The Ensign Group, Inc. (ENSG) 10-Q 27 Oct 21 2021 Q3 Quarterly report Financial data

Cover Page

Cover Page - shares	9 Months Ended
	Sep. 30, 2021	Oct. 22, 2021
Cover [Abstract]
Document Type	10-Q
Document Quarterly Report	true
Document Period End Date	Sep. 30, 2021
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
Entity 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		55,254,806
Entity Central Index Key	0001125376
Current Fiscal Year End Date	--12-31
Document Fiscal Year Focus	2021
Document Fiscal Period Focus	Q3
Amendment Flag	false

UNAUDITED CONDENSED CONSOLIDATE

UNAUDITED CONDENSED CONSOLIDATED BALANCE SHEETS - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Current assets:
Cash and cash equivalents	$ 304,620	$ 236,562
Accounts receivable—less allowance for doubtful accounts of $11,267 and $8,718 at September 30, 2021 and December 31, 2020, respectively	313,858	305,062
Investments—current	12,844	13,449
Prepaid income taxes	4,136	1,224
Prepaid expenses and other current assets	32,660	26,659
Total current assets	668,118	582,956
Property and equipment, net	791,247	778,244
Right-of-use assets	1,175,685	1,025,510
Insurance subsidiary deposits and investments	35,180	32,105
Escrow deposits	0	100
Deferred tax assets	31,966	32,424
Restricted and other assets	44,382	33,155
Intangible assets, net	2,711	2,899
Goodwill	60,469	54,469
Other indefinite-lived intangibles	3,621	3,716
Total assets	2,813,379	2,545,578
Current liabilities:
Accounts payable	57,206	50,901
Accrued wages and related liabilities (Note 3)	246,106	236,614
Lease liabilities—current	52,050	48,187
Accrued self-insurance liabilities—current	38,730	34,396
Advance payment liabilities (Note 3)	0	102,023
Other accrued liabilities	85,469	87,318
Current maturities of long-term debt	3,548	2,960
Total current liabilities	483,109	562,399
Long-term debt—less current maturities	140,680	112,544
Long-term lease liabilities—less current portion	1,093,176	950,320
Accrued self-insurance liabilities—less current portion	68,299	62,402
Other long-term liabilities (Note 3)	48,821	39,686
Total liabilities	1,834,085	1,727,351
Commitments and contingencies (Notes 15, 17 and 18)
Ensign Group, Inc. stockholders' equity:
Common stock: $0.001 par value; 100,000 shares authorized; 58,059 and 55,247 shares issued and outstanding at September 30, 2021, respectively, and 57,417 and 54,626 shares issued and outstanding at December 31, 2020, respectively	58	58
Additional paid-in capital	363,779	338,177
Retained earnings	688,287	551,055
Common stock in treasury, at cost, 2,812 and 2,791 shares at September 30, 2021 and December 31, 2020, respectively (Note 19)	(72,924)	(71,213)
Total Ensign Group, Inc. stockholders' equity	979,200	818,077
Non-controlling interest	94	150
Total equity	979,294	818,227
Total liabilities and equity	$ 2,813,379	$ 2,545,578

UNAUDITED CONDENSED CONSOLIDA_2

UNAUDITED CONDENSED CONSOLIDATED BALANCE SHEETS (Parenthetical) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Statement of Financial Position [Abstract]
Allowance for doubtful accounts	$ 11,267	$ 8,718
Common stock, par value (usd per share)	$ 0.001	$ 0.001
Common stock, shares authorized (in shares)	100,000,000	100,000,000
Common stock, shares issued (in shares)	58,059,000	57,417,000
Common stock, shares outstanding (in shares)	55,247,000	54,626,000
Common stock in treasury, at cost (in shares)	2,812,000	2,791,000

UNAUDITED CONDENSED CONSOLIDA_3

UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF INCOME - USD ($) shares in Thousands, $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Total revenue	$ 668,530	$ 599,255	$ 1,934,319	$ 1,773,567
Expense:
Cost of services	514,106	465,108	1,484,816	1,371,378
Rent—cost of services	35,623	32,504	103,534	97,318
General and administrative expense	38,554	32,817	109,735	96,493
Depreciation and amortization	13,929	13,757	41,383	41,082
Total expenses	602,212	544,186	1,739,468	1,606,271
Income from operations	66,318	55,069	194,851	167,296
Other income (expense):
Interest expense	(1,709)	(1,740)	(4,984)	(7,698)
Other income (expense), net	248	850	2,117	2,630
Other expense, net	(1,461)	(890)	(2,867)	(5,068)
Income before provision for income taxes	64,857	54,179	191,984	162,228
Provision for income taxes	16,513	10,866	43,220	37,026
Net income	48,344	43,313	148,764	125,202
Less:
Net income attributable to noncontrolling interests	1,063	253	2,852	1,045
Net income attributable to The Ensign Group, Inc.	$ 47,281	$ 43,060	$ 145,912	$ 124,157
Net income per share attributable to The Ensign Group, Inc.:
Basic (in dollars per share)	$ 0.87	$ 0.81	$ 2.68	$ 2.33
Diluted (in dollars per share)	$ 0.83	$ 0.77	$ 2.56	$ 2.23
Weighted average common shares outstanding:
Basic (in shares)	54,627	53,328	54,430	53,299
Diluted (in shares)	56,971	55,713	56,954	55,585
Service revenue
Total revenue	$ 664,597	$ 595,341	$ 1,922,482	$ 1,762,371
Rental revenue
Total revenue	$ 3,933	$ 3,914	$ 11,837	$ 11,196

UNAUDITED CONDENSED CONSOLIDA_4

UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF STOCKHOLDERS' EQUITY - USD ($) shares in Thousands, $ in Thousands	Total	Common Stock	Additional Paid-In Capital	Retained Earnings	Treasury Stock	Non-Controlling Interest
Balance at beginning of period (in shares) at Dec. 31, 2019		53,487			2,079
Balance at beginning of period at Dec. 31, 2019	$ 656,144	$ 56	$ 307,914	$ 391,523	$ (45,296)	$ 1,947
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options (in shares)		148
Issuance of common stock to employees and directors resulting from the exercise of stock options	1,552		1,552
Issuance of restricted stock, net of forfeitures (in shares)		723
Issuance of restricted stock, net of forfeitures	3,086	$ 1	3,085
Dividends declared	(2,683)			(2,683)
Employee stock award compensation	3,235		3,235
Repurchase of common stock (Note 19) (in shares)		692			692
Repurchase of common stock (Note 19)	(25,000)				$ (25,000)
Net income attributable to noncontrolling interests	352					352
Distribution to noncontrolling interest holder	(720)					(720)
Net income attributable to the Ensign Group, Inc.	40,849			40,849
Balance at end of period (in shares) at Mar. 31, 2020		53,666			2,771
Balance at end of period at Mar. 31, 2020	676,815	$ 57	315,786	429,689	$ (70,296)	1,579
Balance at beginning of period (in shares) at Dec. 31, 2019		53,487			2,079
Balance at beginning of period at Dec. 31, 2019	656,144	$ 56	307,914	391,523	$ (45,296)	1,947
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Net income attributable to noncontrolling interests	1,045
Net income attributable to the Ensign Group, Inc.	124,157
Balance at end of period (in shares) at Sep. 30, 2020		54,135			2,791
Balance at end of period at Sep. 30, 2020	765,544	$ 57	328,347	507,554	$ (71,203)	789
Balance at beginning of period (in shares) at Mar. 31, 2020		53,666			2,771
Balance at beginning of period at Mar. 31, 2020	676,815	$ 57	315,786	429,689	$ (70,296)	1,579
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options (in shares)		31
Issuance of common stock to employees and directors resulting from the exercise of stock options	456		456
Issuance of restricted stock, net of forfeitures (in shares)		75
Shares of common stock used to satisfy tax withholding obligations (in shares)		17			17
Shares of common stock used to satisfy tax withholding obligations	(753)				$ (753)
Dividends declared	(2,718)			(2,718)
Employee stock award compensation	3,528		3,528
Net income attributable to noncontrolling interests	440					440
Distribution to noncontrolling interest holder	(240)					(240)
Net income attributable to the Ensign Group, Inc.	40,248			40,248
Balance at end of period (in shares) at Jun. 30, 2020		53,755			2,788
Balance at end of period at Jun. 30, 2020	717,776	$ 57	319,770	467,219	$ (71,049)	1,779
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options (in shares)		340
Issuance of common stock to employees and directors resulting from the exercise of stock options	4,404		4,404
Issuance of restricted stock, net of forfeitures (in shares)		43
Shares of common stock used to satisfy tax withholding obligations (in shares)		3			3
Shares of common stock used to satisfy tax withholding obligations	(154)				$ (154)
Dividends declared	(2,725)			(2,725)
Employee stock award compensation	4,173		4,173
Net income attributable to noncontrolling interests	253					253
Distribution to noncontrolling interest holder	(1,243)					(1,243)
Net income attributable to the Ensign Group, Inc.	43,060			43,060
Balance at end of period (in shares) at Sep. 30, 2020		54,135			2,791
Balance at end of period at Sep. 30, 2020	765,544	$ 57	328,347	507,554	$ (71,203)	789
Balance at beginning of period (in shares) at Dec. 31, 2020		54,626			2,791
Balance at beginning of period at Dec. 31, 2020	818,227	$ 58	338,177	551,055	$ (71,213)	150
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options (in shares)		246
Issuance of common stock to employees and directors resulting from the exercise of stock options	3,880		3,880
Issuance of restricted stock, net of forfeitures (in shares)		81
Issuance of restricted stock, net of forfeitures	3,725		3,725
Shares of common stock used to satisfy tax withholding obligations	(9)				$ (9)
Dividends declared	(2,886)			(2,886)
Employee stock award compensation	4,054		4,054
Net income attributable to noncontrolling interests	631					631
Distribution to noncontrolling interest holder	(1,248)					(1,248)
Net income attributable to the Ensign Group, Inc.	49,206			49,206
Balance at end of period (in shares) at Mar. 31, 2021		54,953			2,791
Balance at end of period at Mar. 31, 2021	875,580	$ 58	349,836	597,375	$ (71,222)	(467)
Balance at beginning of period (in shares) at Dec. 31, 2020		54,626			2,791
Balance at beginning of period at Dec. 31, 2020	818,227	$ 58	338,177	551,055	$ (71,213)	150
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Net income attributable to noncontrolling interests	2,852
Net income attributable to the Ensign Group, Inc.	145,912
Balance at end of period (in shares) at Sep. 30, 2021		55,247			2,812
Balance at end of period at Sep. 30, 2021	979,294	$ 58	363,779	688,287	$ (72,924)	94
Balance at beginning of period (in shares) at Mar. 31, 2021		54,953			2,791
Balance at beginning of period at Mar. 31, 2021	875,580	$ 58	349,836	597,375	$ (71,222)	(467)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options (in shares)		148
Issuance of common stock to employees and directors resulting from the exercise of stock options	2,982		2,982
Issuance of restricted stock, net of forfeitures (in shares)		49
Shares of common stock used to satisfy tax withholding obligations (in shares)		20			20
Shares of common stock used to satisfy tax withholding obligations	(1,600)				$ (1,600)
Dividends declared	(2,894)			(2,894)
Employee stock award compensation	4,633		4,633
Net income attributable to noncontrolling interests	1,158					1,158
Distribution to noncontrolling interest holder	(641)					(641)
Net income attributable to the Ensign Group, Inc.	49,425			49,425
Balance at end of period (in shares) at Jun. 30, 2021		55,130			2,811
Balance at end of period at Jun. 30, 2021	928,643	$ 58	357,451	643,906	$ (72,822)	50
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Issuance of common stock to employees and directors resulting from the exercise of stock options (in shares)		69
Issuance of common stock to employees and directors resulting from the exercise of stock options	1,246		1,246
Issuance of restricted stock, net of forfeitures (in shares)		49
Shares of common stock used to satisfy tax withholding obligations (in shares)		1			1
Shares of common stock used to satisfy tax withholding obligations	(102)				$ (102)
Dividends declared	(2,900)			(2,900)
Employee stock award compensation	5,082		5,082
Net income attributable to noncontrolling interests	1,063					1,063
Distribution to noncontrolling interest holder	(1,019)					(1,019)
Net income attributable to the Ensign Group, Inc.	47,281			47,281
Balance at end of period (in shares) at Sep. 30, 2021		55,247			2,812
Balance at end of period at Sep. 30, 2021	$ 979,294	$ 58	$ 363,779	$ 688,287	$ (72,924)	$ 94

UNAUDITED CONDENSED CONSOLIDA_5

UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF STOCKHOLDERS' EQUITY (Parenthetical) - $ / shares	3 Months Ended
	Sep. 30, 2021	Jun. 30, 2021	Mar. 31, 2021	Sep. 30, 2020	Jun. 30, 2020	Mar. 31, 2020
Statement of Stockholders' Equity [Abstract]
Dividends per share (in dollars per share)	$ 0.0525	$ 0.0525	$ 0.0525	$ 0.0500	$ 0.0500	$ 0.0500

UNAUDITED CONDENSED CONSOLIDA_6

UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($)	9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020
Cash flows from operating activities:
Net income	$ 148,764,000	$ 125,202,000
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation and amortization	41,383,000	41,082,000
Impairment of long-lived assets	0	2,681,000
Amortization of deferred financing fees	637,000	630,000
Non-cash leasing arrangement	346,000	337,000
Deferred income taxes	458,000	1,179,000
Provision for doubtful accounts	2,609,000	4,193,000
Stock-based compensation	13,769,000	10,936,000
Loss on sale of asset disposals	155,000	282,000
Change in operating assets and liabilities
Accounts receivable	(16,606,000)	11,441,000
Prepaid income taxes	(2,912,000)	(12,811,000)
Prepaid expenses and other assets	(6,061,000)	(2,090,000)
Cash surrender value of life insurance policy premiums	(9,505,000)	(5,378,000)
Operating lease obligations	(5,668,000)	(542,000)
Deferred compensation liability	9,607,000	5,412,000
Accounts payable	6,332,000	7,197,000
Accrued wages and related liabilities	14,112,000	31,551,000
Income taxes payable	357,000	0
Other accrued liabilities	(2,907,000)	19,333,000
Accrued self-insurance liabilities	9,796,000	8,433,000
Other long-term liabilities	(177,000)	33,093,000
Net cash provided by operating activities	204,489,000	282,161,000
Cash flows from investing activities:
Purchase of property and equipment	(50,133,000)	(37,824,000)
Cash payments for business acquisitions (Note 8)	(6,000,000)	0
Cash payments for asset acquisitions (Note 8)	(5,183,000)	(23,077,000)
Escrow deposits	100,000	(35,000)
Escrow deposits used to fund acquisitions	0	14,050,000
Cash from insurance proceeds	6,705,000	0
Cash proceeds from the sale of assets and ancillary business	951,000	359,000
Purchases of investments	(26,387,000)	(14,648,000)
Maturities of investments	23,917,000	13,626,000
Other restricted assets	(1,839,000)	(936,000)
Net cash used in investing activities	(57,869,000)	(48,485,000)
Cash flows from financing activities:
Proceeds from debt (Note 15)	31,646,000	380,600,000
Payments on debt (Note 15)	(2,146,000)	(592,255,000)
Issuance of common stock upon exercise of options	8,108,000	6,412,000
Repurchase of shares of common stock to satisfy tax withholding obligations	(1,711,000)	(907,000)
Repurchase of shares of common stock (Note 19)	0	(25,000,000)
Dividends paid	(8,647,000)	(8,106,000)
Non-controlling interest distribution	(2,908,000)	(2,203,000)
Payments of deferred financing costs	(881,000)	0
Proceeds from CARES Act Provider Relief Fund and Medicare Advance Payment Program (Note 3)	11,637,000	235,976,000
Repayments of CARES Act Provider Relief Fund and Medicare Advance Payment Program (Note 3)	(113,660,000)	(111,988,000)
Net cash used in financing activities	(78,562,000)	(117,471,000)
Net increase in cash and cash equivalents	68,058,000	116,205,000
Cash and cash equivalents beginning of period	236,562,000	59,175,000
Cash and cash equivalents end of period	304,620,000	175,380,000
Cash paid during the period for:
Interest	4,265,000	8,467,000
Income taxes	45,440,000	48,620,000
Lease liabilities	103,067,000	97,533,000
Non-cash financing and investing activity:
Accrued capital expenditures	3,500,000	2,900,000
Accrued dividends declared	2,900,000	2,725,000
Right-of-use assets obtained in exchange for new and modified operating lease obligations	$ 175,617,000	$ 14,669,000

Description of Business

Description of Business	9 Months Ended
	Sep. 30, 2021
Organization, Consolidation and Presentation of Financial Statements [Abstract]
DESCRIPTION OF BUSINESS	DESCRIPTION OF BUSINESS The Company — The Ensign Group, Inc. (collectively, Ensign or the Company), is a holding company with no direct operating assets, employees or revenue. The Company, through its operating subsidiaries, is a provider of health care services across the post-acute care continuum, engaged in the ownership, acquisition, development and leasing of skilled nursing, senior living and other healthcare-related properties and other ancillary businesses. As of September 30, 2021, the Company operated 242 facilities and other ancillary operations located in Arizona, California, Colorado, Idaho, Iowa, Kansas, Nebraska, Nevada, South Carolina, Texas, Utah, Washington and Wisconsin. The Company's operating subsidiaries, each of which strives to be the operation of choice in the community it serves, provide a broad spectrum of skilled nursing, senior living and other ancillary services. The Company's operating subsidiaries have a collective capacity of approximately 24,700 operational skilled nursing beds and 2,200 senior living units. As of September 30, 2021, the Company operated 177 facilities under long-term lease arrangements, and had options to purchase 11 of those 177 facilities. The Company's real estate portfolio includes 95 owned real estate properties, which included 65 facilities operated and managed by the Company, 31 senior living operations leased to and operated by The Pennant Group, Inc., or Pennant, as part of the spin-off transaction that occurred in October 2019, and the Service Center location. Of those 31 senior living operations, two are located on the same real estate properties as skilled nursing facilities that the Company owns and operates. Certain of the Company’s wholly-owned independent subsidiaries, collectively referred to as the Service Center, provide specific accounting, payroll, human resources, information technology, legal, risk management and other centralized services to the other operating subsidiaries through contractual relationships with such subsidiaries. The Company also has a wholly-owned captive insurance subsidiary (the Captive) that provides some claims-made coverage to the Company’s operating subsidiaries for general and professional liabilities, as well as coverage for certain workers’ compensation insurance liabilities. Each of the Company's affiliated operations are operated by separate, wholly-owned, independent subsidiaries that have their own management, employees and assets. References herein to the consolidated “Company” and “its” assets and activities in this Quarterly Report is not meant to imply, nor should it be construed as meaning that The Ensign Group, Inc. has direct operating assets, employees or revenue, or that any of the subsidiaries, are operated by The Ensign Group, Inc. Segment Updates — In the fourth quarter of 2020, the Company began reporting the results of its real estate portfolio as a new segment. The Company has two reportable segments: (1) skilled services and (2) real estate. Refer to Note 7, Business Segments , for additional information. Corresponding items of segment information for prior periods have been recast to reflect the change of the Company’s segment structure. This structure reflects its current operational and financial management and provides the best structure for the Company to focus on growth and investing opportunities while maintaining financial discipline. Other Information — The accompanying condensed consolidated financial statements as of September 30, 2021 and for the three and nine months ended September 30, 2021 and 2020 (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, 2020 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.

