ 246,080
Current maturities of long-term debt	(10,153)	(10,105)
Long Term Debt, net of Current Maturities and Debt Discount	268,179	233,135
SunTrust Bank [Member] | Revolving Credit Facility [Member]
Debt Instrument [Line Items]
Revolving credit facility with SunTrust	50,000	10,000
Second Amended Credit Facility [Member] | SunTrust Bank [Member] | Revolving Credit Facility [Member]
Debt Instrument [Line Items]
Term loan with SunTrust	109,375	113,125
Less: debt issuance costs	(2,707)	(2,840)
Collateralized Debt Obligations [Member] | Notes Payable, Other Payables [Member]
Debt Instrument [Line Items]
Mortgage loans and promissory note	$ 121,664	$ 122,955

Debt Additional Disclosures (De

Debt Additional Disclosures (Details) $ in Thousands	Feb. 05, 2016USD ($)Rate	Jul. 30, 2019USD ($)	Jun. 30, 2019USD ($)	Dec. 31, 2018USD ($)	Jul. 19, 2016USD ($)Rate	May 30, 2014USD ($)
Secured Debt [Member] | Senior Debt Obligations [Member]
Long-Term Debt Additional Disclosures [Line Items]
Increase in Letters of Credit			$ 560
Pledged Financial Instruments, Not Separately Reported, Securities for Letter of Credit Facilities			5,342
SunTrust Bank [Member] | Revolving Credit Facility [Member]
Long-Term Debt Additional Disclosures [Line Items]
Revolving credit facility with SunTrust			50,000	$ 10,000
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%
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			101,875
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			159,375
Term loan with SunTrust			$ 109,375	$ 113,125
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		$ 111,250
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, 2014Rate	Dec. 27, 2017USD ($)facilitiesRate	Jun. 30, 2019USD ($)	Dec. 31, 2018USD ($)
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 | $			$ 121,664	$ 122,955
Notes Payable, Current | $			2,653
Notes Payable, Noncurrent | $			$ 119,011
Notes Payable to Banks [Member]
Debt Instrument [Line Items]
Debt Instrument, Interest Rate, Stated Percentage		3.30%
Notes Payable to Banks [Member] | Minimum [Member]
Debt Instrument [Line Items]
Debt Instrument, Interest Rate, Stated Percentage	2.60%
Notes Payable to Banks [Member] | Maximum [Member]
Debt Instrument [Line Items]
Debt Instrument, Interest Rate, Stated Percentage	5.30%

Options and Awards Lead Paragra

Options and Awards Lead Paragraphs (Details) shares in Thousands	May 25, 2017installmentshares	Jun. 30, 2019Agreementsshares	Jun. 30, 2018shares	Jun. 30, 2019Agreementsshares	Jun. 30, 2018shares
Stock Options granted [Line Items]
Number of Option Plans | Agreements		1		1
Shares Granted or Issued, Share-based Payment Arrangement [Abstract]
Award Vesting Period				5 years
Options Granted		258	227	399	395
Nonvested Restricted Awards, Granted		89	217	194	274
2017 Plan [Member]
Shares Granted or Issued, Share-based Payment Arrangement [Abstract]
Number of Shares Available for Grant		3,908		3,908
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]
Shares Granted or Issued, Share-based Payment Arrangement [Abstract]
Share-based Compensation Arrangement by Share-based Payment Award, Number of Installments | installment	3
Award Requisite Service Period	3 years

Options and Awards Valuation As

Options and Awards Valuation Assumptions (Details) - shares shares in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Options and Awards [Abstract]
Options Granted	258	227	399	395
Fair Value Assumptions and Methodology
Weighted Average Risk-Free Rate	2.10%	2.70%	2.20%	2.70%
Expected Life	6 years 3 months 18 days	6 years 2 months 12 days	6 years 3 months 18 days	6 years 2 months 12 days
Weighted Average Volatility	34.00%	32.00%	33.90%	32.00%
Weighted Average Dividend Yield	0.40%	0.50%	0.30%	0.60%