Summary of Significant Accounti

Summary of Significant Accounting Policies	9 Months Ended
	Sep. 30, 2021
Accounting Policies [Abstract]
SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES	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 operations, senior living operations and related ancillary services. All intercompany transactions and balances have been eliminated in consolidation. The Company presents noncontrolling interests within the equity section of its condensed consolidated balance sheets and 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. Additionally, 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 are 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 nine months ended September 30, 2021 and 2020. Reclassifications — Certain prior period results have been reclassified to be consistent with the current period presentation, including presenting the change of the deferred compensation separately on the Company's Consolidated Statements of Cash Flows. Prior period results also reflect reclassifications, for comparative purposes, related to the change in the Company's segment structure. Refer to Note 7, Business Segments , for additional information related to segments. Prior to the fourth quarter of 2020, the Company only presented total revenue for all revenue services. As a result of the change in segments, the presentation of the Company's service revenue and rental revenue are presented separately on the Company's Condensed Consolidated Statements of Income. The reclassifications had no effect on the reported condensed consolidated results of operations. 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, acquired property and equipment, intangible assets and goodwill, right-of-use assets, impairment of long-lived assets, lease liabilities, general and professional liabilities, 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. Contracts insuring the lives of certain employees who are eligible to participate in non-qualified deferred compensation plans are held in a rabbi trust. Cash surrender value of the contracts is based on performance measurement funds that shadow the deferral investment allocations made by participants in the deferred compensation plan. The fair value of the pooled investment funds is derived using Level 2 inputs. Service Revenue Recognition — The Company recognizes revenue in accordance with Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) Topic 606, Revenue from Contracts with Customers (ASC 606). See Note 4, Revenue and Accounts Receivable. Rental Revenue Recognition — The Company recognizes rental revenue for operating leases on a straight-line basis over the lease term when collectability of all minimum lease payments is probable in accordance with FASB ASC Topic 842, Leases (ASC 842). 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. 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 Leases and Leasehold Improvements — The Company leases skilled nursing facilities, senior living facilities and commercial office space. The Company determines if an arrangement is a lease at the inception of each lease. Leases commencing prior to the ASC 842 adoption date were classified as operating lease under historical guidance. As the Company has elected the package of practical expedients allowing it to not reassess lease classification, these leases are classified as operating leases under ASC 842 as well. For leases commencing subsequent to the ASC 842 adoption date, the Company performs an evaluation to determine whether the lease should be classified as an operating or finance lease at the inception of the lease. As of September 30, 2021, the Company does not have any leases that are classified as finance leases. Rights and obligations of operating leases are included as 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 utilized a third-party valuation specialist to assist in estimating the incremental borrowing rate. 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. Renewals are not assumed in the determination of the lease term unless they are deemed to be reasonably assured at the inception of the lease. 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's real estate leases generally have initial lease terms of ten years or more and typically include one or more options to renew, with renewal terms that generally extend the lease term for an additional ten 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 determined there was no impairment during the three and nine months ended September 30, 2021. The Company recorded an impairment charge of $2,681 during the three and nine months ended September 30, 2020. Intangible Assets and Goodwill — Definite-lived intangible assets consist primarily of patient base, facility trade names and customer relationships. Patient base is amortized over a period of four 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 indicate that its carrying value may not be recoverable. The Company performs its annual test for impairment during the fourth quarter of each year. The Company did not identify any goodwill or intangible asset impairment during the three and nine months ended September 30, 2021 and 2020. Self-Insurance — The Company is partially self-insured for general and professional liability claims 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 majority of the self-insured retention and deductible limits for general and professional liabilities and workers' compensation liabilities 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 actuarial estimated costs to settle open claims of insureds, as well as an estimate of the cost of insured claims that have been incurred but not reported. The Company develops information about the size of the ultimate claims based on historical experience, current industry information and actuarial analysis, and evaluates the estimates for claim loss exposure on a quarterly basis. The Company uses actuarial valuations to estimate the liability based on historical experience and industry information. Accrued general liability and professional malpractice liabilities on an undiscounted basis, net of anticipated insurance recoveries, were $63,689 and $57,628 as of September 30, 2021 and December 31, 2020, respectively. The Company’s operating subsidiaries are self-insured for workers’ compensation liabilities 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 $625 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington, are under a loss sensitive plan that insures individual claims that exceed $350 per occurrence. In the state of Washington, the Company is self insured and has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. For all of the self insured plans and retention, 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 $25,968 and $24,499 as of September 30, 2021 and December 31, 2020, respectively. In addition, the Company has recorded an asset and equal liability of $7,573 and $7,138 as of September 30, 2021 and December 31, 2020, 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 $500 for each covered person for fiscal year 2021. The Company’s accrued liability under these plans recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets was $9,799 and $7,533 as of September 30, 2021 and December 31, 2020, 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 liabilities exceed its estimates of losses, 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. 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. Stock-Based Compensation — The Company measures and recognizes compensation expense for all stock-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 FASB 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 December 2019, the FASB issued Accounting Standards Update (ASU) 2019-12 "Simplifying the Accounting for Income Taxes (Topic 740)" as part of its simplification initiative to reduce the cost and complexity in accounting for income taxes. ASU 2019-12 removes certain exceptions related to the approach for intra-period tax allocation, the methodology for calculating income taxes in an interim period and the recognition of deferred tax liabilities for outside basis differences. ASU 2019-12 also amends other aspects of the guidance to help simplify and promote consistent application of GAAP. The Company adopted this standard on January 1, 2021 and determined there was no material impact on the Company's financial position, results of operations and liquidity. In May 2020, the SEC issued Final Rule Release No. 33-10786 “ Amendments to Financial Disclosures about Acquired and Disposed Businesses ” (“SEC Rule 33-10786”), which amends the disclosure requirements applicable to acquisitions and dispositions of businesses. Amendments within SEC Rule 33-10786 primarily impact (1) the tests and thresholds used to determine the significance of acquisitions and dispositions; (2) the form and content of pro forma information required to be disclosed in connection with significant acquisitions and dispositions; (3) acquiree financial statement requirements; and (4) thresholds used to determine the significance of acquisitions and dispositions of real estate operations, and related financial statement requirements, among others. The Company adopted this standard on January 1, 2021 and determined there was no material impact on the Company's condensed consolidated financial statements. Accounting Standards Recently Issued but Not Yet Adopted by the Company In February 2020, the FASB issued ASU 2020-04 "Reference Rate Reform (Topic 848)," which provides temporary, optional practical expedients and exceptions to enable a smoother transition to reference rates which are expected to replace LIBOR reference rates. Adoption of the provisions of ASU 2020-04 is optional. The amendments are effective for all entities from the beginning of the interim period that includes the issuance date of the ASU. An entity may elect to apply the amendments prospectively through December 31, 2022. The Company is currently evaluating the impact of ASU 2020-04 on its financial position, results of operations and liquidity. In November 2020, the SEC issued final rules 33-10890 and 34-90459 “ Management’s Discussion and Analysis, Selected Financial Data, and Supplementary Financial Information ,” which modernizes and simplifies certain disclosure requirements of Regulation S-K. Certain key rule amendments eliminate the requirement to disclose Selected Financial Data; Selected Quarterly Financial Data, with certain exceptions; the impact of inflation and changing prices, provided the impact is not material; off-balance sheet arrangements in tabular form; and the aggregate amount of contractual obligations in tabular form. The final rules also amended various aspects of Item 303, “ Management’s Discussion and Analysis of Financial Condition and Results of Operations ,” among others. The final rules are effective for all registration statements and annual reports filed on or after August 9, 2021, with early adoption permitted. The Company is currently evaluating the impact of the disclosure changes in its annual reports. In July 2021, the FASB issued ASU 2021-05 “ Lessors—Certain Leases with Variable Lease Payments (Topic 842), ” which amends the lessor classification guidance to introduce additional criteria when classifying leases with variable lease payments that do not depend on a reference index or a rate. This guidance is effective for annual periods beginning after December 15, 2021, which will be the Company's fiscal year 2022, with early adoption permitted. The Company has not yet determined the effect of the ASU 2021-05 on its results of operations, financial condition or cash flows.

COVID-19 Update

COVID-19 Update	9 Months Ended
	Sep. 30, 2021
Unusual or Infrequent Items, or Both [Abstract]
COVID-19 UPDATE	COVID-19 UPDATE The Company's affiliated operations continued to be impacted by the worldwide outbreak of the 2019 coronavirus disease (COVID-19). The Company received cash distribution of relief fund payments (Provider Relief Funds) from the Coronavirus Aid, Relief, and Economic Security Act of 2020 (the CARES Act) and funds authorized by U.S. Department of Health and Human Services (HHS) to be used to protect residents of nursing homes and long-term care facilities from the impact of COVID-19 throughout 2020 and 2021. During the three and nine months ended September 30, 2021, the Company received and returned $99 and $11,637, respectively, in Provider Relief Funds. During both the three and nine months ended September 30, 2020, the Company received $23,296 and $132,052, respectively, in Provider Relief Funds, of which $108,756 was returned in the third quarter of 2020. The remaining amount received was subsequently returned in the fourth quarter of 2020. The Company may continue to receive additional funding in future periods. In fiscal year 2020, the Company applied for and received $105,255 through the Medicare Accelerated and Advance Payment Program under the CARES Act. The purpose of the program is to assist in providing needed liquidity to care delivery providers. The Company repaid $3,232 of the funds in 2020. In March 2021, the Company repaid the remaining funds of $102,023.

Revenue and Accounts Receivable

Revenue and Accounts Receivable	9 Months Ended
	Sep. 30, 2021
Revenue from Contract with Customer [Abstract]
REVENUE AND ACCOUNTS RECEIVABLE	REVENUE AND ACCOUNTS RECEIVABLE Service Revenue The Company's service revenue is derived primarily from providing healthcare services to its patients. Revenue is 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 skilled 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 on a per day basis, 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 73.6% for both the three and nine months ended September 30, 2021, and 75.5% and 74.0% for the three and nine months ended September 30, 2020, respectively. Settlements 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 the final settlement. The Company recorded adjustments to revenue which were not material to the Company's consolidated revenue for the three and nine months ended September 30, 2021 and 2020. Rental Revenue The Company's rental revenues are primarily generated by leasing healthcare-related properties through triple-net lease arrangements, under which the tenant is solely responsible for the costs related to the property. Revenue is recognized on a straight-line basis over the lease term if it has been deemed probable of collection. The Company has elected the single component practical expedient, which allows a lessor, by class of underlying asset, not to allocate the total consideration to the lease and non-lease components based on their relative stand-alone selling prices where certain criteria are met. This single component practical expedient requires the Company to account for the lease component and non-lease component(s) associated with that lease as a single component if (1) the timing and pattern of transfer of the lease component and the non-lease component(s) associated with it are the same and (2) the lease component would be classified as an operating lease if it were accounted for separately. If the Company determines that the lease component is the predominant component, it accounts for the single component as an operating lease in accordance with the new lease standards. Conversely, the Company is required to account for the combined component under the revenue recognition standard if it determines that the non-lease component is the predominant component. As a result of this assessment, rental revenues from the lease of real estate assets that qualify for this expedient are accounted for as a single component under the new lease standards. The components of the Company's operating leases qualify for the single component presentation. Tenant reimbursements related to property taxes and insurance are neither considered lease nor non-lease components under the new lease standards. Lessee payments for taxes and insurance paid directly to a third party, on behalf of the Company, are excluded from variable lease payments and rental revenue in the Company’s condensed consolidated statements of income. Otherwise, tenant reimbursements for taxes and insurance that are paid by the Company directly to a third party are classified as additional rental revenue and expense and recognized by the Company on a gross basis. Disaggregation of Revenue The Company disaggregates revenue from contracts with its patients by 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. Revenue by Payor The Company’s revenue is derived primarily from providing 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. Service revenue for the three and nine months ended September 30, 2021 and 2020 is summarized in the following tables: Three Months Ended September 30, 2021 2020 Revenue % of Revenue Revenue % of Revenue Medicaid (1) $ 267,008 40.2 % $ 222,192 37.3 % Medicare 176,660 26.6 189,237 31.8 Medicaid — skilled 45,308 6.8 38,232 6.4 Total Medicaid and Medicare 488,976 73.6 449,661 75.5 Managed care 114,917 17.3 87,648 14.7 Private and other (2) 60,704 9.1 58,032 9.8 Service revenue $ 664,597 100.0 % $ 595,341 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP for the three months ended September 30, 2021 and 2020 . (2) Private and other payors also includes revenue from all payors generated in other an cillary services for the three months ended September 30, 2021 and 2020 . Nine Months Ended September 30, 2021 2020 Revenue % of Revenue Revenue % of Revenue Medicaid (1) $ 749,821 39.0 % $ 672,506 38.2 % Medicare 536,971 27.9 519,865 29.5 Medicaid — skilled 128,041 6.7 110,626 6.3 Total Medicaid and Medicare 1,414,833 73.6 1,302,997 74.0 Managed care 336,225 17.5 271,993 15.4 Private and other (2) 171,424 8.9 187,381 10.6 Service revenue $ 1,922,482 100.0 % $ 1,762,371 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP for the nine months ended September 30, 2021 and 2020. (2) Private and other payors also includes revenue from all payors generated in other ancillary services for the nine months ended September 30, 2021 and 2020. In addition to the service revenue above, the Company's rental revenue derived from triple-net lease arrangements with third parties is $3,933 and $11,837, respectively, for the three and nine months ended September 30, 2021 and $3,914 and $11,196, respectively, for the three and nine months ended September 30, 2020. Balance Sheet Impact Included in the Company’s condensed consolidated balance sheets are contract balances, 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 and contract assets as of September 30, 2021 and December 31, 2020, or activity during the three and nine months ended September 30, 2021 and 2020. Accounts receivable as of September 30, 2021 and December 31, 2020, is summarized in the following table: September 30, 2021 December 31, 2020 Medicaid $ 118,102 $ 102,077 Managed care 74,902 61,743 Medicare 56,343 80,904 Private and other payors 75,778 69,056 325,125 313,780 Less: allowance for doubtful accounts (11,267) (8,718) Accounts receivable, net $ 313,858 $ 305,062 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	9 Months Ended
	Sep. 30, 2021
Earnings Per Share [Abstract]
COMPUTATION OF NET INCOME PER COMMON SHARE	COMPUTATION OF NET INCOME PER COMMON SHAREBasic net income per share is computed by dividing income from 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 September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Numerator: Net income $ 48,344 $ 43,313 $ 148,764 $ 125,202 Less: net income attributable to noncontrolling interests 1,063 253 2,852 1,045 Net income attributable to The Ensign Group, Inc. $ 47,281 $ 43,060 $ 145,912 $ 124,157 Denominator: Weighted average shares outstanding for basic net income per share 54,627 53,328 54,430 53,299 Basic net income per common share: $ 0.87 $ 0.81 $ 2.68 $ 2.33 A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Numerator: Net income $ 48,344 $ 43,313 $ 148,764 $ 125,202 Less: net income attributable to noncontrolling interests 1,063 253 2,852 1,045 Net income attributable to The Ensign Group, Inc. $ 47,281 $ 43,060 $ 145,912 $ 124,157 Denominator: Weighted average common shares outstanding 54,627 53,328 54,430 53,299 Plus: incremental shares from assumed conversion (1) 2,344 2,385 2,524 2,286 Adjusted weighted average common shares outstanding 56,971 55,713 56,954 55,585 Diluted net income per common share: $ 0.83 $ 0.77 $ 2.56 $ 2.23 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 365 and 139 fo r the three and nine months ended September 30, 2021, respectively, and 1,144 and 979 for the three and nine months ended September 30, 2020, respectivel

Fair Value Measurements

Fair Value Measurements	9 Months Ended
	Sep. 30, 2021
Fair Value Disclosures [Abstract]
FAIR VALUE MEASUREMENTS	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 fair value of cash and cash equivalents of $304,620 and $236,562 as of September 30, 2021 and December 31, 2020, respectively, is derived using Level 1 inputs. The Company's other financial assets include contracts insuring the lives of certain employees who are eligible to participate in non-qualified deferred compensation plans which are held in a rabbi trust. The cash surrender value of these contracts is based on performance measurement funds that shadow the deferral investment allocations made by participants in the deferred compensation plan. As of September 30, 2021, and December 31, 2020, the fair value of the pooled investment funds of $16,082 and $6,577, respectively, is derived using Level 2 inputs. The pooled investment funds are included in restricted and other assets in the Condensed Consolidated Balance Sheets. See Note 12 Restricted and Other Assets. The Company's non-financial assets, which includes goodwill, intangible assets, property and equipment and right-of-use assets, 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. Debt Security Investments - Held to Maturity As of September 30, 2021 and December 31, 2020, the Company had approximately $48,024 and $45,554, 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 September 30, 2021, the debt security investments were held in AA, A and BBB r ated de bt securities. The Company believes its debt security investments that were in an unrealized loss position as of September 30, 2021 were not other-than-temporarily impaired, nor has any event occurred subsequent to that date that would indicate any other-than-temporary impairment.