Options and Awards Exercise Pri

Options and Awards Exercise Price and Fair Value (Details) - $ / shares shares in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Share-based Compensation Arrangement by Share-based Payment Award, Options, Grants in Period, Net of Forfeitures [Abstract]
Options Granted	258	227	399	395
Weighted Average Exercise Price			$ 53.67	$ 32.33
Weighted Average Fair Value of Options			19.35	11.15
Intrinsic Value of Options Granted on Grant Date [Abstract]
Grant Date Intrinsic Value			$ 0	$ 0

Options and Awards Options Outs

Options and Awards Options Outstanding Rollforward (Details) - $ / shares shares in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Options outstanding January 1,			4,188
Weighted average exercise price January 1,			$ 17.35
Options vested January 1,			2,431
Weighted Average Exercise Price of Options Vested January 1,			$ 12.37
Options Granted	258	227	399	395
Weighted Average Exercise Price, Options Granted			$ 53.67	$ 32.33
Options Forfeited in Period			(27)
Weighted Average Exercise Price, Options Forfeited in Period			$ 26.16
Options Exercised in Period			(531)
Weighted Average Exercise Price, Options Exercised in Period			$ 10.45
Options outstanding June 30,	4,029		4,029
Weighted average exercise price June 30,	$ 21.80		$ 21.80
Options vested June 30,	2,407		2,407
Weighted Average Exercise Price of Options Vested June 30,	$ 13.88		$ 13.88

Options and Awards Options Ou_2

Options and Awards Options Outstanding by Exercise Price (Details) $ / shares in Units, shares in Thousands, $ in Thousands	6 Months Ended
	Jun. 30, 2019USD ($)$ / sharesshares
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Number of Outstanding Options	4,029
Black-Scholes Fair Value | $	$ 33,520
Stock Options Vested and Exercisable	2,407
2009
Share-based Payment Arrangement, Option, 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	40
Black-Scholes Fair Value | $	$ 83
Remaining Contractual Life (Years)	0 years
Stock Options Vested and Exercisable	40
2010
Share-based Payment Arrangement, Option, 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	50
Black-Scholes Fair Value | $	$ 122
Remaining Contractual Life (Years)	1 year
Stock Options Vested and Exercisable	50
2011
Share-based Payment Arrangement, Option, 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	80
Black-Scholes Fair Value | $	$ 274
Remaining Contractual Life (Years)	2 years
Stock Options Vested and Exercisable	80
2012
Share-based Payment Arrangement, Option, 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	217
Black-Scholes Fair Value | $	$ 797
Remaining Contractual Life (Years)	3 years
Stock Options Vested and Exercisable	217
2013
Share-based Payment Arrangement, Option, 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	355
Black-Scholes Fair Value | $	$ 1,712
Remaining Contractual Life (Years)	4 years
Stock Options Vested and Exercisable	355
2014
Share-based Payment Arrangement, Option, 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	1,049
Black-Scholes Fair Value | $	$ 5,953
Remaining Contractual Life (Years)	5 years
Stock Options Vested and Exercisable	1,025
2015
Share-based Payment Arrangement, Option, 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	431
Black-Scholes Fair Value | $	$ 3,926
Remaining Contractual Life (Years)	6 years
Stock Options Vested and Exercisable	272
2016
Share-based Payment Arrangement, Option, 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	381
Black-Scholes Fair Value | $	$ 2,652
Remaining Contractual Life (Years)	7 years
Stock Options Vested and Exercisable	180
2017
Share-based Payment Arrangement, Option, 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	420
Black-Scholes Fair Value | $	$ 2,931
Remaining Contractual Life (Years)	8 years
Stock Options Vested and Exercisable	118
2018
Share-based Payment Arrangement, Option, 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	607
Black-Scholes Fair Value | $	$ 7,346
Remaining Contractual Life (Years)	9 years
Stock Options Vested and Exercisable	70
2019
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise Price, Lower Range Limit | $ / shares	$ 53.50
Exercise Price, Upper Range Limit | $ / shares	$ 53.99
Number of Outstanding Options	399
Black-Scholes Fair Value | $	$ 7,724
Remaining Contractual Life (Years)	10 years
Stock Options Vested and Exercisable	0