Business Segments

Business Segments	9 Months Ended
	Sep. 30, 2021
Segment Reporting [Abstract]
BUSINESS SEGMENTS	BUSINESS SEGMENTS In the fourth quarter of 2020, the Company's Chief Executive Officer, who is its chief operating decision maker, or CODM, began reviewing the results of the Company's real estate portfolio. Accordingly, the Company began reporting a new segment as it continues to expand its real estate investment strategy. The Company has two reportable segments: (1) skilled services, which includes the operation of skilled nursing facilities and rehabilitation therapy services and (2) real estate, which is comprised of properties owned by the Company and leased to skilled nursing and assisted living operations where the properties are subject to triple-net long-term leases, including operations that are owned and operated by the Company. Prior to this new segment structure, the Company had one reportable segment, skilled services. Corresponding items of segment information for prior periods have been recast to reflect the change of the Company’s segment structure. As of September 30, 2021, the skilled services segment includes 211 skilled nursing operations and 22 campus operations that provide both skilled nursing and rehabilitative care services and senior living services. The Company's real estate segment includes 95 owned real estate properties. These properties include 65 operations the Company operated and managed, real estate properties of 31 senior living operations that are leased to and operated by Pennant and the Service Center location, which continues to lease office space to various third parties. Of the 31 real estate operations leased to Pennant, two senior living operations are located on the same real estate properties as skilled nursing facilities that the Company owns and operates. The Company also reports an “All Other” category that includes results from its senior living operations, which includes nine stand-alone senior living operations and 22 campus operations that provide both skilled nursing and rehabilitative care services and senior living services, mobile diagnostics, medical transportation and other ancillary operations. Services included in the “All Other” category are insignificant individually, and therefore do not constitute a reportable segment. The Company’s reportable segments are significant operating segments that offer differentiated services. The Company's CODM reviews financial information for each operating segment to evaluate performance and allocate capital resources. This structure reflects its current operational and financial management and provides the best structure to maximize the quality of care and investment strategy provided, while maintaining financial discipline. The Company's CODM does not review assets by segment in his resource allocation and therefore assets by segment are not disclosed below. Beginning in the fourth quarter of 2020, segment income and loss was changed from profit or loss from operations before interest and provision for income taxes to profit or loss from operations before provision for income taxes, excluding gain or loss from sale of real estate, insurance recoveries and impairment charges from operations. Prior period presentation has been revised to reflect the new measurement. With the exception of intercompany rental revenue, the accounting policies of the reportable segments are the same as those described in Note 2, Summary of Significant Accounting Policies . Rental revenue from Ensign-affiliated operations are based on mutually agreed-upon base rent that are subject to change from time to time. Intercompany revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of the related healthcare facilities. Included in the real estate segment income is interest expense related to the borrowings to fund real estate acquisitions. The following tables set forth financial information for the segments: Three Months Ended September 30, 2021 Skilled Services Real Estate All Other (1) Intercompany Elimination (2) Total Service revenue $ 642,075 $ — $ 22,522 $ — $ 664,597 Rental revenue — 16,271 — (12,338) 3,933 Total revenue $ 642,075 $ 16,271 $ 22,522 $ (12,338) $ 668,530 Segment income (loss) 94,429 8,910 (38,482) — 64,857 Income before provision for income taxes $ 64,857 Depreciation and amortization 7,715 4,936 1,278 — 13,929 Other expense (income), net (3) $ — $ 1,705 $ (244) $ — $ 1,461 (1) General and administrative expense are included in the "all other" category. (2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities. (3) Other expense (income), net includes interest expense, interest income and gain and loss on investments. Three Months Ended September 30, 2020 Skilled Services Real Estate All Other (1) Intercompany Elimination (2) Total Service revenue $ 570,282 $ — $ 25,059 $ — $ 595,341 Rental revenue — 15,536 — (11,622) 3,914 Total revenue $ 570,282 $ 15,536 $ 25,059 $ (11,622) $ 599,255 Segment income (loss) 84,747 8,474 (36,289) — 56,932 Loss on sale of real estate and impairment charges (2,753) Income before provision for income taxes $ 54,179 Depreciation and amortization 7,094 4,522 2,141 — 13,757 Other expense (income), net (3) $ — $ 1,731 $ (841) $ — $ 890 (1) General and administrative expense is included in the "all other" category (2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities. (3) Other expense (income), net includes interest expense and interest income. Nine Months Ended September 30, 2021 Skilled Services Real Estate All Other (1) Intercompany Elimination (2) Total Service revenue $ 1,855,993 $ — $ 66,489 $ — $ 1,922,482 Rental revenue — 48,181 — (36,344) 11,837 Total revenue $ 1,855,993 $ 48,181 $ 66,489 $ (36,344) $ 1,934,319 Segment income (loss) 273,370 26,622 (108,448) — 191,544 Gain on sale of real estate 440 Income before provision for income taxes $ 191,984 Depreciation and amortization 22,893 14,413 4,077 — 41,383 Other expense (income), net (3) $ — $ 4,980 $ (2,113) $ — $ 2,867 (1) General and administrative expense are included in the "all other" category. (2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities. (3) Other expense, net includes interest expense, interest income and gain and loss on investments. Nine Months Ended September 30, 2020 Skilled Services Real Estate All Other (1) Intercompany Elimination (2) Total Service revenue $ 1,685,263 $ — $ 77,108 $ — $ 1,762,371 Rental revenue — 45,489 — (34,293) 11,196 Total revenue $ 1,685,263 $ 45,489 $ 77,108 $ (34,293) $ 1,773,567 Segment income (loss) 243,640 22,593 (101,252) — 164,981 Loss on sale of real estate and impairment charges (2,753) Income before provision for income taxes $ 162,228 Depreciation and amortization 21,247 13,624 6,211 — 41,082 Other expense (income), net (3) $ — $ 7,689 $ (2,621) $ — $ 5,068 (1) General and administrative expense is included in the "all other" category (2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities. (3) Other expense, net includes interest expense and interest income. Service revenue by major payor source were as follows: Three Months Ended September 30, 2021 Skilled Services All Other Total Service Revenue Revenue % Medicaid $ 263,072 $ 3,936 (1) $ 267,008 40.2 % Medicare 176,660 — 176,660 26.6 Medicaid-skilled 45,308 — 45,308 6.8 Subtotal 485,040 3,936 488,976 73.6 Managed care 114,917 — 114,917 17.3 Private and other 42,118 18,586 (2) 60,704 9.1 Total service revenue $ 642,075 $ 22,522 $ 664,597 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP for the three months ended September 30, 2021. (2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the three months ended September 30, 2021. Three Months Ended September 30, 2020 Skilled Services All Other Total Service Revenue Revenue % Medicaid $ 218,840 $ 3,352 (1) $ 222,192 37.3 % Medicare 189,237 — 189,237 31.8 Medicaid-skilled 38,232 — 38,232 6.4 Subtotal 446,309 3,352 449,661 75.5 Managed care 87,648 — 87,648 14.7 Private and other 36,325 21,707 (2) 58,032 9.8 Total service revenue $ 570,282 $ 25,059 $ 595,341 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP for the three months ended September 30, 2020. (2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the three months ended September 30, 2020. Nine Months Ended September 30, 2021 Skilled Services All Other Total Service Revenue Revenue % Medicaid $ 738,484 $ 11,337 (1) $ 749,821 39.0 % Medicare 536,971 — 536,971 27.9 Medicaid-skilled 128,041 — 128,041 6.7 Subtotal 1,403,496 11,337 1,414,833 73.6 Managed care 336,225 — 336,225 17.5 Private and other 116,272 55,152 (2) 171,424 8.9 Total service revenue $ 1,855,993 $ 66,489 $ 1,922,482 100.0 % (1) Medicaid payor includes revenue generated from senior living operations and revenue related to FMAP for the nine months ended September 30, 2021. (2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the nine months ended September 30, 2021. Nine Months Ended September 30, 2020 Skilled Services All Other Total Service Revenue Revenue % Medicaid $ 662,733 $ 9,773 (1) $ 672,506 38.2 % Medicare 519,865 — 519,865 29.5 Medicaid-skilled 110,626 — 110,626 6.3 Subtotal 1,293,224 9,773 1,302,997 74.0 Managed care 271,993 — 271,993 15.4 Private and other 120,046 67,335 (2) 187,381 10.6 Total service revenue $ 1,685,263 $ 77,108 $ 1,762,371 100.0 % (1) Medicaid payor includes revenue generated from senior living operations and revenue related to FMAP for the nine months ended September 30, 2020. (2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the nine months ended September 30, 2020. In addition to the service revenue above, the Company's rental revenue derived from triple-net lease arrangements with third parties is $3,933 and $11,837, respectively, for the three and nine months ended September 30, 2021 and $3,914 and $11,196, respectively, for the three and nine months ended September 30, 2020.

Operation Expansions

Operation Expansions	9 Months Ended
	Sep. 30, 2021
Business Combination and Asset Acquisition [Abstract]
Operation Expansions	OPERATION EXPANSIONS The Company's subsidiaries expansion focus 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, a real estate affiliated subsidiary will acquire the property of facilities that have previously been operated under third-party leases. 2021 Expansions During the nine months ended September 30, 2021, the Company expanded its operations through a combination of long-term leases and a real estate purchase, with the addition of fourteen stand-alone skilled nursing operations. Of these additions, one is related to a purchase of owned property, further expanding the Company's real estate portfolio. These new operations added a total of 1,504 operational skilled nursing beds operated by the Company's affiliated operating subsidiaries. The aggregate purchase price for these acquisitions during the nine months ended September 30, 2021 was $11,183 . In connection with the new operations made through long-term leases, the Company did not acquire any material assets or assume any liabilities other than the tenant's post-assumption rights and obligations under the long-term lease. The Company entered into a separate operations transfer agreement with the prior operator as part of each transaction. The fair value of assets for ten of the acquisitions was concentrated in property and equipment and as such, the transaction was classified as an asset acquisition. The aggregate purchase price for the asset acquisitions during the nine months ended September 30, 2021 was $5,183 , which primarily consists of building and improvements of $4,547. The fair value of assets for the remaining four additions was concentrated in goodwill of $6,000 and as such, the transaction was classified as a business combination. Subsequent to September 30, 2021, the Company expanded its operations through long-term leases with the addition of three stand-alone skilled nursing operations. These new operations added 328 operational skilled nursing beds to be operated by the Company's affiliated operating subsidiaries. 2020 Expansions During the nine months ended September 30, 2020, the Company expanded its operations through a combination of long-term leases and real estate purchases, with the addition of three stand-alone skilled nursing operations, one stand-alone senior living operation and one campus operation. Of these additions, three are related to purchases of owned properties, further expanding the Company's real estate portfolio. These new operations added a total of 303 operational skilled nursing beds and 298 operational senior living units to be operated by the Company's affiliated operating subsidiaries. In connection with the new operations made through long-term leases, the Company did not acquire any material assets or assume any liabilities other than the tenant's post-assumption rights and obligations under the long-term lease. The Company 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 nine months ended September 30, 2020 was $23,077. The fair value of assets for the purchases of these properties was concentrated in property and equipment and as such, these transactions were classified as asset acquisitions. The purchase price for the asset acquisitions primarily consists of building and improvements of $13,365 and land of $8,938. During the first quarter of 2020, the Company entered into a long-term lease agreement to transfer two senior living operations to Pennant. Ensign affiliates retained ownership of the real estate for these two senior living communities. 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 operations added by the Company are frequently underperforming financially and can have regulatory and clinical challenges to overcome. Financial information, especially with underperforming operations, 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 assets added during the nine months ended September 30, 2021 were not material operations to the Company individually or in the aggregate. Accordingly, pro forma financial information is not presented. These additions have been included in the September 30, 2021 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 date the Company gained effective control.

Property and Equipment _ Net

Property and Equipment — Net	9 Months Ended
	Sep. 30, 2021
Property, Plant and Equipment [Abstract]
PROPERTY AND EQUIPMENT— Net	PROPERTY AND EQUIPMENT - NET Property and equipment, net consists of the following: September 30, 2021 December 31, 2020 Land $ 101,552 $ 101,236 Buildings and improvements 568,331 555,416 Leasehold improvements 136,728 129,727 Equipment 259,102 233,453 Furniture and fixtures 4,499 4,409 Construction in progress 8,841 3,008 1,079,053 1,027,249 Less: accumulated depreciation (287,806) (249,005) Property and equipment, net $ 791,247 $ 778,244 See also Note 8, Operation Expansions for information on acquisitions during the nine months ended September 30, 2021 and 2020.

Intangible Assets _ Net

Intangible Assets — Net	9 Months Ended
	Sep. 30, 2021
Intangible Assets, Net (Excluding Goodwill) [Abstract]
INTANGIBLE ASSETS — NET	INTANGIBLE ASSETS - NET September 30, 2021 December 31, 2020 Weighted Average Life (Years) Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Assembled occupancy 0.4 $ 68 $ (68) $ — $ 39 $ (26) $ 13 Facility trade name 30.0 733 (384) 349 733 (366) 367 Customer relationships 18.4 4,582 (2,220) 2,362 4,640 (2,121) 2,519 Total $ 5,383 $ (2,672) $ 2,711 $ 5,412 $ (2,513) $ 2,899 Estimated amortization expense for each of the years ending December 31 is as follows: Year Amount 2021 (remainder) $ 59 2022 234 2023 234 2024 234 2025 234 2026 234 Thereafter 1,482 $ 2,711

Goodwill and Other Indefinite-L

Goodwill and Other Indefinite-Lived Intangible Assets	9 Months Ended
	Sep. 30, 2021
Goodwill and Intangible Assets Disclosure [Abstract]
GOODWILL AND OTHER INDEFINITE-LIVED INTANGIBLE ASSETS	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 FASB ASC 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 a goodwill impairment test by comparing the carrying value of each reporting unit to its respective fair value. The Company determines the estimated fair value of each reporting unit using a discounted cash flow analysis. The fair value of the reporting unit is the implied fair value of goodwill. In the event a reporting unit's carrying value exceeds its fair value, an impairment loss will be recognized. An impairment loss is measured by the difference between the carrying value of the reporting unit and its fair value. The Company anticipates that the majority of total goodwill recognized will be fully deductible for tax purposes as of September 30, 2021. Provided that goodwill corresponds to the acquisition of a business and not merely the acquisition of real estate property, the Company's real estate segment appropriately does not carry a goodwill balance. The following table represents the goodwill value by skilled service segment and "all other" category, which includes other ancillary services, as of and for the nine months ended September 30, 2021: Goodwill Skilled Services All Other Total January 1, 2021 $ 45,486 $ 8,983 $ 54,469 Additions 6,000 — 6,000 September 30, 2021 $ 51,486 $ 8,983 $ 60,469 Other indefinite-lived intangible assets consist of the following: September 30, 2021 December 31, 2020 Trade name $ 889 $ 889 Medicare and Medicaid licenses 2,732 2,827 $ 3,621 $ 3,716

Restricted and Other Assets

Restricted and Other Assets	9 Months Ended
	Sep. 30, 2021
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
RESTRICTED AND OTHER ASSETS	RESTRICTED AND OTHER ASSETS Restricted and other assets consist of the following: September 30, 2021 December 31, 2020 Debt issuance costs, net $ 2,131 $ 2,664 Long-term insurance losses recoverable asset 7,573 7,138 Deposits with landlords 12,268 12,400 Capital improvement reserves with landlords and lenders 6,328 4,376 Cash surrender value of life insurance related to deferred compensation plan 16,082 6,577 Restricted and other assets $ 44,382 $ 33,155 Included in restricted and other assets as of September 30, 2021 and December 31, 2020 are anticipated insurance recoveries related to the Company's workers' compensation liabilities and general and professional liability claims that are recorded on a gross rather than net basis in accordance with ASU issued by the FASB. The Company implemented a non-qualified deferred compensation plan (the DCP) that was effective in 2019 for certain employees and was expanded to other highly compensated employees on January 1, 2020. The plan allows for the employee deferrals to be deposited into a rabbi trust and the funds are generally invested in individual variable life insurance contracts owned by the Company that are specifically designed to informally fund savings plans of this nature. Cash surrender value of the contracts is based on performance measurement funds that shadow the deferral investment allocations made by participants in the deferred compensation plan.

Other Accrued Liabilities

Other Accrued Liabilities	9 Months Ended
	Sep. 30, 2021
Payables and Accruals [Abstract]
OTHER ACCRUED LIABILITIES	OTHER ACCRUED LIABILITIES Other accrued liabilities consists of the following: September 30, 2021 December 31, 2020 Quality assurance fee $ 6,470 $ 6,631 Refunds payable 36,702 36,323 Resident advances 4,129 8,558 Unapplied state relief funds 4,392 6,520 Cash held in trust for patients 6,883 6,052 Dividends payable 2,900 2,868 Property taxes 11,462 9,222 Other 12,531 11,144 Other accrued liabilities $ 85,469 $ 87,318 Quality assurance fee represents the aggregate of amounts payable to Arizona, California, Colorado, Idaho, Iowa, Kansas, Nebraska, Nevada, Utah, Washington and Wisconsin as a result of a mandated fee based on patient days or licensed beds. Refunds payable includes payables related to overpayments, duplicate payments and credit balances from various payor sources. Resident advances occur when the Company receives payments in advance of services provided. Resident deposits include refundable deposits to patients. Cash held in trust for patients reflects monies received from or on behalf of patients. Maintaining a trust account for patients is a regulatory requirement and, while the trust assets offset the liabilities, the Company assumes a fiduciary responsibility for these funds. The cash balance related to this liability is included in other current assets in the accompanying condensed consolidated balance sheets.

Income Taxes

Income Taxes	9 Months Ended
	Sep. 30, 2021
Income Tax Disclosure [Abstract]
INCOME TAXES	INCOME TAXES The Company recorded income tax expense of $43,220 and $37,026 during the nine months ended September 30, 2021 and 2020, respectively, or 22.5% of earnings before income taxes for the nine months ended September 30, 2021, compared to 22.8% for the nine months ended September 30, 2020. The effective tax rate for both periods is driven by the impact of higher excess tax benefits from stock-based compensation, partially offset by non-deductible expenses, compared to prior year. During the current quarter, the state of Wisconsin initiated an examination of the Company's income tax returns for fiscal years 2017, 2018 and 2019. Th e Company is not currently under examination by any other major income tax jurisdiction. During 2021, the statutes of limitations will lapse on the Company's 2017 Federal tax year and certain 2016 and 2017 state tax years. The Company does not believe the Federal or state statute lapses or any other event will significantly impact the balance of unrecognized tax benefits in the next twelve months. The net balance of unrecognized tax benefits was not material to the Interim Financial Statements for the nine months ended September 30, 2021 and 2020.

Debt

Debt	9 Months Ended
	Sep. 30, 2021
Debt Disclosure [Abstract]
DEBT	DEBT Debt consists of the following: September 30, 2021 December 31, 2020 Mortgage loans and promissory notes $ 147,306 $ 117,806 Less: current maturities (3,548) (2,960) Less: debt issuance costs, net (3,078) (2,302) Long-term debt less current maturities $ 140,680 $ 112,544 Mortgage Loans and Promissory Notes As of September 30, 2021, the Company's operating subsidiaries had $147,306 outstanding under the mortgage loans and notes, of which $3,548 is classified as short-term and the remaining $143,758 is classified as long-term. The Company was in compliance with all loan covenants as of September 30, 2021. During nine months ended September 30, 2021, three of the Company's subsidiaries entered into the Department of Housing and Urban Development (HUD) mortgage loans in the aggregate amount of $31,420. As a result, 22 of the Company's subsidiaries have mortgage loans insured with HUD in the aggregate amount of $143,776, as of September 30, 2021, which subjects these subsidiaries to HUD oversight and periodic inspections. The mortgage loans bear effective interest rates range of 3.1% to 4.2%, including fixed interest rates range of 2.4% to 3.3% per annum. In addition to the interest rate, we incur other fees for HUD placement, including but not limited to audit fees. Amounts borrowed under the mortgage loans may be prepaid, subject to prepayment fees based on the principal balance on the date of prepayment. For the majority of the loans, during the first three years, the prepayment fee is 10.0% and is reduced by 3.0% in the fourth year of the loan, and reduced by 1.0% per year for years five ten ten In addition to the HUD mortgage loans above, the Company has two promissory notes. The notes bear fixed interest rates of 5.0% and 5.3% per annum and the term of the notes are ten months and 12 years, respectively. The 12 year note which was used for an acquisition is secured by the real property comprising the facility and the rent, issues and profits thereof, as well as all personal property used in the operation of the facility. 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. Credit Facility with a Lending Consortium Arranged by Truist The Company maintains a revolving credit facility under the Third Amended and Restated Credit Agreements, dated as of October 1, 2019, between the Company and Truist Financial Corporation (Truist) (formerly known as SunTrust Bank, Inc.) (the Credit Facility). The Credit Facility includes a revolving line of credit of up to $350,000 in aggregate principal amount. The maturity date of the Credit Facility is October 1, 2024. Borrowings are supported by a lending consortium arranged by Truist. 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 0.50% to 1.50% per annum or LIBOR plus a margin range from 1.50% to 2.50% 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 that ranges from 0.25% to 0.45% per annum, depending on the Consolidated Total Net Debt to Consolidated EBITDA ratio. 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 (i) a maximum consolidated total net debt to consolidated EBITDA ratio (which shall not be greater than 3.00:1.00; provided that if the aggregate consideration for approved acquisitions in a six month period is greater than $50,000, then the ratio can be increased at the election of the Company with notice to the administrative agent to 3.50:1.00 for the first fiscal quarter and the immediately following three fiscal quarters), and (ii) a minimum interest/rent coverage ratio (which cannot be less than 1.50:1.00). As of September 30, 2021, and October 22, 2021, there was no outstanding debt under the Credit Facility. The Company was in compliance with all loan covenants as of September 30, 2021. Off-Balance Sheet Arrangements As of September 30, 2021, the Company had approximately $6,544 o

Options and Awards

Options and Awards	9 Months Ended
	Sep. 30, 2021
Share-based Payment Arrangement [Abstract]
OPTIONS AND AWARDS	OPTIONS AND AWARDS Stock-based compensation expense consists of stock-based payment awards made to employees and directors, including employee stock options and restricted stock awards, based on estimated fair values. As stock-based compensation expense recognized in the Company’s condensed consolidated statements of income for the three and nine months ended September 30, 2021 and 2020 was based on awards ultimately expected to vest, it has been reduced for estimated forfeitures. The Company estimates forfeitures at the time of grant and, if necessary, revises the estimate in subsequent periods if actual forfeitures differ. 2017 Omnibus Incentive Plan - The Company has one active stock incentive plan, the 2017 Omnibus Incentive Plan (the 2017 Plan). The 2017 Plan provided for the issuance of 6,881 shares of common stock which are to be proportionally adjusted in the event of any Equity Restructuring. The number of shares available to be issued under the 2017 Plan were adjusted to 8,118 shares of common stock in order to reflect the proportional adjustments as part of the spin-off transaction that occurred in October 2019. The number of shares available to be issued under the 2017 Plan will be reduced by (i) one share for each share that relates to an option or stock appreciation right award and (ii) 2.5 shares for each share which relates to an award other than a stock option or stock appreciation right award (a full-value award). Granted non-employee director options vest and become exercisable in three equal annual installments, or the length of the term if less than three years, on the completion of each year of service measured from the grant date. All other options generally vest over five years at 20% per year on the anniversary of the grant date. Options expire ten years from the date of grant. As of September 30, 2021, there were approximately 2,270 unissued shares of common stock available for issuance under this plan. The Company uses the Black-Scholes option-pricing model to recognize the value of stock-based compensation expense for stock option awards. Determining the appropriate fair-value model and calculating the fair value of stock option awards at the grant date requires judgment, including estimating stock price volatility, expected option life, and forfeiture rates. The fair-value of the restricted stock awards at the grant date is based on the market price on the grant date, adjusted for forfeiture rates. The Company develops estimates based on historical data and market information, which can change significantly over time. Stock Options The Company granted 151 and 496 stock options during the three and nine months ended September 30, 2021, respectively. The Company used the following assumptions for stock options granted during the three months ended September 30, 2021 and 2020: Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2021 151 1.0% 6.1 years 42.5% 0.3% 2020 160 0.4% 6.3 years 41.8% 0.3% The Company used the following assumptions for stock options granted during the nine months ended September 30, 2021 and 2020: Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2021 496 0.9% 6.2 years 42.3% 0.3% 2020 540 0.7% 6.2 years 38.8% 0.4% For the nine months ended September 30, 2021 and 2020, 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 2021 496 $ 81.89 $ 33.45 2020 540 $ 50.46 $ 18.62 The weighted average exercise price equaled the weighted average fair value of common stock on the grant date for all options granted during the periods ended September 30, 2021 and 2020 and therefore, the intrinsic value was $0 at the date of grant. The following table represents the employee stock option activity during the nine months ended September 30, 2021: Number of Options Outstanding Weighted Average Number of Weighted Average Exercise Price of Options Vested January 1, 2021 4,038 $ 27.71 2,148 $ 16.66 Granted 496 81.89 Forfeited (77) 41.69 Exercised (463) 17.51 September 30, 2021 3,994 $ 35.35 2,129 $ 20.25 The following summary information reflects stock options outstanding, vested and related details as of September 30, 2021: Stock Options Outstanding Stock Options Vested Number Outstanding Black-Scholes Fair Value Remaining Contractual Life (Years) Vested and Exercisable Year of Grant Exercise Price 2011 $5.00 - $6.77 3 $ 3 0 3 2012 5.56 - 6.75 73 220 1 73 2013 6.76 - 9.74 140 539 2 140 2014 8.94 - 16.05 625 3,002 3 625 2015 18.20 - 21.39 279 2,164 4 279 2016 15.93 - 16.86 257 1,514 5 245 2017 15.80 - 19.41 315 1,851 6 208 2018 22.49 - 32.71 532 5,146 7 250 2019 41.07 - 45.76 662 10,394 8 216 2020 44.84 - 59.49 616 12,104 9 90 2021 $79.88 - $83.64 492 16,465 10 — Total 3,994 $ 53,402 2,129 The aggregate intrinsic value of options outstanding, vested and expected to vest as of September 30, 2021 and December 31, 2020 is as follows: Options September 30, 2021 December 31, 2020 Outstanding $ 161,371 $ 182,552 Vested 116,340 120,867 Expected to vest 40,548 53,366 The intrinsic value is calculated as the difference between the market value of the underlying common stock and the exercise price of the options . The aggregate intrinsic value of options that vested during the nine months ended September 30, 2021 and 2020 was $18,500 and $13,681, respectively. The total intrinsic value of options exercised during the nine months ended September 30, 2021 and 2020 was $31,167 and $21,044, respectively. Restricted Stock Awards The Company granted 51 and 195 restricted stock awards during the three and nine months ended September 30, 2021, respectively. The Company granted 48 and 242 restricted stock awards during the three and nine months ended September 30, 2020, respectively. All awards were granted at an issue price of $0 and generally vest over five years. The fair value per share of restricted awards granted during the nine months ended September 30, 2021 and 2020 ranged from $82.20 to $93.31 and $35.47 to $58.06, respectively. The fair value per share includes quarterly stock awards to non-employee directors. A summary of the status of the Company's non-vested restricted stock awards as of September 30, 2021 and changes during the nine months ended September 30, 2021 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2021 591 $ 38.90 Granted 195 82.81 Vested (213) 48.45 Forfeited (16) 45.65 Nonvested at September 30, 2021 557 $ 50.43 During the three and nine months ended September 30, 2021, the Company granted six and 17 automatic quarterly stock awards to non-employee directors for their service on the Company's board of directors. The fair value per share of these stock awards was $84.70 to $93.31 based on the market price on the grant date. Long-Term Incentive Plan On August 27, 2019, the Board approved the Long-Term Incentive Plan (the 2019 LTI Plan). The 2019 LTI Plan provides that certain employees of the Company who assisted in the consummation of the spin-off transaction that occurred in October 2019 are granted shares of restricted stock upon the successful completion of the spin-off. The 2019 LTI Plan provides for the issuance of 500 shares of Pennant restricted stock. The shares are vested over five years at 20% per year on the anniversary of the grant date. If a recipient is terminated or voluntarily leaves the Company, all shares subject to restriction or not yet vested shall be entirely forfeited. The total stock-based compensation related to the 2019 LTI Plan was approximately $248 and $651 for the three and nine months ended September 30, 2021, respectively, compared to $286 and $675 for the three and nine months ended September 30, 2020, respectively. Stock-based compensation expense recognized for the Company's equity incentive plans and long-term incentive plan for the three and nine months ended September 30, 2021 and 2020 was as follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Stock-based compensation expense related to stock options $ 2,371 $ 1,692 $ 6,130 $ 4,656 Stock-based compensation expense related to restricted stock awards 2,217 2,221 6,131 5,596 Stock-based compensation expense related to stock options and restricted stock awards to non-employee directors 494 260 1,508 684 Total $ 5,082 $ 4,173 $ 13,769 $ 10,936 In future periods, the Company expects to recognize approximately $34,086 and $29,021 in stock-based compensation expense for unvested options and unvested restricted stock awards, respectively, that were outstanding as of September 30, 2021. Future stock-based compensation expense will be recognized over 3.9 and 3.6 weighted average years for unvested options and restricted stock awards, respectively. There were 1,865 unvested and outstanding options as of September 30, 2021, of which 1,754 shares are expected to vest. The weighted average contractual life for options outstanding, vested and expected to vest as of September 30, 2021 was 6.1 years.

Leases

Leases	9 Months Ended
	Sep. 30, 2021
Leases [Abstract]
LEASES	LEASES The Company leases from CareTrust REIT, Inc. (CareTrust) real property associated with 95 affiliated skilled nursing and senior living facilities used in the Company’s operations, 94 of which are under nine “triple-net” master lease agreements (collectively, the Master Leases), which range in terms from 13 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. Additionally, four of the 95 facilities leased from CareTrust include an option to purchase that the Company can exercise starting on December 1, 2024. In the second quarter of 2021, the Company added four operations and extended the term for one of the Master Leases for an additional 15 years. In the third quarter of 2021, the Company added two operations and extended the term for one of the Master Leases for an additional 17 years. As a result, the total lease liabilities and right-of-use assets increased by $54,716 and $63,374, respectively, to reflect the new lease obligations. 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. 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. The terms and conditions of the one stand-alone lease are substantially the same as those for the master leases described above. Total rent expense under the Master Leases was approximately $15,445 and $43,944 for the three and nine months ended September 30, 2021, respectively, and $13,139 and $39,394 for the three and nine months ended September 30, 2020, 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 in compliance with requirements of the Master Leases as of September 30, 2021. In connection with the spin-off transaction that occurred in October 2019, the Company guaranteed certain leases of Pennant based on the underlying terms of the leases. The Company does not consider these guarantees to be probable and the likelihood of Pennant defaulting is remote, and therefore no liabilities have been accrued. The Company also leases certain affiliated operations and certain administrative offices under non-cancelable operating leases, most of which have initial lease terms ranging from five three Forty-three of the Company’s affiliated facilities, excluding the facilities that are operated under the Master Leases with CareTrust, are operated under eight 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. The components of operating lease expense are as follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Rent - cost of services (1) $ 35,623 $ 32,504 $ 103,534 $ 97,318 General and administrative expense 23 16 64 48 Depreciation and amortization (2) 289 289 869 933 Variable lease costs (3) 3,582 3,229 10,719 9,692 $ 39,517 $ 36,038 $ 115,186 $ 107,991 (1) Rent - cost of services includes deferred rent expense adju stments of $125 and $346 for the three and nine months ended September 30, 2021, respectively, and $101 and $337 for the three and nine months ended September 30, 2020, respectively. Additionally, rent - cost of services includes other variable lease costs such as CPI increases and short-term leases of $1,127 and $2,543 for the three and nine months ended September 30, 2021, respectively, and $567 and $1,781 for the three and nine months ended September 30, 2020, respectively. (2) Depreciation and amortization is related to the amortization of favorable and direct lease costs. (3) Variable lease costs, including property taxes and insurance, are classified in cost of services in the Company's condensed consolidated statements of income. Future minimum lease payments for all leases as of September 30, 2021 are as follows: Year Amount 2021 (remainder) $ 34,660 2022 138,592 2023 136,845 2024 135,889 2025 135,813 2026 135,708 Thereafter 1,201,777 Total lease payments 1,919,284 Less: present value adjustment (774,058) Present value of total lease liabilities 1,145,226 Less: current lease liabilities (52,050) Long-term operating lease liabilities $ 1,093,176 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 September 30, 2021, the weighted average remaining lease term is 14.9 years and the weighted average discount rate used to determine the operating lease liabilities is 7.7%. Subsequent to September 30, 2021, the Company expanded its operations through a long-term lease arrangement with the addition of three stand-alone skilled nursing facilities under a new triple-net master lease, adding a total of 328 operational skilled nursing beds operated by the Company’s affiliated operating subsidiaries. The aggregate impact to the fair value of lease liabilities and right-of-use assets related to new master lease is estimated to be approximately $22,828. Lessor Activities In connection with the spin-off transaction that occurred in October 2019, Ensign affiliates retained ownership of the real estate at 29 senior living operations that were contributed to Pennant. During the first quarter of 2020, the Company transferred the operations of an additional two senior living operations to Pennant. Ensign affiliates retained ownership of the real estate for these 31 senior living communities. All of these properties are leased to Pennant on a triple-net basis, whereas the respective Pennant affiliates are responsible for all costs at the properties including: (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. The initial terms range between 14 to 16 years. Total rental income from all third-party sources for the three and nine months ended September 30, 2021 and 2020 is as follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Pennant (1) $ 3,468 $ 3,443 $ 10,396 $ 9,675 Other third-party 465 471 1,441 1,521 $ 3,933 $ 3,914 $ 11,837 $ 11,196 (1) Pennant rental income includes variable rent such as property taxes of $301 and $881 during the three and nine months ended September 30, 2021 and $312 and $909 for the three and nine months ended September 30, 2020. Future annual rental income for all leases as of September 30, 2021 were as follows: Year Amount (1) 2021 (remainder) $ 3,900 2022 15,238 2023 14,937 2024 14,249 2025 13,911 2026 13,700 Thereafter 84,838 Total $ 160,773
LEASES	LEASES The Company leases from CareTrust REIT, Inc. (CareTrust) real property associated with 95 affiliated skilled nursing and senior living facilities used in the Company’s operations, 94 of which are under nine “triple-net” master lease agreements (collectively, the Master Leases), which range in terms from 13 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. Additionally, four of the 95 facilities leased from CareTrust include an option to purchase that the Company can exercise starting on December 1, 2024. In the second quarter of 2021, the Company added four operations and extended the term for one of the Master Leases for an additional 15 years. In the third quarter of 2021, the Company added two operations and extended the term for one of the Master Leases for an additional 17 years. As a result, the total lease liabilities and right-of-use assets increased by $54,716 and $63,374, respectively, to reflect the new lease obligations. 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. 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. The terms and conditions of the one stand-alone lease are substantially the same as those for the master leases described above. Total rent expense under the Master Leases was approximately $15,445 and $43,944 for the three and nine months ended September 30, 2021, respectively, and $13,139 and $39,394 for the three and nine months ended September 30, 2020, 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 in compliance with requirements of the Master Leases as of September 30, 2021. In connection with the spin-off transaction that occurred in October 2019, the Company guaranteed certain leases of Pennant based on the underlying terms of the leases. The Company does not consider these guarantees to be probable and the likelihood of Pennant defaulting is remote, and therefore no liabilities have been accrued. The Company also leases certain affiliated operations and certain administrative offices under non-cancelable operating leases, most of which have initial lease terms ranging from five three Forty-three of the Company’s affiliated facilities, excluding the facilities that are operated under the Master Leases with CareTrust, are operated under eight 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. The components of operating lease expense are as follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Rent - cost of services (1) $ 35,623 $ 32,504 $ 103,534 $ 97,318 General and administrative expense 23 16 64 48 Depreciation and amortization (2) 289 289 869 933 Variable lease costs (3) 3,582 3,229 10,719 9,692 $ 39,517 $ 36,038 $ 115,186 $ 107,991 (1) Rent - cost of services includes deferred rent expense adju stments of $125 and $346 for the three and nine months ended September 30, 2021, respectively, and $101 and $337 for the three and nine months ended September 30, 2020, respectively. Additionally, rent - cost of services includes other variable lease costs such as CPI increases and short-term leases of $1,127 and $2,543 for the three and nine months ended September 30, 2021, respectively, and $567 and $1,781 for the three and nine months ended September 30, 2020, respectively. (2) Depreciation and amortization is related to the amortization of favorable and direct lease costs. (3) Variable lease costs, including property taxes and insurance, are classified in cost of services in the Company's condensed consolidated statements of income. Future minimum lease payments for all leases as of September 30, 2021 are as follows: Year Amount 2021 (remainder) $ 34,660 2022 138,592 2023 136,845 2024 135,889 2025 135,813 2026 135,708 Thereafter 1,201,777 Total lease payments 1,919,284 Less: present value adjustment (774,058) Present value of total lease liabilities 1,145,226 Less: current lease liabilities (52,050) Long-term operating lease liabilities $ 1,093,176 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 September 30, 2021, the weighted average remaining lease term is 14.9 years and the weighted average discount rate used to determine the operating lease liabilities is 7.7%. Subsequent to September 30, 2021, the Company expanded its operations through a long-term lease arrangement with the addition of three stand-alone skilled nursing facilities under a new triple-net master lease, adding a total of 328 operational skilled nursing beds operated by the Company’s affiliated operating subsidiaries. The aggregate impact to the fair value of lease liabilities and right-of-use assets related to new master lease is estimated to be approximately $22,828. Lessor Activities In connection with the spin-off transaction that occurred in October 2019, Ensign affiliates retained ownership of the real estate at 29 senior living operations that were contributed to Pennant. During the first quarter of 2020, the Company transferred the operations of an additional two senior living operations to Pennant. Ensign affiliates retained ownership of the real estate for these 31 senior living communities. All of these properties are leased to Pennant on a triple-net basis, whereas the respective Pennant affiliates are responsible for all costs at the properties including: (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. The initial terms range between 14 to 16 years. Total rental income from all third-party sources for the three and nine months ended September 30, 2021 and 2020 is as follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Pennant (1) $ 3,468 $ 3,443 $ 10,396 $ 9,675 Other third-party 465 471 1,441 1,521 $ 3,933 $ 3,914 $ 11,837 $ 11,196 (1) Pennant rental income includes variable rent such as property taxes of $301 and $881 during the three and nine months ended September 30, 2021 and $312 and $909 for the three and nine months ended September 30, 2020. Future annual rental income for all leases as of September 30, 2021 were as follows: Year Amount (1) 2021 (remainder) $ 3,900 2022 15,238 2023 14,937 2024 14,249 2025 13,911 2026 13,700 Thereafter 84,838 Total $ 160,773