Options and Awards Restricted A

Options and Awards Restricted Awards Granted (Details) - USD ($) $ / shares in Units, shares in Thousands, $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Restricted awards granted [Line Items]
Restricted Awards Grant Date Fair Value Range, Minimum			$ 41.68	$ 23.61
Restricted Awards Grant Date Fair Value Range, Maximum			$ 53.99	$ 36.61
Share-based Compensation, Restricted Awards, Exercise Price			$ 0
Issuance of restricted stock to employees (in shares)	89	217	194	274
Award Vesting Period			5 years
Director [Member]
Restricted awards granted [Line Items]
Restricted Awards Grant Date Fair Value Range, Minimum			$ 41.68
Restricted Awards Grant Date Fair Value Range, Maximum			$ 51.78
Options Granted to Non-employee Directors	8		14

Options and Awards Restricted_2

Options and Awards Restricted Award Rollforward (Details) - $ / shares shares in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Restricted Stock Rollforward [Line Items]
Nonvested Restricted Awards, Nonvested at January 1,			573
Weighted Average Grant Date Fair Value, Nonvested at January 1,			$ 29.31
Nonvested Restricted Awards, Granted	89	217	194	274
Weighted Average Grant Date Fair Value, Restricted Awards Granted in the Period			$ 52.16
Nonvested Restricted Awards, Vested in the Period			(166)
Weighted Average Grant Date Fair Value, Restricted Awards Vested in the Period			$ 38.79
Nonvested Restricted Awards, Forfeited in the Period			(5)
Weighted Average Grant Date Fair Value, Restricted Awards Forfeited in the Period			$ 28.67
Nonvested Restricted Awards, Nonvested at June 30,	596		596
Weighted Average Grant Date Fair Value, Nonvested at June 30,	$ 34.13		$ 34.13

Options and Awards Compensation

Options and Awards Compensation Expense (Details) - USD ($) shares in Thousands, $ in Thousands	3 Months Ended				6 Months Ended
	Jun. 30, 2019	Mar. 31, 2019	Jun. 30, 2018	Mar. 31, 2018	Jun. 30, 2019	Jun. 30, 2018
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 3,066	$ 2,612	$ 2,177	$ 1,971	$ 5,678	$ 4,148
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					6 years 1 month 6 days
Stock Options
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	1,479		1,292		$ 2,822	2,508
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	$ 17,760				$ 17,760
Employee Service Share-based Compensation, Nonvested Awards, Total Compensation Cost Not yet Recognized, Period for Recognition					3 years 10 months 24 days
Employee Service Share-based Compensation, Nonvested Awards	1,622				1,622
Share-based Compensation Arrangement by Share-based Payment Award, Options, Expected to Vest, Number	1,517				1,517
Restricted Stock Awards
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 1,199		675		$ 2,197	1,253
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	18,860				$ 18,860
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	$ 388		$ 210		$ 659	$ 387

Options and Awards Intrinsic Va

Options and Awards Intrinsic Values (Details) - Stock Options - USD ($) $ in Thousands	6 Months Ended	12 Months Ended
	Jun. 30, 2019	Dec. 31, 2018
Outstanding	$ 141,531	$ 89,806
Vested	103,589	64,222
Expected to Vest	32,597	22,963
Exercised	$ 21,118	$ 27,646