Commitments and Contingencies

Commitments and Contingencies	9 Months Ended
	Sep. 30, 2021
Commitments and Contingencies Disclosure [Abstract]
COMMITMENTS AND CONTINGENCIES	COMMITMENTS AND CONTINGENCIES Regulatory Matters — Laws and regulations governing Medicare and Medicaid programs are complex and subject to review and interpretation. Compliance with such laws and regulations is evaluated regularly, the results of which can be subject to future governmental review and interpretation, and can include significant regulatory action including fines, penalties, and exclusion from certain governmental programs. Included in these laws and regulations is monitoring performed by the Office of Civil Rights which covers the Health Insurance Portability and Accountability Act of 1996, the terms of which require healthcare providers (among other things) to safeguard the privacy and security of certain patient protected health information. Cost-Containment Measures — Both government and private pay sources have instituted cost-containment measures designed to limit payments made to providers of healthcare services, and there can be no assurance that future measures designed to limit payments made to providers will not adversely affect the Company. Indemnities — From time to time, the Company enters into certain types of contracts that contingently require the Company to indemnify parties against third-party claims. These contracts primarily include (i) certain real estate leases, under which the Company may be required to indemnify property owners or prior facility operators for post-transfer environmental or other liabilities and other claims arising from the Company’s use of the applicable premises, (ii) operations transfer agreements, in which the Company agrees to indemnify past operators of facilities the Company acquires against certain liabilities arising from the transfer of the operation and/or the operation thereof after the transfer to the Company's independent operating subsidiary, (iii) certain lending agreements, under which the Company may be required to indemnify the lender against various claims and liabilities, and (iv) certain agreements with the Company’s officers, directors and others, under which the Company may be required to indemnify such persons for liabilities arising out of the nature of their relationship to the Company. The terms of such obligations vary by contract and, in most instances, do not expressly state or include a specific or maximum dollar amount. Generally, amounts under these contracts cannot be reasonably estimated until a specific claim is asserted. Consequently, because no claims have been asserted, no liabilities have been recorded for these obligations on the Company’s condensed consolidated balance sheets for any of the periods presented. In connection with the spin-off transaction that occurred in October 2019, certain landlords required, in exchange for their consent to the transaction, that the Company's lease guarantees remain in place for a certain period of time following the spin-off. These guarantees could result in significant additional liabilities and obligations for the Company if Pennant were to default on their obligations under their leases with respect to these properties. U.S. 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 was investigating whether there had been a violation of the False Claims Act and/or the Anti-Kickback Statute with respect to relationships between certain of the Company’s independently operated skilled nursing facilities and persons who serve or have served as medical directors, advisory board participants or other potential referral sources. The CID covered the period from October 3, 2013 through 2018, 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 through 2018, relating to the same topic. As a general matter, the Company’s independent operating entities have established and maintain policies and procedures to promote compliance with the False Claims Act, the Anti-Kickback Statute, and other applicable regulatory requirements. The Company fully cooperated with the U.S. Department of Justice and promptly responded to its requests for information; in April 2020, the Company was advised that the U.S. Department of Justice declined to intervene in any subsequent action filed by a relator in connection with the subject matter of this investigation. U.S. House of Representatives Select Subcommittee Request — In 2020, the U.S. House of Representatives Select Subcommittee on the Coronavirus Crisis launched a nation-wide investigation into the COVID-19 pandemic, which included the impact of the coronavirus on residents and employees in nursing homes. In June 2020, the Company received a document and information request from the House Select Subcommittee in connection with its investigation. The Company has cooperated in responding to this inquiry. However, it is not possible to predict the ultimate outcome of any such investigation or whether and what other investigations or regulatory responses may result from the investigation, which could have a material adverse effect on our reputation, business, financial condition, and results of operations. Litigation — The skilled nursing business involves a significant risk of liability given the age and health of the patients and residents served by the Company's independent operating subsidiaries. The Company, its independent operating subsidiaries, and others in the industry are subject to an increasing number of claims and lawsuits, including professional liability claims, alleging that services provided have resulted in personal injury, elder abuse, wrongful death or other related claims. In addition, the Company, its independent operating subsidiaries, and others in the industry are subject to claims and lawsuits in connection with COVID-19 and a facility's preparation for and/or response to COVID-19. The defense of these lawsuits may result in significant legal costs, regardless of the outcome, and can result in large settlement amounts or damage awards. In addition to the potential lawsuits and claims described above, the Company and its independent operating subsidiaries are also subject to potential lawsuits under the Federal False Claims Act and comparable state laws alleging submission of fraudulent claims for services to any healthcare program (such as Medicare or Medicaid) or other payor. A violation may provide the basis for exclusion from Federally-funded healthcare programs. Such exclusions could have a correlative negative impact on the Company’s financial performance. Under the qui tam or "whistleblower" provisions of the False Claims Act, a private individual with knowledge of fraud or potential fraud may bring a claim on behalf of the Federal Government and receive a percentage of the Federal Government's recovery. Due to these whistleblower incentives, qui tam lawsuits have become more frequent. For example, and despite the decision of the U.S. Department of Justice to decline to participate in litigation based on the subject matter of its previously issued Civil Investigative Demand, the involved qui tam relator has continued on with the lawsuit and is pursuing claims that the Company and certain of its independent operating subsidiaries have allegedly violated the False Claims Act and/or the Anti-Kickback Statute. In addition to the Federal False Claims Act, some states, including California, Arizona and Texas, have enacted similar whistleblower and false claims laws and regulations. Further, the Deficit Reduction Act of 2005 created incentives for states to enact anti-fraud legislation modeled on the Federal False Claims Act. As such, the Company and its independent operating subsidiaries could face increased scrutiny, potential liability and legal expenses and costs based on claims under state false claims acts in markets in which its independent operating subsidiaries do business. In May 2009, Congress passed the Fraud Enforcement and Recovery Act (FERA) which made significant changes to the Federal False Claims Act and expanded the types of activities subject to prosecution and whistleblower liability. Following changes by FERA, health care providers face significant penalties for the knowing retention of government overpayments, even if no false claim was involved. Health care providers can now be liable for knowingly and improperly avoiding or decreasing an obligation to pay money or property to the government. This includes the retention of any government overpayment. The government can argue, therefore, that a Federal False Claims Act violation can occur without any affirmative fraudulent action or statement, as long as the action or statement is knowingly improper. In addition, FERA extended protections against retaliation for whistleblowers, including protections not only for employees, but also contractors and agents. Thus, an employment relationship is generally not required in order to qualify for protection against retaliation for whistleblowing. Healthcare litigation (including class action litigation) is common and is filed based upon a wide variety of claims and theories, and the Company's independent operating subsidiaries are routinely subjected to varying types of claims, including class action "staffing" suits where the allegation is understaffing at the facility level. These class-action “staffing” suits have the potential to result in large jury verdicts and settlements, and may result in significant legal costs. The Company expects the plaintiffs' bar to continue to be aggressive in their pursuit of these staffing and similar claims. While the Company has been able to settle these claims without an ongoing material adverse effect on its business, future claims could be brought that may materially affect its business, financial condition and results of operations. Other claims and suits, including class actions, continue to be filed against the Company and other companies in its industry. The Company and its independent operating subsidiaries have been subjected to, and are currently involved in, class action litigation alleging violations (alone or in combination) of state and federal wage and hour laws as related to the alleged failure to pay wages, to timely provide and au thorize meal and rest breaks, and related causes of action. The Company does not believe that the ultimate resolution of these actions will have an ongoing material adverse effect on the Company’s business, cash flows, financial condition or results of operations. The Company and its independent operating subsidiaries have been, and continue to be, subject to claims and legal actions that arise in the ordinary course of business, including potential claims filed by residents and responsible parties related to patient care and treatment (professional negligence claims), as well as employment related claims filed by current or former employees. A significant increase in the number of these claims, or an increase in the amounts owing should plaintiffs be successful in their prosecution of these claims, could materially adversely affect the Company’s business, financial condition, results of operations and cash flows. The Company and its independent subsidiaries are also subject to requests for information and investigations by other State and Federal governmental entities (e.g., offices of the attorney general and offices of the inspector general). The Company cannot predict or provide any assurance as to the possible outcome of any inquiry, investigation or litigation. If any such inquiry, investigation or litigation were to proceed, and the Company and its independent operating subsidiaries are subjected to, alleged to be liable for, or agree to a settlement of, claims or obligations under Federal Medicare statutes, the Federal False Claims Act, or similar state and federal statutes and related regulations, or if the Company or its independent operating subsidiaries are alleged or found to be liable on theories of general or professional negligence or wage and hour violations, the Company's business, financial condition and results of operations and cash flows could be materially and adversely affected and its stock price could be adversely impacted. Among other things, any settlement or litigation could involve the payment of substantial sums to settle any alleged violations, and may also include the assumption of specific procedural and financial obligations by the Company or its operating subsidiaries under a corporate integrity agreement and/or other such arrangement. Medicare Revenue Recoupments — The Company's independent operating entities are subject to regulatory reviews relating to the provision of Medicare services, billings and potential overpayments as a result of Recovery Audit Contractors (RAC), Program Safeguard Contractors, and Medicaid Integrity Contractors programs (collectively referred to as Reviews). For several months during the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) suspended its Targeted Probe and Educate Program. Beginning in August 2020, CMS resumed Targeted Probe and Educate Program activity. If an operation fails a Review and/or subsequent Reviews, the operation could then be subject to extended review or an extrapolation of the identified error rate to billings in the same time period. The Company anticipates that these Reviews could increase in frequency in the future. As of September 30, 2021 and subsequently, seven of the Company's independent operating subsidiaries had Reviews scheduled, on appeal, or in a dispute resolution process. Concentrations Credit Risk — The Company has significant accounts receivable balances, the collectability of which is dependent on the availability of funds from certain governmental programs, primarily Medicare and Medicaid. These receivables represent the only significant concentration of credit risk for the Company. The Company does not believe there are significant credit risks associated with these governmental programs. The Company believes that an appropriate allowance has been recorded for the possibility of these receivables proving uncollectible, and continually monitors and adjusts these allowances as necessary. The Company’s receivables from Medicare and Medicaid payor programs accounted for 53.7% and 58.3% of its total accounts receivable as of September 30, 2021 and December 31, 2020, respectively. Revenue from reimbursement under the Medicare and Medicaid programs accounted for 73.6% of the Company's service revenue for both the three and nine months ended September 30, 2021, and 75.5% and 74.0% for the three and nine months ended September 30, 2020, 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 October 22, 2021, the Company had approximately $677 in uninsured cash deposits. All uninsured bank deposits are held at high quality credit institutions.

Common Stock Repurchase Program

Common Stock Repurchase Program	9 Months Ended
	Sep. 30, 2021
Equity [Abstract]
COMMON STOCK REPURCHASE PROGRAM	COMMON STOCK REPURCHASE PROGRAM As approved by the Board of Directors on March 4, 2020 and March 13, 2020, the Company entered into two stock repurchase programs pursuant to which the Company was authorized to repurchase up to $20,000 and $5,000, respectively, of its common stock under the programs for a period of approximately 12 months. Under these programs, the Company was 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. During the first quarter of 2020, the Company repurchased 503 and 189 shares of its common stock for $20,000 and $5,000, respectively. These repurchase programs expired upon the repurchase of the full authorized amount under the two plans. As approved by the Board of Directors on August 26, 2019, the Company entered into a stock repurchase program pursuant to which the Company may repurchase up to $20,000 of its common stock under the program for a period of approximately 12 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 Company repurchased 138 shares of its common stock for a total of $6,406 in fiscal year 2019 before the repurchase program was cancelled in the first quarter of 2020.

Summary of Significant Accoun_2

Summary of Significant Accounting Policies (Policies)	9 Months Ended
	Sep. 30, 2021
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 operations, senior living operations and related ancillary services. All intercompany transactions and balances have been eliminated in consolidation. The Company presents noncontrolling interests within the equity section of its condensed consolidated balance sheets and 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.
Reclassifications	Reclassifications — Certain prior period results have been reclassified to be consistent with the current period presentation, including presenting the change of the deferred compensation separately on the Company's Consolidated Statements of Cash Flows. Prior period results also reflect reclassifications, for comparative purposes, related to the change in the Company's segment structure. Refer to Note 7, Business Segments
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, acquired property and equipment, intangible assets and goodwill, right-of-use assets, impairment of long-lived assets, lease liabilities, general and professional liabilities, 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. Contracts insuring the lives of certain employees who are eligible to participate in non-qualified deferred compensation plans are held in a rabbi trust. Cash surrender value of the contracts is based on performance measurement funds that shadow the deferral investment allocations made by participants in the deferred compensation plan. The fair value of the pooled investment funds is derived using Level 2 inputs.
Revenue Recognition	Service Revenue Recognition — The Company recognizes revenue in accordance with Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) Topic 606, Revenue from Contracts with Customers Rental Revenue Recognition — The Company recognizes rental revenue for operating leases on a straight-line basis over the lease term when collectability of all minimum lease payments is probable in accordance with FASB ASC Topic 842, Leases
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.
Property and Equipment	Property and Equipment — three
Leases and Leasehold Improvements	Leases and Leasehold Improvements — The Company leases skilled nursing facilities, senior living facilities and commercial office space. The Company determines if an arrangement is a lease at the inception of each lease. Leases commencing prior to the ASC 842 adoption date were classified as operating lease under historical guidance. As the Company has elected the package of practical expedients allowing it to not reassess lease classification, these leases are classified as operating leases under ASC 842 as well. For leases commencing subsequent to the ASC 842 adoption date, the Company performs an evaluation to determine whether the lease should be classified as an operating or finance lease at the inception of the lease. As of September 30, 2021, the Company does not have any leases that are classified as finance leases. Rights and obligations of operating leases are included as 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 utilized a third-party valuation specialist to assist in estimating the incremental borrowing rate. 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. Renewals are not assumed in the determination of the lease term unless they are deemed to be reasonably assured at the inception of the lease. The lease term used for this evaluation also provides the basis for establishing depreciable lives for buildings subject to lease and leasehold improvements. ten
Impairment of Long-Lived Assets	Impairment of Long-Lived Assets —
Intangible Assets and Goodwill	Intangible Assets and Goodwill — Definite-lived intangible assets consist primarily of patient base, facility trade names and customer relationships. Patient base is amortized over a period of four 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.
Self-Insurance	Self-Insurance — The Company is partially self-insured for general and professional liability claims 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 majority of the self-insured retention and deductible limits for general and professional liabilities and workers' compensation liabilities 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 actuarial estimated costs to settle open claims of insureds, as well as an estimate of the cost of insured claims that have been incurred but not reported. The Company develops information about the size of the ultimate claims based on historical experience, current industry information and actuarial analysis, and evaluates the estimates for claim loss exposure on a quarterly basis. The Company uses actuarial valuations to estimate the liability based on historical experience and industry information. Accrued general liability and professional malpractice liabilities on an undiscounted basis, net of anticipated insurance recoveries, were $63,689 and $57,628 as of September 30, 2021 and December 31, 2020, respectively. The Company’s operating subsidiaries are self-insured for workers’ compensation liabilities 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 $625 per occurrence. In Texas, the operating subsidiaries have elected non-subscriber status for workers’ compensation claims and the Company has purchased individual stop-loss coverage that insures individual claims that exceed $750 per occurrence. The Company’s operating subsidiaries in all other states, with the exception of Washington, are under a loss sensitive plan that insures individual claims that exceed $350 per occurrence. In the state of Washington, the Company is self insured and has purchased individual specific excess insurance coverage that insures individual claims that exceed $500 per occurrence. For all of the self insured plans and retention, 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 $25,968 and $24,499 as of September 30, 2021 and December 31, 2020, respectively. In addition, the Company has recorded an asset and equal liability of $7,573 and $7,138 as of September 30, 2021 and December 31, 2020, 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 $500 for each covered person for fiscal year 2021. The Company’s accrued liability under these plans recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets was $9,799 and $7,533 as of September 30, 2021 and December 31, 2020, respectively.
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 —
Stock-Based Compensation	Stock-Based Compensation — The Company measures and recognizes compensation expense for all stock-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 FASB 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 December 2019, the FASB issued Accounting Standards Update (ASU) 2019-12 "Simplifying the Accounting for Income Taxes (Topic 740)" as part of its simplification initiative to reduce the cost and complexity in accounting for income taxes. ASU 2019-12 removes certain exceptions related to the approach for intra-period tax allocation, the methodology for calculating income taxes in an interim period and the recognition of deferred tax liabilities for outside basis differences. ASU 2019-12 also amends other aspects of the guidance to help simplify and promote consistent application of GAAP. The Company adopted this standard on January 1, 2021 and determined there was no material impact on the Company's financial position, results of operations and liquidity. In May 2020, the SEC issued Final Rule Release No. 33-10786 “ Amendments to Financial Disclosures about Acquired and Disposed Businesses ” (“SEC Rule 33-10786”), which amends the disclosure requirements applicable to acquisitions and dispositions of businesses. Amendments within SEC Rule 33-10786 primarily impact (1) the tests and thresholds used to determine the significance of acquisitions and dispositions; (2) the form and content of pro forma information required to be disclosed in connection with significant acquisitions and dispositions; (3) acquiree financial statement requirements; and (4) thresholds used to determine the significance of acquisitions and dispositions of real estate operations, and related financial statement requirements, among others. The Company adopted this standard on January 1, 2021 and determined there was no material impact on the Company's condensed consolidated financial statements. Accounting Standards Recently Issued but Not Yet Adopted by the Company In February 2020, the FASB issued ASU 2020-04 "Reference Rate Reform (Topic 848)," which provides temporary, optional practical expedients and exceptions to enable a smoother transition to reference rates which are expected to replace LIBOR reference rates. Adoption of the provisions of ASU 2020-04 is optional. The amendments are effective for all entities from the beginning of the interim period that includes the issuance date of the ASU. An entity may elect to apply the amendments prospectively through December 31, 2022. The Company is currently evaluating the impact of ASU 2020-04 on its financial position, results of operations and liquidity. In November 2020, the SEC issued final rules 33-10890 and 34-90459 “ Management’s Discussion and Analysis, Selected Financial Data, and Supplementary Financial Information ,” which modernizes and simplifies certain disclosure requirements of Regulation S-K. Certain key rule amendments eliminate the requirement to disclose Selected Financial Data; Selected Quarterly Financial Data, with certain exceptions; the impact of inflation and changing prices, provided the impact is not material; off-balance sheet arrangements in tabular form; and the aggregate amount of contractual obligations in tabular form. The final rules also amended various aspects of Item 303, “ Management’s Discussion and Analysis of Financial Condition and Results of Operations ,” among others. The final rules are effective for all registration statements and annual reports filed on or after August 9, 2021, with early adoption permitted. The Company is currently evaluating the impact of the disclosure changes in its annual reports. In July 2021, the FASB issued ASU 2021-05 “ Lessors—Certain Leases with Variable Lease Payments (Topic 842), ” which amends the lessor classification guidance to introduce additional criteria when classifying leases with variable lease payments that do not depend on a reference index or a rate. This guidance is effective for annual periods beginning after December 15, 2021, which will be the Company's fiscal year 2022, with early adoption permitted. The Company has not yet determined the effect of the ASU 2021-05 on its results of operations, financial condition or cash flows.