Options and Awards Subsidiary C

Options and Awards Subsidiary Common Stock Shares and Restricted Stock (Details) - $ / shares shares in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Class of Stock [Line Items]
Nonvested Restricted Awards, Granted	89	217	194	274
Weighted Average Grant Date Fair Value, Restricted Awards Granted in the Period			$ 52.16
Nonvested Restricted Awards, Vested in the Period			(166)
Award Vesting Period			5 years
Options Granted	258	227	399	395
Subsidiaries Stock awards [Member] | Subsidiaries [Member]
Class of Stock [Line Items]
Common Stock Required to Settle Subsidiary Shares	328	235	328	235
Nonvested Restricted Awards, Granted			0	0
Nonvested Restricted Awards, Vested in the Period			(976)	(976)
Options Granted			0	221
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	3 Months Ended				6 Months Ended
	Jun. 30, 2019	Mar. 31, 2019	Jun. 30, 2018	Mar. 31, 2018	Jun. 30, 2019	Jun. 30, 2018
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Share-based compensation expense	$ 3,066	$ 2,612	$ 2,177	$ 1,971	$ 5,678	$ 4,148
Subsidiaries [Member] | Subsidiaries Stock awards [Member]
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Share-based compensation expense	$ 236		$ 343		$ 577	$ 681

Options and Awards Sale of Stoc

Options and Awards Sale of Stock by Subsidiary (Details) - USD ($) shares in Thousands, $ in Thousands	3 Months Ended	6 Months Ended
	Jun. 30, 2019	Jun. 30, 2019	Jun. 30, 2018
Subsidiary, Sale of Stock [Line Items]
Payments for Repurchase of Common Stock		$ 2,293	$ 0
Proceeds from Issuance or Sale of Equity		$ 2,293	$ 0
Subsidiaries [Member] | Subsidiaries Stock awards [Member]
Subsidiary, Sale of Stock [Line Items]
Stock Repurchased During Period, Shares	469
Payments for Repurchase of Common Stock	$ 2,293
Proceeds from Issuance or Sale of Equity	$ 2,293

Leases (Details)

Leases (Details) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019USD ($)facilitiesAgreementsRenewals	Jun. 30, 2018USD ($)	Jun. 30, 2019USD ($)facilitiesAgreementsRenewals	Jun. 30, 2018USD ($)	Jun. 01, 2014facilitiesAgreementsRenewals
Operating Leased Assets [Line Items]
Master Lease Agreements | Agreements	7		7
Facilities under Master Lease Arrangement | facilities	39		39
Various Landlords [Member] [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract	15 years		15 years
Lessee Leasing Arrangements, Operating Leases, Number of Renewal Terms	2		2
Lessee, Operating Lease, Renewal Term	5 years		5 years
CareTrust REIT [Member]
Operating Leased Assets [Line Items]
Skilled Nursing, Assisted Living and Independent Living Facilities | facilities					93
Master Lease Agreements | Agreements					8
Lessee, Operating Lease, Renewal Term					5 years
Operating Leases of Lessee, Contingent Rentals, Basis Spread on Variable Rate					2.50%
Payments for Rent | $	$ 15,057	$ 14,538	$ 29,896	$ 28,956
Minimum [Member] | Various Landlords [Member] [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract	5 years		5 years
Average Term of Non-Cancellable Equipment Leases			3 years
Minimum [Member] | CareTrust REIT [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract					12 years
Lessee Leasing Arrangements, Operating Leases, Number of Renewal Terms					2
Maximum [Member] | Various Landlords [Member] [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract	20 years		20 years
Average Term of Non-Cancellable Equipment Leases			5 years
Maximum [Member] | CareTrust REIT [Member]
Operating Leased Assets [Line Items]
Lessee, Operating Lease, Term of Contract					20 years
Lessee Leasing Arrangements, Operating Leases, Number of Renewal Terms					3
Cost of Sales and General and Administrative Expense [Member]
Operating Leased Assets [Line Items]
Rent | $	$ 37,211	$ 34,476	$ 73,181	$ 68,640

Leases Balance Sheet Impact on

Leases Balance Sheet Impact on New Lease Guidance (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Mar. 31, 2019	Jan. 01, 2019	Dec. 31, 2018	Jun. 30, 2018	Mar. 31, 2018	Dec. 31, 2017
Operating Leased Assets [Line Items]
Assets	$ 2,321,521			$ 1,181,958
Liabilities	1,644,214			579,618
Stockholders' Equity, Including Portion Attributable to Noncontrolling Interest	$ 677,307	$ 645,003		$ 602,340	$ 550,279	$ 525,943	$ 500,059
Accounting Standards Update 2016-02 [Member] | Adjustments Due to ASC 842 [Member]
Operating Leased Assets [Line Items]
Assets			$ 1,015,937
Liabilities			1,006,907
Stockholders' Equity, Including Portion Attributable to Noncontrolling Interest			9,030
Accounting Standards Update 2016-02 [Member] | Calculated under New Lease Guidance in Effect [Member]
Operating Leased Assets [Line Items]
Assets			2,197,895
Liabilities			1,586,525
Stockholders' Equity, Including Portion Attributable to Noncontrolling Interest			$ 611,370

Leases Lease Cost (Details)

Leases Lease Cost (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2019	Jun. 30, 2018	Jun. 30, 2019	Jun. 30, 2018
Operating Leased Assets [Line Items]
Amortization of deferred rent	$ 434		$ 688
Rent—cost of services (Note 17)	37,060	$ 34,472	72,846	$ 68,322
Operating Lease, Cost	37,706	35,135	74,171	69,630
Favorable leases
Operating Leased Assets [Line Items]
Rent—cost of services (Note 17)	495	495	990	990
General and Administrative Expense [Member]
Operating Leased Assets [Line Items]
Rent—cost of services (Note 17)	$ 151	$ 168	$ 335	$ 318

Leases Future minimum lease pay

Leases Future minimum lease payments (Details) - USD ($) $ in Thousands	Jun. 30, 2019	Dec. 31, 2018
Leases [Abstract]
2019 (remainder)	$ 74,865
2020	149,083
2021	148,086
2022	146,540
2023	144,852
2024	142,880
Thereafter	912,928
Total lease payments	1,719,234
Less: present value adjustment	(646,138)
Lessee, Operating Lease, Liability, Variable Rent	(25,265)
Present value of total lease liabilities	1,047,831
Less: current lease liabilities	(59,686)	$ 0
Long-term operating lease liabilities	$ 988,145	0
2019		142,497
2020		141,536
2021		140,524
2022		139,018
2023		137,349
Thereafter		967,027
Total lease payments		$ 1,667,951

Leases Additional Disclosures (

Leases Additional Disclosures (Details)	Jun. 30, 2019Rate
Operating Leased Assets [Line Items]
Operating Lease, Weighted Average Remaining Lease Term	12 years
Operating Lease, Weighted Average Discount Rate, Percent	8.66%

Commitments and Contingencies L

Commitments and Contingencies Litigation (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2018	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)	Jun. 30, 2019facilities
Probe Reviews [Abstract]
Facilities under Medicare Probe Reviews	10

Commitments and Contingencies O

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

Commitments and Contingencies C

Commitments and Contingencies Concentrations (Details) - Total Medicaid and Medicare	3 Months Ended		6 Months Ended
	Jun. 30, 2019Rate	Jun. 30, 2018Rate	Jun. 30, 2019Rate	Jun. 30, 2018Rate	Dec. 31, 2018Rate
Concentration Risk [Line Items]
Accounts receivable by payor as a percent of total accounts receivable	60.30%		60.30%		60.60%
% of Revenue	68.00%	68.20%	68.00%	68.00%

Commitments and Contingencies_2

Commitments and Contingencies Cash in Excess of FDIC Limits (Details) - USD ($) $ in Thousands	Jul. 30, 2019	Jun. 30, 2019
Cash in Excess of FDIC limits [Line Items]
Cash, FDIC Insured Amount		$ 250
Subsequent Event [Member]
Cash in Excess of FDIC limits [Line Items]
Cash, Uninsured Amount	$ 1,066

Common Stock (Details)

Common Stock (Details) $ in Thousands	Apr. 03, 2018USD ($)
Common Stock Transactions [Line Items]
Stock Repurchase Program, Period in Force	11 years
Stock Repurchase Program Expiration Date	Feb. 20, 2019
Common Stock [Member]
Common Stock Transactions [Line Items]
Stock Repurchase Program, Authorized Amount	$ 30,000