Revenue and Accounts Receivab_2

Revenue and Accounts Receivable (Tables)	9 Months Ended
	Sep. 30, 2021
Revenue from Contract with Customer [Abstract]
Disaggregation of Revenue	Service revenue for the three and nine months ended September 30, 2021 and 2020 is summarized in the following tables: Three Months Ended September 30, 2021 2020 Revenue % of Revenue Revenue % of Revenue Medicaid (1) $ 267,008 40.2 % $ 222,192 37.3 % Medicare 176,660 26.6 189,237 31.8 Medicaid — skilled 45,308 6.8 38,232 6.4 Total Medicaid and Medicare 488,976 73.6 449,661 75.5 Managed care 114,917 17.3 87,648 14.7 Private and other (2) 60,704 9.1 58,032 9.8 Service revenue $ 664,597 100.0 % $ 595,341 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP for the three months ended September 30, 2021 and 2020 . (2) Private and other payors also includes revenue from all payors generated in other an cillary services for the three months ended September 30, 2021 and 2020 . Nine Months Ended September 30, 2021 2020 Revenue % of Revenue Revenue % of Revenue Medicaid (1) $ 749,821 39.0 % $ 672,506 38.2 % Medicare 536,971 27.9 519,865 29.5 Medicaid — skilled 128,041 6.7 110,626 6.3 Total Medicaid and Medicare 1,414,833 73.6 1,302,997 74.0 Managed care 336,225 17.5 271,993 15.4 Private and other (2) 171,424 8.9 187,381 10.6 Service revenue $ 1,922,482 100.0 % $ 1,762,371 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP for the nine months ended September 30, 2021 and 2020.
Schedule of Accounts, Notes, Loans and Financing Receivable	Accounts receivable as of September 30, 2021 and December 31, 2020, is summarized in the following table: September 30, 2021 December 31, 2020 Medicaid $ 118,102 $ 102,077 Managed care 74,902 61,743 Medicare 56,343 80,904 Private and other payors 75,778 69,056 325,125 313,780 Less: allowance for doubtful accounts (11,267) (8,718) Accounts receivable, net $ 313,858 $ 305,062

Computation of Net Income Per_2

Computation of Net Income Per Common Share (Tables)	9 Months Ended
	Sep. 30, 2021
Earnings Per Share [Abstract]
Schedule of Earnings Per Share, Basic, by Common Class, Including Two Class Method	A reconciliation of the numerator and denominator used in the calculation of basic net income per common share follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Numerator: Net income $ 48,344 $ 43,313 $ 148,764 $ 125,202 Less: net income attributable to noncontrolling interests 1,063 253 2,852 1,045 Net income attributable to The Ensign Group, Inc. $ 47,281 $ 43,060 $ 145,912 $ 124,157 Denominator: Weighted average shares outstanding for basic net income per share 54,627 53,328 54,430 53,299 Basic net income per common share: $ 0.87 $ 0.81 $ 2.68 $ 2.33
Schedule of Earnings Per Share, Diluted, by Common Class, Including Two Class Method	A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Numerator: Net income $ 48,344 $ 43,313 $ 148,764 $ 125,202 Less: net income attributable to noncontrolling interests 1,063 253 2,852 1,045 Net income attributable to The Ensign Group, Inc. $ 47,281 $ 43,060 $ 145,912 $ 124,157 Denominator: Weighted average common shares outstanding 54,627 53,328 54,430 53,299 Plus: incremental shares from assumed conversion (1) 2,344 2,385 2,524 2,286 Adjusted weighted average common shares outstanding 56,971 55,713 56,954 55,585 Diluted net income per common share: $ 0.83 $ 0.77 $ 2.56 $ 2.23 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 365 and 139 fo r the three and nine months ended September 30, 2021, respectively, and 1,144 and 979 for the three and nine months ended September 30, 2020, respectivel

Business Segments (Tables)

Business Segments (Tables)	9 Months Ended
	Sep. 30, 2021
Segment Reporting [Abstract]
Schedule of Segment Reporting Information, by Segment	The following tables set forth financial information for the segments: Three Months Ended September 30, 2021 Skilled Services Real Estate All Other (1) Intercompany Elimination (2) Total Service revenue $ 642,075 $ — $ 22,522 $ — $ 664,597 Rental revenue — 16,271 — (12,338) 3,933 Total revenue $ 642,075 $ 16,271 $ 22,522 $ (12,338) $ 668,530 Segment income (loss) 94,429 8,910 (38,482) — 64,857 Income before provision for income taxes $ 64,857 Depreciation and amortization 7,715 4,936 1,278 — 13,929 Other expense (income), net (3) $ — $ 1,705 $ (244) $ — $ 1,461 (1) General and administrative expense are included in the "all other" category. (2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities. (3) Other expense (income), net includes interest expense, interest income and gain and loss on investments. Three Months Ended September 30, 2020 Skilled Services Real Estate All Other (1) Intercompany Elimination (2) Total Service revenue $ 570,282 $ — $ 25,059 $ — $ 595,341 Rental revenue — 15,536 — (11,622) 3,914 Total revenue $ 570,282 $ 15,536 $ 25,059 $ (11,622) $ 599,255 Segment income (loss) 84,747 8,474 (36,289) — 56,932 Loss on sale of real estate and impairment charges (2,753) Income before provision for income taxes $ 54,179 Depreciation and amortization 7,094 4,522 2,141 — 13,757 Other expense (income), net (3) $ — $ 1,731 $ (841) $ — $ 890 (1) General and administrative expense is included in the "all other" category (2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities. (3) Other expense (income), net includes interest expense and interest income. Nine Months Ended September 30, 2021 Skilled Services Real Estate All Other (1) Intercompany Elimination (2) Total Service revenue $ 1,855,993 $ — $ 66,489 $ — $ 1,922,482 Rental revenue — 48,181 — (36,344) 11,837 Total revenue $ 1,855,993 $ 48,181 $ 66,489 $ (36,344) $ 1,934,319 Segment income (loss) 273,370 26,622 (108,448) — 191,544 Gain on sale of real estate 440 Income before provision for income taxes $ 191,984 Depreciation and amortization 22,893 14,413 4,077 — 41,383 Other expense (income), net (3) $ — $ 4,980 $ (2,113) $ — $ 2,867 (1) General and administrative expense are included in the "all other" category. (2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities. (3) Other expense, net includes interest expense, interest income and gain and loss on investments. Nine Months Ended September 30, 2020 Skilled Services Real Estate All Other (1) Intercompany Elimination (2) Total Service revenue $ 1,685,263 $ — $ 77,108 $ — $ 1,762,371 Rental revenue — 45,489 — (34,293) 11,196 Total revenue $ 1,685,263 $ 45,489 $ 77,108 $ (34,293) $ 1,773,567 Segment income (loss) 243,640 22,593 (101,252) — 164,981 Loss on sale of real estate and impairment charges (2,753) Income before provision for income taxes $ 162,228 Depreciation and amortization 21,247 13,624 6,211 — 41,082 Other expense (income), net (3) $ — $ 7,689 $ (2,621) $ — $ 5,068 (1) General and administrative expense is included in the "all other" category (2) Intercompany elimination represents rental income at the real estate segment generated from triple-net lease arrangements with the Company's affiliated wholly-owned healthcare facilities. Intercompany rental revenue is eliminated in consolidation, along with corresponding intercompany rent expenses of related healthcare facilities. (3) Other expense, net includes interest expense and interest income.
Reconciliation of Revenue from Segments to Consolidated	Service revenue by major payor source were as follows: Three Months Ended September 30, 2021 Skilled Services All Other Total Service Revenue Revenue % Medicaid $ 263,072 $ 3,936 (1) $ 267,008 40.2 % Medicare 176,660 — 176,660 26.6 Medicaid-skilled 45,308 — 45,308 6.8 Subtotal 485,040 3,936 488,976 73.6 Managed care 114,917 — 114,917 17.3 Private and other 42,118 18,586 (2) 60,704 9.1 Total service revenue $ 642,075 $ 22,522 $ 664,597 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP for the three months ended September 30, 2021. (2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the three months ended September 30, 2021. Three Months Ended September 30, 2020 Skilled Services All Other Total Service Revenue Revenue % Medicaid $ 218,840 $ 3,352 (1) $ 222,192 37.3 % Medicare 189,237 — 189,237 31.8 Medicaid-skilled 38,232 — 38,232 6.4 Subtotal 446,309 3,352 449,661 75.5 Managed care 87,648 — 87,648 14.7 Private and other 36,325 21,707 (2) 58,032 9.8 Total service revenue $ 570,282 $ 25,059 $ 595,341 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to FMAP for the three months ended September 30, 2020. (2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the three months ended September 30, 2020. Nine Months Ended September 30, 2021 Skilled Services All Other Total Service Revenue Revenue % Medicaid $ 738,484 $ 11,337 (1) $ 749,821 39.0 % Medicare 536,971 — 536,971 27.9 Medicaid-skilled 128,041 — 128,041 6.7 Subtotal 1,403,496 11,337 1,414,833 73.6 Managed care 336,225 — 336,225 17.5 Private and other 116,272 55,152 (2) 171,424 8.9 Total service revenue $ 1,855,993 $ 66,489 $ 1,922,482 100.0 % (1) Medicaid payor includes revenue generated from senior living operations and revenue related to FMAP for the nine months ended September 30, 2021. (2) Private and other payors also includes revenue from senior living operations and all payors generated in other ancillary services for the nine months ended September 30, 2021. Nine Months Ended September 30, 2020 Skilled Services All Other Total Service Revenue Revenue % Medicaid $ 662,733 $ 9,773 (1) $ 672,506 38.2 % Medicare 519,865 — 519,865 29.5 Medicaid-skilled 110,626 — 110,626 6.3 Subtotal 1,293,224 9,773 1,302,997 74.0 Managed care 271,993 — 271,993 15.4 Private and other 120,046 67,335 (2) 187,381 10.6 Total service revenue $ 1,685,263 $ 77,108 $ 1,762,371 100.0 % (1) Medicaid payor includes revenue generated from senior living operations and revenue related to FMAP for the nine months ended September 30, 2020.

Property and Equipment _ Net (T

Property and Equipment — Net (Tables)	9 Months Ended
	Sep. 30, 2021
Property, Plant and Equipment [Abstract]
Schedule of Property and Equipment	Property and equipment, net consists of the following: September 30, 2021 December 31, 2020 Land $ 101,552 $ 101,236 Buildings and improvements 568,331 555,416 Leasehold improvements 136,728 129,727 Equipment 259,102 233,453 Furniture and fixtures 4,499 4,409 Construction in progress 8,841 3,008 1,079,053 1,027,249 Less: accumulated depreciation (287,806) (249,005) Property and equipment, net $ 791,247 $ 778,244

Intangible Assets _ Net (Tables

Intangible Assets — Net (Tables)	9 Months Ended
	Sep. 30, 2021
Intangible Assets, Net (Excluding Goodwill) [Abstract]
Schedule of Finite-Lived Intangible Assets	September 30, 2021 December 31, 2020 Weighted Average Life (Years) Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Assembled occupancy 0.4 $ 68 $ (68) $ — $ 39 $ (26) $ 13 Facility trade name 30.0 733 (384) 349 733 (366) 367 Customer relationships 18.4 4,582 (2,220) 2,362 4,640 (2,121) 2,519 Total $ 5,383 $ (2,672) $ 2,711 $ 5,412 $ (2,513) $ 2,899
Schedule of Finite-Lived Intangible Assets, Future Amortization Expense	Estimated amortization expense for each of the years ending December 31 is as follows: Year Amount 2021 (remainder) $ 59 2022 234 2023 234 2024 234 2025 234 2026 234 Thereafter 1,482 $ 2,711

Goodwill and Other Indefinite_2

Goodwill and Other Indefinite-Lived Intangible Assets (Tables)	9 Months Ended
	Sep. 30, 2021
Goodwill and Intangible Assets Disclosure [Abstract]
Schedule of Goodwill	The following table represents the goodwill value by skilled service segment and "all other" category, which includes other ancillary services, as of and for the nine months ended September 30, 2021: Goodwill Skilled Services All Other Total January 1, 2021 $ 45,486 $ 8,983 $ 54,469 Additions 6,000 — 6,000 September 30, 2021 $ 51,486 $ 8,983 $ 60,469
Schedule of Other Indefinite-lived Intangible Assets by Major Class	Other indefinite-lived intangible assets consist of the following: September 30, 2021 December 31, 2020 Trade name $ 889 $ 889 Medicare and Medicaid licenses 2,732 2,827 $ 3,621 $ 3,716

Restricted and Other Assets (Ta

Restricted and Other Assets (Tables)	9 Months Ended
	Sep. 30, 2021
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Schedule of Restricted and Other Assets	Restricted and other assets consist of the following: September 30, 2021 December 31, 2020 Debt issuance costs, net $ 2,131 $ 2,664 Long-term insurance losses recoverable asset 7,573 7,138 Deposits with landlords 12,268 12,400 Capital improvement reserves with landlords and lenders 6,328 4,376 Cash surrender value of life insurance related to deferred compensation plan 16,082 6,577 Restricted and other assets $ 44,382 $ 33,155

Other Accrued Liabilities (Tabl

Other Accrued Liabilities (Tables)	9 Months Ended
	Sep. 30, 2021
Payables and Accruals [Abstract]
Schedule of Other Accrued Liabilities	Other accrued liabilities consists of the following: September 30, 2021 December 31, 2020 Quality assurance fee $ 6,470 $ 6,631 Refunds payable 36,702 36,323 Resident advances 4,129 8,558 Unapplied state relief funds 4,392 6,520 Cash held in trust for patients 6,883 6,052 Dividends payable 2,900 2,868 Property taxes 11,462 9,222 Other 12,531 11,144 Other accrued liabilities $ 85,469 $ 87,318

Debt (Tables)

Debt (Tables)	9 Months Ended
	Sep. 30, 2021
Debt Disclosure [Abstract]
Schedule of Long-term Debt	Debt consists of the following: September 30, 2021 December 31, 2020 Mortgage loans and promissory notes $ 147,306 $ 117,806 Less: current maturities (3,548) (2,960) Less: debt issuance costs, net (3,078) (2,302) Long-term debt less current maturities $ 140,680 $ 112,544

Options and Awards (Tables)

Options and Awards (Tables)	9 Months Ended
	Sep. 30, 2021
Share-based Payment Arrangement [Abstract]
Schedule of Share-based Payment Award, Stock Options, Valuation Assumptions	The Company used the following assumptions for stock options granted during the three months ended September 30, 2021 and 2020: Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2021 151 1.0% 6.1 years 42.5% 0.3% 2020 160 0.4% 6.3 years 41.8% 0.3% The Company used the following assumptions for stock options granted during the nine months ended September 30, 2021 and 2020: Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2021 496 0.9% 6.2 years 42.3% 0.3% 2020 540 0.7% 6.2 years 38.8% 0.4%
Schedule of Weighted Average Grant Date Fair Value and Exercise Price of Options	For the nine months ended September 30, 2021 and 2020, 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 2021 496 $ 81.89 $ 33.45 2020 540 $ 50.46 $ 18.62
Schedule of Common Stock Outstanding Roll Forward	The following table represents the employee stock option activity during the nine months ended September 30, 2021: Number of Options Outstanding Weighted Average Number of Weighted Average Exercise Price of Options Vested January 1, 2021 4,038 $ 27.71 2,148 $ 16.66 Granted 496 81.89 Forfeited (77) 41.69 Exercised (463) 17.51 September 30, 2021 3,994 $ 35.35 2,129 $ 20.25
Share-based Payment Arrangement, Option, Exercise Price Range	The following summary information reflects stock options outstanding, vested and related details as of September 30, 2021: Stock Options Outstanding Stock Options Vested Number Outstanding Black-Scholes Fair Value Remaining Contractual Life (Years) Vested and Exercisable Year of Grant Exercise Price 2011 $5.00 - $6.77 3 $ 3 0 3 2012 5.56 - 6.75 73 220 1 73 2013 6.76 - 9.74 140 539 2 140 2014 8.94 - 16.05 625 3,002 3 625 2015 18.20 - 21.39 279 2,164 4 279 2016 15.93 - 16.86 257 1,514 5 245 2017 15.80 - 19.41 315 1,851 6 208 2018 22.49 - 32.71 532 5,146 7 250 2019 41.07 - 45.76 662 10,394 8 216 2020 44.84 - 59.49 616 12,104 9 90 2021 $79.88 - $83.64 492 16,465 10 — Total 3,994 $ 53,402 2,129
Schedule of Aggregate Intrinsic Value of Options	The aggregate intrinsic value of options outstanding, vested and expected to vest as of September 30, 2021 and December 31, 2020 is as follows: Options September 30, 2021 December 31, 2020 Outstanding $ 161,371 $ 182,552 Vested 116,340 120,867 Expected to vest 40,548 53,366
Schedule of Nonvested Restricted Stock Units Activity	A summary of the status of the Company's non-vested restricted stock awards as of September 30, 2021 and changes during the nine months ended September 30, 2021 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2021 591 $ 38.90 Granted 195 82.81 Vested (213) 48.45 Forfeited (16) 45.65 Nonvested at September 30, 2021 557 $ 50.43
Schedule of Stock-Based Compensation Expense	Stock-based compensation expense recognized for the Company's equity incentive plans and long-term incentive plan for the three and nine months ended September 30, 2021 and 2020 was as follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Stock-based compensation expense related to stock options $ 2,371 $ 1,692 $ 6,130 $ 4,656 Stock-based compensation expense related to restricted stock awards 2,217 2,221 6,131 5,596 Stock-based compensation expense related to stock options and restricted stock awards to non-employee directors 494 260 1,508 684 Total $ 5,082 $ 4,173 $ 13,769 $ 10,936

Leases (Tables)

Leases (Tables)	9 Months Ended
	Sep. 30, 2021
Leases [Abstract]
Lease, Cost	The components of operating lease expense are as follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Rent - cost of services (1) $ 35,623 $ 32,504 $ 103,534 $ 97,318 General and administrative expense 23 16 64 48 Depreciation and amortization (2) 289 289 869 933 Variable lease costs (3) 3,582 3,229 10,719 9,692 $ 39,517 $ 36,038 $ 115,186 $ 107,991 (1) Rent - cost of services includes deferred rent expense adju stments of $125 and $346 for the three and nine months ended September 30, 2021, respectively, and $101 and $337 for the three and nine months ended September 30, 2020, respectively. Additionally, rent - cost of services includes other variable lease costs such as CPI increases and short-term leases of $1,127 and $2,543 for the three and nine months ended September 30, 2021, respectively, and $567 and $1,781 for the three and nine months ended September 30, 2020, respectively. (2) Depreciation and amortization is related to the amortization of favorable and direct lease costs. (3) Variable lease costs, including property taxes and insurance, are classified in cost of services in the Company's condensed consolidated statements of income.
Lessee, Operating Lease, Liability, Maturity	Future minimum lease payments for all leases as of September 30, 2021 are as follows: Year Amount 2021 (remainder) $ 34,660 2022 138,592 2023 136,845 2024 135,889 2025 135,813 2026 135,708 Thereafter 1,201,777 Total lease payments 1,919,284 Less: present value adjustment (774,058) Present value of total lease liabilities 1,145,226 Less: current lease liabilities (52,050) Long-term operating lease liabilities $ 1,093,176
Operating Lease, Lease Income	Total rental income from all third-party sources for the three and nine months ended September 30, 2021 and 2020 is as follows: Three Months Ended September 30, Nine Months Ended September 30, 2021 2020 2021 2020 Pennant (1) $ 3,468 $ 3,443 $ 10,396 $ 9,675 Other third-party 465 471 1,441 1,521 $ 3,933 $ 3,914 $ 11,837 $ 11,196
Lessor, Operating Lease, Payments to be Received, Maturity	Future annual rental income for all leases as of September 30, 2021 were as follows: Year Amount (1) 2021 (remainder) $ 3,900 2022 15,238 2023 14,937 2024 14,249 2025 13,911 2026 13,700 Thereafter 84,838 Total $ 160,773

Description of Business (Detail

Description of Business (Details)	9 Months Ended	12 Months Ended
	Sep. 30, 2021operationfacilitybedsegmentseniorLivingUnit	Dec. 31, 2020segment	Sep. 30, 2020bed	Mar. 31, 2020facility	Oct. 31, 2019facility
Restructuring Cost and Reserve [Line Items]
Health care facilities	242
Operational skilled nursing beds | bed	24,700
Operational senior living units | seniorLivingUnit	2,200
Number of real estate properties leased	177
Number of real estate properties leased with an option to purchase	11
Number of real estate properties	95
Number of reportable segments | segment	2	1
Skilled Nursing Operations
Restructuring Cost and Reserve [Line Items]
Operational skilled nursing beds | bed	1,504		303
Senior Living Facilities | The Pennant Group, Inc.
Restructuring Cost and Reserve [Line Items]
Number of real estate properties				2
Spinoff | Remaining Company | Skilled Nursing Operations
Restructuring Cost and Reserve [Line Items]
Number of real estate properties | operation	2
Spinoff | Senior Living Facilities | The Pennant Group, Inc.
Restructuring Cost and Reserve [Line Items]
Number of real estate properties	31				29
Owned Properties
Restructuring Cost and Reserve [Line Items]
Number of real estate properties	65

Summary of Significant Accoun_3

Summary of Significant Accounting Policies - Property and Equipment (Details)	9 Months Ended
	Sep. 30, 2021
Minimum
Property, Plant and Equipment [Line Items]
Property, plant and equipment, useful life	3 years
Maximum
Property, Plant and Equipment [Line Items]
Property, plant and equipment, useful life	59 years

Summary of Significant Accoun_4

Summary of Significant Accounting Policies - Leases and Leasehold Improvements (Details)	Sep. 30, 2021
Real Estate Properties [Line Items]
Lessee, operating lease, term of contract	10 years
Maximum
Real Estate Properties [Line Items]
Lessee, operating lease, renewal term	15 years
Minimum
Real Estate Properties [Line Items]
Lessee, operating lease, renewal term	10 years

Summary of Significant Accoun_5

Summary of Significant Accounting Policies - Impairment of Long-Lived Assets (Details) - USD ($)	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Accounting Policies [Abstract]
Impairment of long-lived assets	$ 0	$ 2,681,000	$ 0	$ 2,681,000

Summary of Significant Accoun_6

Summary of Significant Accounting Policies - Intangible Assets and Goodwill (Details) - USD ($)	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Finite-Lived Intangible Assets [Line Items]
Goodwill and intangible asset impairment	$ 0	$ 0	$ 0	$ 0
Facility 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
Minimum | Assembled occupancy
Finite-Lived Intangible Assets [Line Items]
Finite-lived intangible asset, useful life			4 months
Maximum | Assembled occupancy
Finite-Lived Intangible Assets [Line Items]
Finite-lived intangible asset, useful life			8 months

Summary of Significant Accoun_7

Summary of Significant Accounting Policies - Self-Insurance General and Professional (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
General and Professional Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Malpractice loss contingency, accrual, undiscounted	$ 63,689	$ 57,628
Self-Insurance Retention Per Claim | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	500
Self-Insurance Retention Per Claim | Parent Company | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	500
Aggregate Deductible | Parent Company | California | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	750
Aggregate Deductible | Parent Company | Non-California | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	1,000
Blanket Aggregate | Third-Party Payor | All States Except Colorado | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	5,000
Per Occurence | Third-Party Payor | All States Except Colorado | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	1,000
Per Occurence | Third-Party Payor | Colorado | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	1,000
Per Facility | Third-Party Payor | All States Except Colorado | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	3,000
Per Facility | Third-Party Payor | Colorado | General Liability
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	$ 3,000

Summary of Significant Accoun_8

Summary of Significant Accounting Policies - Self-Insurance Workers' Compensation (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Workers' Compensation
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	$ 25,968	$ 24,499
Workers' Compensation
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	625
Workers' Compensation | TEXAS
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	750
Workers' Compensation | Loss-Sensitive Limit Per Claim | Other States, Except California, Texas and Washington
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	350
General Liability | Self-Insurance Retention Per Claim
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	$ 500

Summary of Significant Accoun_9

Summary of Significant Accounting Policies - Self Insurance Recoveries (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Accounting Policies [Abstract]
Long-term insurance losses recoverable asset	$ 7,573	$ 7,138

Summary of Significant Accou_10

Summary of Significant Accounting Policies - Self-Insurance Health Insurance (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Health
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	$ 9,799	$ 7,533
Health Liability Insurance | Stop-Loss Insurance Limit Per Claim
Liability for Claims and Claims Adjustment Expense [Line Items]
Self insurance reserve	$ 500

COVID-19 Update (Details)

COVID-19 Update (Details) - USD ($) $ in Thousands	1 Months Ended		3 Months Ended		9 Months Ended		12 Months Ended
	Mar. 31, 2021	Jul. 31, 2020	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020	Dec. 31, 2020
Unusual or Infrequent Items, or Both [Abstract]
Coronavirus Aid, Relief, and Economic Security (“CARES”) funds received and returned			$ 99	$ 23,296	$ 11,637	$ 132,052
Repayments of CARES Act Provider Relief Fund and Medicare Advance Payment Program (Note 3)				108,756	113,660	111,988
Medicare Accelerated and Advance Payment							$ 105,255
Repayment of Medicare Accelerated and Advance Payment Program	$ 102,023	$ 3,232
Unapplied state relief funds			4,392		4,392		6,520
FMAP payments received			17,829	17,344	50,250	32,455
Revenue, FMAP payments received			19,229	$ 11,691	52,386	$ 24,825
Total deferred payment of social security taxes							48,309
Deferred payment of social security taxes, current			24,155		24,155		24,155
Deferred payment of social security taxes, noncurrent			$ 24,154		$ 24,154		$ 24,154

Revenue and Accounts Receivab_3

Revenue and Accounts Receivable - Revenue from Medicare and Medicaid Programs (Details)	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Customer Concentration Risk | Revenue Benchmark | Total Medicare and Medicaid
Disaggregation of Revenue [Line Items]
Concentration risk	73.60%	75.50%	73.60%	74.00%

Revenue and Accounts Receivab_4

Revenue and Accounts Receivable - Disaggregation of Revenue (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Disaggregation of Revenue [Line Items]
Total revenue	$ 668,530	$ 599,255	$ 1,934,319	$ 1,773,567
Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	664,597	595,341	1,922,482	1,762,371
Rental revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 3,933	$ 3,914	$ 11,837	$ 11,196
Customer Concentration Risk | Revenue Benchmark | Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	100.00%	100.00%	100.00%	100.00%
Medicaid | Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 267,008	$ 222,192	$ 749,821	$ 672,506
Medicaid | Customer Concentration Risk | Revenue Benchmark | Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	40.20%	37.30%	39.00%	38.20%
Medicare | Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 176,660	$ 189,237	$ 536,971	$ 519,865
Medicare | Customer Concentration Risk | Revenue Benchmark | Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	26.60%	31.80%	27.90%	29.50%
Medicaid — skilled | Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 45,308	$ 38,232	$ 128,041	$ 110,626
Medicaid — skilled | Customer Concentration Risk | Revenue Benchmark | Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	6.80%	6.40%	6.70%	6.30%
Total Medicaid and Medicare | Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 488,976	$ 449,661	$ 1,414,833	$ 1,302,997
Total Medicaid and Medicare | Customer Concentration Risk | Revenue Benchmark
Disaggregation of Revenue [Line Items]
Concentration risk	73.60%	75.50%	73.60%	74.00%
Total Medicaid and Medicare | Customer Concentration Risk | Revenue Benchmark | Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	73.60%	75.50%	73.60%	74.00%
Managed care | Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 114,917	$ 87,648	$ 336,225	$ 271,993
Managed care | Customer Concentration Risk | Revenue Benchmark | Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	17.30%	14.70%	17.50%	15.40%
Private and other | Service revenue
Disaggregation of Revenue [Line Items]
Total revenue	$ 60,704	$ 58,032	$ 171,424	$ 187,381
Private and other | Customer Concentration Risk | Revenue Benchmark | Service revenue
Disaggregation of Revenue [Line Items]
Concentration risk	9.10%	9.80%	8.90%	10.60%

Revenue and Accounts Receivab_5

Revenue and Accounts Receivable - Accounts Receivable (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	$ 325,125	$ 313,780
Less: allowance for doubtful accounts	(11,267)	(8,718)
Accounts receivable, net	313,858	305,062
Medicaid
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	118,102	102,077
Managed care
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	74,902	61,743
Medicare
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	56,343	80,904
Private and other payors
Accounts, Notes, Loans and Financing Receivable [Line Items]
Accounts receivable	$ 75,778	$ 69,056

Computation of Net Income Per_3

Computation of Net Income Per Common Share (Details) - USD ($) $ / shares in Units, shares in Thousands, $ in Thousands	3 Months Ended						9 Months Ended
	Sep. 30, 2021	Jun. 30, 2021	Mar. 31, 2021	Sep. 30, 2020	Jun. 30, 2020	Mar. 31, 2020	Sep. 30, 2021	Sep. 30, 2020
Numerator:
Net income	$ 48,344			$ 43,313			$ 148,764	$ 125,202
Less: net income attributable to noncontrolling interests	1,063			253			2,852	1,045
Net income attributable to The Ensign Group, Inc.	$ 47,281	$ 49,425	$ 49,206	$ 43,060	$ 40,248	$ 40,849	$ 145,912	$ 124,157
Denominator:
Weighted average shares outstanding for basic net income per share (in shares)	54,627			53,328			54,430	53,299
Basic net income per common share (in dollars per share)	$ 0.87			$ 0.81			$ 2.68	$ 2.33
Plus: incremental shares from assumed conversion (in shares)	2,344			2,385			2,524	2,286
Adjusted weighted average common shares outstanding (in shares)	56,971			55,713			56,954	55,585
Diluted net income per common share (in dollars per share)	$ 0.83			$ 0.77			$ 2.56	$ 2.23
Antidilutive securities excluded from computation of earnings per share, amount (in shares)	365			1,144			139	979

Fair Value Measurements - Sched

Fair Value Measurements - Schedule of Fair Value, of Assets and Liabilities Measured on Recurring Basis (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Fair Value, Inputs, Level 1
Fair Value, Balance Sheet Grouping, Financial Statement Captions [Line Items]
Cash and cash equivalents, fair value disclosure	$ 304,620	$ 236,562
Fair Value, Inputs, Level 2
Fair Value, Balance Sheet Grouping, Financial Statement Captions [Line Items]
Cash surrender value of life insurance related to deferred compensation plan	$ 16,082	$ 6,577

Fair Value Measurements - Inves

Fair Value Measurements - Investments (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Debt Security, Corporate, US
Schedule of Held-to-maturity Securities [Line Items]
Debt securities, held-to-maturity	$ 48,024	$ 45,554

Business Segments - Narrative (

Business Segments - Narrative (Details)	9 Months Ended	12 Months Ended
	Sep. 30, 2021operationfacilitysegment	Dec. 31, 2020segment	Mar. 31, 2020facility	Oct. 31, 2019facility
Segment Reporting Information [Line Items]
Number of reportable segments | segment	2	1
Transitional and skilled service facilities	211
Transitional and skilled services and senior living campuses	22
Number of real estate properties	95
Senior living facilities	9
Spinoff | Remaining Company | Skilled Nursing Operations
Segment Reporting Information [Line Items]
Number of real estate properties | operation	2
The Pennant Group, Inc. | Senior Living Facilities
Segment Reporting Information [Line Items]
Number of real estate properties			2
The Pennant Group, Inc. | Senior Living Facilities | Spinoff
Segment Reporting Information [Line Items]
Number of real estate properties	31			29
Owned Properties
Segment Reporting Information [Line Items]
Number of real estate properties	65

Business Segments - Schedule of

Business Segments - Schedule of Segment Reporting Information, by Segment (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Segment Reporting Information [Line Items]
Total revenue	$ 668,530	$ 599,255	$ 1,934,319	$ 1,773,567
Segment income (loss)	64,857	56,932	191,544	164,981
Gain (loss) on sale of real estate		(2,753)	440	(2,753)
Income before provision for income taxes	64,857	54,179	191,984	162,228
Depreciation and amortization	13,929	13,757	41,383	41,082
Other expense (income), net	1,461	890	2,867	5,068
Service revenue
Segment Reporting Information [Line Items]
Total revenue	664,597	595,341	1,922,482	1,762,371
Rental revenue
Segment Reporting Information [Line Items]
Total revenue	3,933	3,914	11,837	11,196
Operating Segments | Skilled Services
Segment Reporting Information [Line Items]
Total revenue	642,075	570,282	1,855,993	1,685,263
Segment income (loss)	94,429	84,747	273,370	243,640
Depreciation and amortization	7,715	7,094	22,893	21,247
Other expense (income), net	0	0	0	0
Operating Segments | Skilled Services | Service revenue
Segment Reporting Information [Line Items]
Total revenue	642,075	570,282	1,855,993	1,685,263
Operating Segments | Skilled Services | Rental revenue
Segment Reporting Information [Line Items]
Total revenue	0	0	0	0
Operating Segments | Real Estate
Segment Reporting Information [Line Items]
Total revenue	16,271	15,536	48,181	45,489
Segment income (loss)	8,910	8,474	26,622	22,593
Depreciation and amortization	4,936	4,522	14,413	13,624
Other expense (income), net	1,705	1,731	4,980	7,689
Operating Segments | Real Estate | Service revenue
Segment Reporting Information [Line Items]
Total revenue	0	0	0	0
Operating Segments | Real Estate | Rental revenue
Segment Reporting Information [Line Items]
Total revenue	16,271	15,536	48,181	45,489
All Other
Segment Reporting Information [Line Items]
Total revenue	22,522	25,059	66,489	77,108
Segment income (loss)	(38,482)	(36,289)	(108,448)	(101,252)
Depreciation and amortization	1,278	2,141	4,077	6,211
Other expense (income), net	(244)	(841)	(2,113)	(2,621)
All Other | Service revenue
Segment Reporting Information [Line Items]
Total revenue	22,522	25,059	66,489	77,108
All Other | Rental revenue
Segment Reporting Information [Line Items]
Total revenue	0	0	0	0
Intercompany Eliminations
Segment Reporting Information [Line Items]
Total revenue	(12,338)	(11,622)	(36,344)	(34,293)
Segment income (loss)	0		0	0
Depreciation and amortization	0	0	0	0
Other expense (income), net	0	0	0	0
Intercompany Eliminations | Service revenue
Segment Reporting Information [Line Items]
Total revenue	0	0	0	0
Intercompany Eliminations | Rental revenue
Segment Reporting Information [Line Items]
Total revenue	$ (12,338)	$ (11,622)	$ (36,344)	$ (34,293)

Business Segments - Revenue by

Business Segments - Revenue by Segment (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 668,530	$ 599,255	$ 1,934,319	$ 1,773,567
Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 664,597	$ 595,341	$ 1,922,482	$ 1,762,371
Revenue Benchmark | Customer Concentration Risk | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	100.00%	100.00%	100.00%	100.00%
Medicaid | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 267,008	$ 222,192	$ 749,821	$ 672,506
Medicaid | Revenue Benchmark | Customer Concentration Risk | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	40.20%	37.30%	39.00%	38.20%
Medicare | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 176,660	$ 189,237	$ 536,971	$ 519,865
Medicare | Revenue Benchmark | Customer Concentration Risk | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	26.60%	31.80%	27.90%	29.50%
Medicaid — skilled | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 45,308	$ 38,232	$ 128,041	$ 110,626
Medicaid — skilled | Revenue Benchmark | Customer Concentration Risk | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	6.80%	6.40%	6.70%	6.30%
Total Medicaid and Medicare | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 488,976	$ 449,661	$ 1,414,833	$ 1,302,997
Total Medicaid and Medicare | Revenue Benchmark | Customer Concentration Risk
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	73.60%	75.50%	73.60%	74.00%
Total Medicaid and Medicare | Revenue Benchmark | Customer Concentration Risk | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	73.60%	75.50%	73.60%	74.00%
Managed care | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 114,917	$ 87,648	$ 336,225	$ 271,993
Managed care | Revenue Benchmark | Customer Concentration Risk | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	17.30%	14.70%	17.50%	15.40%
Private and other | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 60,704	$ 58,032	$ 171,424	$ 187,381
Private and other | Revenue Benchmark | Customer Concentration Risk | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Concentration risk	9.10%	9.80%	8.90%	10.60%
Operating Segments | Skilled Services
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 642,075	$ 570,282	$ 1,855,993	$ 1,685,263
Operating Segments | Skilled Services | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	642,075	570,282	1,855,993	1,685,263
Operating Segments | Medicaid | Skilled Services | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	263,072	218,840	738,484	662,733
Operating Segments | Medicare | Skilled Services | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	176,660	189,237	536,971	519,865
Operating Segments | Medicaid — skilled | Skilled Services | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	45,308	38,232	128,041	110,626
Operating Segments | Total Medicaid and Medicare | Skilled Services | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	485,040	446,309	1,403,496	1,293,224
Operating Segments | Managed care | Skilled Services | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	114,917	87,648	336,225	271,993
Operating Segments | Private and other | Skilled Services | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	42,118	36,325	116,272	120,046
All Other
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	22,522	25,059	66,489	77,108
All Other | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	22,522	25,059	66,489	77,108
All Other | Medicaid | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	3,936	3,352	11,337	9,773
All Other | Medicare | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
All Other | Medicaid — skilled | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
All Other | Total Medicaid and Medicare | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	3,936	3,352	11,337	9,773
All Other | Managed care | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	0	0	0	0
All Other | Private and other | Service revenue
Segment Reporting, Revenue Reconciling Item [Line Items]
Total revenue	$ 18,586	$ 21,707	$ 55,152	$ 67,335

Operation Expansions (Details)

Operation Expansions (Details) $ in Thousands	1 Months Ended	9 Months Ended
	Oct. 27, 2021bedoperation	Sep. 30, 2021bedfacilityseniorLivingUnitoperation	Sep. 30, 2021ownedPropertybedfacilityseniorLivingUnit	Sep. 30, 2021USD ($)facilitybedseniorLivingUnit	Sep. 30, 2021bedfacilitybusinessseniorLivingUnit	Sep. 30, 2020USD ($)seniorLivingUnitoperationbedfacility	Mar. 31, 2020facility
Business Acquisition [Line Items]
Operational skilled nursing beds | bed		24,700	24,700	24,700	24,700
Payments to acquire business and asset acquisitions				$ 11,183
Goodwill acquired				$ 6,000
Operational senior living units | seniorLivingUnit		2,200	2,200	2,200	2,200
Number of real estate properties | facility		95	95	95	95
Senior Living Facilities | The Pennant Group, Inc.
Business Acquisition [Line Items]
Number of real estate properties | facility							2
Nine Acquisitions Concentrated in Property, Plant And Equipment
Business Acquisition [Line Items]
Number of businesses acquired | business					10
Asset acquisition, purchase price				$ 5,183
Nine Acquisitions Concentrated in Property, Plant And Equipment | Buildings and improvements
Business Acquisition [Line Items]
Property, plant and equipment				$ 4,547
Asset Acquisition
Business Acquisition [Line Items]
Asset acquisition, purchase price						$ 23,077
Asset Acquisition | Buildings and improvements
Business Acquisition [Line Items]
Property, plant and equipment						13,365
Asset Acquisition | Land
Business Acquisition [Line Items]
Property, plant and equipment						$ 8,938
Skilled Nursing Operations | Subsequent Event
Business Acquisition [Line Items]
Number of businesses acquired | operation	3
Operational skilled nursing beds | bed	328
Skilled Nursing Operations
Business Acquisition [Line Items]
Number of businesses acquired		14	1			3
Operational skilled nursing beds | bed		1,504	1,504	1,504	1,504	303
Four Acquisitions Concentrated In Goodwill
Business Acquisition [Line Items]
Number of businesses acquired | business					4
Goodwill acquired				$ 6,000
Senior Living Facilities
Business Acquisition [Line Items]
Number of businesses acquired | operation						1
Operational senior living units | seniorLivingUnit						298
Transitional and Skilled Services and Senior Living Campuses
Business Acquisition [Line Items]
Number of businesses acquired | operation						1
Owned Properties
Business Acquisition [Line Items]
Number of businesses acquired | facility						3

Property and Equipment _ Net (D

Property and Equipment — Net (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Property, Plant and Equipment [Line Items]
Property and equipment	$ 1,079,053	$ 1,027,249
Less: accumulated depreciation	(287,806)	(249,005)
Property and equipment, net	791,247	778,244
Land
Property, Plant and Equipment [Line Items]
Property and equipment	101,552	101,236
Buildings and improvements
Property, Plant and Equipment [Line Items]
Property and equipment	568,331	555,416
Leasehold improvements
Property, Plant and Equipment [Line Items]
Property and equipment	136,728	129,727
Equipment
Property, Plant and Equipment [Line Items]
Property and equipment	259,102	233,453
Furniture and fixtures
Property, Plant and Equipment [Line Items]
Property and equipment	4,499	4,409
Construction in progress
Property, Plant and Equipment [Line Items]
Property and equipment	$ 8,841	$ 3,008

Intangible Assets _ Net - Sched

Intangible Assets — Net - Schedule of Finite Lived Intangible Assets (Details) - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2021	Dec. 31, 2020
Acquired Finite-Lived Intangible Assets [Line Items]
Gross Carrying Amount	$ 5,383	$ 5,412
Accumulated Amortization	(2,672)	(2,513)
Net	$ 2,711	2,899
Assembled occupancy
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	4 months 24 days
Gross Carrying Amount	$ 68	39
Accumulated Amortization	(68)	(26)
Net	$ 0	13
Facility trade name
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	30 years
Gross Carrying Amount	$ 733	733
Accumulated Amortization	(384)	(366)
Net	$ 349	367
Customer relationships
Acquired Finite-Lived Intangible Assets [Line Items]
Weighted Average Life (Years)	18 years 4 months 24 days
Gross Carrying Amount	$ 4,582	4,640
Accumulated Amortization	(2,220)	(2,121)
Net	$ 2,362	$ 2,519

Intangible Assets _ Net - Narra

Intangible Assets — Net - Narrative (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Finite-Lived Intangible Assets [Line Items]
Amortization of intangible assets	$ 363	$ 354	$ 1,087	$ 1,445
Operating lease expense	39,517	36,038	115,186	107,991
Depreciation and amortization
Finite-Lived Intangible Assets [Line Items]
Operating lease expense	$ 289	$ 289	$ 869	$ 933

Intangible Assets _ Net - Futur

Intangible Assets — Net - Future Amortization (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Year
2021 (remainder)	$ 59
2022	234
2023	234
2024	234
2025	234
2026	234
Thereafter	1,482
Net	$ 2,711	$ 2,899

Goodwill and Other Indefinite_3

Goodwill and Other Indefinite-Lived Intangible Assets - Goodwill Rollforward (Details) $ in Thousands	9 Months Ended
	Sep. 30, 2021USD ($)
Goodwill [Roll Forward]
Balance at beginning of period	$ 54,469
Additions	6,000
Balance at end of period	60,469
Operating Segments | Skilled Services
Goodwill [Roll Forward]
Balance at beginning of period	45,486
Additions	6,000
Balance at end of period	51,486
All Other
Goodwill [Roll Forward]
Balance at beginning of period	8,983
Additions	0
Balance at end of period	$ 8,983

Goodwill and Other Indefinite_4

Goodwill and Other Indefinite-Lived Intangible Assets - Indefinite-Lived Intangible Assets (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 3,621	$ 3,716
Trade name
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	889	889
Medicare and Medicaid licenses
Indefinite-lived Intangible Assets [Line Items]
Other indefinite-lived intangibles	$ 2,732	$ 2,827

Restricted and Other Assets - S

Restricted and Other Assets - Schedule of Restricted and Other Assets (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Debt issuance costs, net	$ 2,131	$ 2,664
Long-term insurance losses recoverable asset	7,573	7,138
Deposits with landlords	12,268	12,400
Capital improvement reserves with landlords and lenders	6,328	4,376
Cash surrender value of life insurance related to deferred compensation plan	16,082	6,577
Restricted and other assets	$ 44,382	$ 33,155

Restricted and Other Assets - N

Restricted and Other Assets - Narrative (Details) - USD ($) $ in Thousands	3 Months Ended	9 Months Ended
	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Deferred Costs, Capitalized, Prepaid, and Other Assets Disclosure [Abstract]
Gain on deferral investment	$ 252	$ 940	$ 710
Deferral investment expense	$ 268	$ 1,046	$ 657

Other Accrued Liabilities (Deta

Other Accrued Liabilities (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020	Sep. 30, 2020
Payables and Accruals [Abstract]
Quality assurance fee	$ 6,470	$ 6,631
Refunds payable	36,702	36,323
Resident advances	4,129	8,558
Unapplied state relief funds	4,392	6,520
Cash held in trust for patients	6,883	6,052
Dividends payable	2,900	2,868	$ 2,725
Property taxes	11,462	9,222
Other	12,531	11,144
Other accrued liabilities	$ 85,469	$ 87,318

Income Taxes - Narrative (Detai

Income Taxes - Narrative (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Income Tax Disclosure [Abstract]
Provision for income taxes	$ 16,513	$ 10,866	$ 43,220	$ 37,026
Total income tax provision			22.50%	22.80%

Debt - Schedule of Long term de

Debt - Schedule of Long term debt (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Debt Instrument [Line Items]
Less: current maturities	$ (3,548)	$ (2,960)
Less: debt issuance costs, net	(3,078)	(2,302)
Long-term debt—less current maturities	140,680	112,544
Mortgage loans and promissory notes | Mortgage loans and promissory notes
Debt Instrument [Line Items]
Mortgage loans and promissory notes	$ 147,306	$ 117,806

Debt - Mortgage Loans and Promi

Debt - Mortgage Loans and Promissory Notes and Off-Balance Sheet Arrangements (Details) $ in Thousands	3 Months Ended	9 Months Ended
	Sep. 30, 2021USD ($)subsidiary	Sep. 30, 2021USD ($)promissoryNotesubsidiary	Dec. 31, 2020USD ($)
Debt Instrument [Line Items]
Amount outstanding, current	$ 3,548	$ 3,548	$ 2,960
Letters of credit outstanding, pledged amount	6,544	$ 6,544
Letter of Credit
Debt Instrument [Line Items]
Letter of credit increase	(1,036)
Mortgage loans and promissory notes
Debt Instrument [Line Items]
Number of promissory notes | promissoryNote		2
Mortgage loans and promissory notes | Notes Payable Other Payables
Debt Instrument [Line Items]
Long-term debt, gross	147,306	$ 147,306	$ 117,806
Long-term debt—less current maturities	$ 143,758	$ 143,758
Mortgage loans and promissory notes | Mortgages
Debt Instrument [Line Items]
Prepayment penalty reduced rate during first three years	10.00%	10.00%
Prepayment penalty reduced rate during the fourth year	3.00%	3.00%
Prepayment penalty reduced rate for the fifth through tenth years	1.00%	1.00%
Mortgage loans and promissory notes | Mortgages | Three Subsidiaries
Debt Instrument [Line Items]
Number of operating subsidiaries that entered into HUD mortgage loans during period | subsidiary		3
Notes payable	$ 31,420	$ 31,420
Mortgage loans and promissory notes | Mortgages | Twenty Two Subsidiaries
Debt Instrument [Line Items]
Notes payable	$ 143,776	$ 143,776
Number of operating subsidiaries | subsidiary	22	22
Mortgage loans and promissory notes | Mortgages | Minimum
Debt Instrument [Line Items]
Debt Instrument, pre-payment fee reduction, term		5 years
Debt instrument, term		25 years
Mortgage loans and promissory notes | Mortgages | Maximum
Debt Instrument [Line Items]
Debt Instrument, pre-payment fee reduction, term		10 years
Debt instrument, term		35 years
Mortgage loans and promissory notes | Notes Payable to Banks | Minimum
Debt Instrument [Line Items]
Debt instrument, interest rate, effective percentage	3.10%	3.10%
Debt instrument, interest rate, stated percentage	2.40%	2.40%
Mortgage loans and promissory notes | Notes Payable to Banks | Maximum
Debt Instrument [Line Items]
Debt instrument, interest rate, effective percentage	4.20%	4.20%
Debt instrument, interest rate, stated percentage	3.30%	3.30%
Mortgage loans and promissory notes | Promissory Note, 5.0%
Debt Instrument [Line Items]
Debt instrument, interest rate, stated percentage	5.00%	5.00%
Debt instrument, term		10 months
Mortgage loans and promissory notes | Promissory Note, 5.3%
Debt Instrument [Line Items]
Debt instrument, interest rate, stated percentage	5.30%	5.30%
Debt instrument, term		12 years

Debt - Credit Facility with a L

Debt - Credit Facility with a Lending Consortium Arranged by SunTrust (Details) - Truist - Revolving credit facility with Truist	Oct. 01, 2019USD ($)	Oct. 22, 2021USD ($)	Sep. 30, 2021USD ($)
Debt Instrument [Line Items]
Total net debt ratio, maximum	3
Long-term debt, threshold for EBITDA ratio increase election	$ 50,000,000
Total net debt ratio, maximum after increase election	3.50
Total net debt ratio, minimum	1.50
Minimum
Debt Instrument [Line Items]
Line of credit facility, unused capacity, commitment fee percentage	0.25%
Maximum
Debt Instrument [Line Items]
Line of credit facility, unused capacity, commitment fee percentage	0.45%
Third Amended Credit Facility
Debt Instrument [Line Items]
Line of credit facility, maximum borrowing capacity	$ 350,000,000
Long-term debt, gross			$ 0
Third Amended Credit Facility | Subsequent Event
Debt Instrument [Line Items]
Long-term debt, gross		$ 0
Base Rate | Minimum
Debt Instrument [Line Items]
Interest rate margin	0.50%
Base Rate | Maximum
Debt Instrument [Line Items]
Interest rate margin	1.50%
LIBOR | Minimum
Debt Instrument [Line Items]
Interest rate margin	1.50%
LIBOR | Maximum
Debt Instrument [Line Items]
Interest rate margin	2.50%

Options and Awards - Stock Opti

Options and Awards - Stock Options Narrative (Details) shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021planshares	Sep. 30, 2020shares	Sep. 30, 2021installmentplan$ / sharesshares	Sep. 30, 2020$ / sharesshares	Oct. 31, 2019shares	Dec. 31, 2017shares
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of option plans | plan	1		1
Options granted (in shares)	151	160	496	540
Grant date intrinsic value (in dollars per share) | $ / shares			$ 0	$ 0
2017 Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of shares authorized (in shares)						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
Number of shares available for grant (in shares)	2,270		2,270
2017 Plan | Non-employee directors
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of installments | installment			3
Award requisite service period			3 years
Spinoff | 2017 Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of shares authorized (in shares)					8,118

Options and Awards - Valuation

Options and Awards - Valuation Assumptions (Details) - shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Share-based Payment Arrangement [Abstract]
Options Granted (in shares)	151	160	496	540
Weighted Average Risk-Free Rate	1.00%	0.40%	0.90%	0.70%
Expected Life	6 years 1 month 6 days	6 years 3 months 18 days	6 years 2 months 12 days	6 years 2 months 12 days
Weighted Average Volatility	42.50%	41.80%	42.30%	38.80%
Weighted Average Dividend Yield	0.30%	0.30%	0.30%	0.40%

Options and Awards - Exercise P

Options and Awards - Exercise Price and Fair Value (Details) - $ / shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Share-based Payment Arrangement [Abstract]
Granted (in shares)	151	160	496	540
Weighted Average Exercise Price (in dollars per share)			$ 81.89	$ 50.46
Weighted Average Fair Value of Options (in dollars per share)			$ 33.45	$ 18.62

Options and Awards - Options Ou

Options and Awards - Options Outstanding Rollforward (Details) - $ / shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020	Dec. 31, 2020
Number of Options Outstanding
Balance at beginning of period, (in shares)			4,038
Granted (in shares)	151	160	496	540
Forfeited (in shares)			(77)
Exercised (in shares)			(463)
Balance at end of period, (in shares)	3,994		3,994
Weighted Average Exercise Price
Balance at beginning of period (in dollars per share)			$ 27.71
Granted (in dollars per share)			81.89	$ 50.46
Forfeited (in dollars per share)			41.69
Exercised (in dollars per share)			17.51
Balance at end of period (in dollars per share)	$ 35.35		$ 35.35
Number of options vested (in shares)	2,129		2,129		2,148
Weighted average exercise price of options vested (in dollars per share)	$ 20.25		$ 20.25		$ 16.66

Options and Awards - Options _2

Options and Awards - Options Outstanding by Exercise Price (Details) $ / shares in Units, shares in Thousands, $ in Thousands	9 Months Ended
	Sep. 30, 2021USD ($)$ / sharesshares
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Number outstanding (in shares)	3,994
Black-Scholes Fair Value | $	$ 53,402
Stock options vested and exercisable (in shares)	2,129
2011
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 5
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 6.77
Number outstanding (in shares)	3
Black-Scholes Fair Value | $	$ 3
Remaining Contractual Life (Years)	0 years
Stock options vested and exercisable (in shares)	3
2012
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 5.56
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 6.75
Number outstanding (in shares)	73
Black-Scholes Fair Value | $	$ 220
Remaining Contractual Life (Years)	1 year
Stock options vested and exercisable (in shares)	73
2013
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 6.76
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 9.74
Number outstanding (in shares)	140
Black-Scholes Fair Value | $	$ 539
Remaining Contractual Life (Years)	2 years
Stock options vested and exercisable (in shares)	140
2014
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 8.94
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 16.05
Number outstanding (in shares)	625
Black-Scholes Fair Value | $	$ 3,002
Remaining Contractual Life (Years)	3 years
Stock options vested and exercisable (in shares)	625
2015
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 18.20
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 21.39
Number outstanding (in shares)	279
Black-Scholes Fair Value | $	$ 2,164
Remaining Contractual Life (Years)	4 years
Stock options vested and exercisable (in shares)	279
2016
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 15.93
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 16.86
Number outstanding (in shares)	257
Black-Scholes Fair Value | $	$ 1,514
Remaining Contractual Life (Years)	5 years
Stock options vested and exercisable (in shares)	245
2017
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 15.80
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 19.41
Number outstanding (in shares)	315
Black-Scholes Fair Value | $	$ 1,851
Remaining Contractual Life (Years)	6 years
Stock options vested and exercisable (in shares)	208
2018
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 22.49
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 32.71
Number outstanding (in shares)	532
Black-Scholes Fair Value | $	$ 5,146
Remaining Contractual Life (Years)	7 years
Stock options vested and exercisable (in shares)	250
2019
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 41.07
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 45.76
Number outstanding (in shares)	662
Black-Scholes Fair Value | $	$ 10,394
Remaining Contractual Life (Years)	8 years
Stock options vested and exercisable (in shares)	216
2020
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 44.84
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 59.49
Number outstanding (in shares)	616
Black-Scholes Fair Value | $	$ 12,104
Remaining Contractual Life (Years)	9 years
Stock options vested and exercisable (in shares)	90
2021
Share-based Payment Arrangement, Option, Exercise Price Range [Line Items]
Exercise price, lower range limit (in dollars per share) | $ / shares	$ 79.88
Exercise price, upper range limit (in dollars per share) | $ / shares	$ 83.64
Number outstanding (in shares)	492
Black-Scholes Fair Value | $	$ 16,465
Remaining Contractual Life (Years)	10 years
Stock options vested and exercisable (in shares)	0

Options and Awards - Intrinsic

Options and Awards - Intrinsic Values (Details) - USD ($) $ in Thousands	9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Dec. 31, 2020
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Outstanding	$ 161,371		$ 182,552
Vested	116,340		120,867
Expected to vest	40,548		$ 53,366
Intrinsic value of options exercised in period	31,167	$ 21,044
Stock Options
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Aggregate intrinsic value of options that vested in period	$ 18,500	$ 13,681

Options and Awards - Restricted

Options and Awards - Restricted Stock Awards Narrative (Details) - Restricted Stock Awards - $ / shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Nonvested restricted awards, granted (in shares)	51	48	195	242
Share-based compensation, restricted awards, exercise price (in dollars per share)			$ 0
Award vesting period			5 years
Granted (in dollars per share)			$ 82.81
Non-employee directors
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Options granted to non-employee directors (in shares)	6		17
Minimum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Granted (in dollars per share)			$ 82.20	$ 35.47
Minimum | Non-employee directors
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Granted (in dollars per share)			84.70
Maximum
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Granted (in dollars per share)			93.31	$ 58.06
Maximum | Non-employee directors
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Granted (in dollars per share)			$ 93.31

Options and Awards - Restrict_2

Options and Awards - Restricted Award Rollforward (Details) - Restricted Stock Awards - $ / shares shares in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Non-Vested Restricted Awards
Nonvested at beginning of period (in shares)			591
Granted (in shares)	51	48	195	242
Vested (in shares)			(213)
Forfeited (in shares)			(16)
Nonvested at end of period (in shares)	557		557
Weighted Average Grant Date Fair Value
Nonvested at beginning of period (in dollars per share)			$ 38.90
Granted (in dollars per share)			82.81
Vested (in dollars per share)			48.45
Forfeited (in dollars per share)			45.65
Nonvested at end of period (in dollars per share)	$ 50.43		$ 50.43

Options and Awards - Long-Term

Options and Awards - Long-Term Incentive Plan (Details) - USD ($) $ in Thousands	Aug. 27, 2019	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Share-based compensation expense		$ 5,082	$ 4,173	$ 13,769	$ 10,936
Spinoff | 2019 LTI Plan
Share-based Compensation Arrangement by Share-based Payment Award [Line Items]
Number of shares authorized (in shares)	500,000
Award vesting period	5 years
Award vesting rights, percentage	20.00%
Share-based compensation expense		$ 248	$ 286	$ 651	$ 675

Options and Awards - Compensati

Options and Awards - Compensation Expense (Details) - USD ($) shares in Thousands, $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 5,082	$ 4,173	$ 13,769	$ 10,936
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	2,371	1,692	$ 6,130	4,656
Employee service share-based compensation, nonvested awards, total compensation cost not yet recognized	$ 34,086		$ 34,086
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 (in shares)	1,865		1,865
Share-based compensation arrangement by share-based payment award, options, expected to vest, number (in shares)	1,754		1,754
Restricted Stock Awards
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 2,217	2,221	$ 6,131	5,596
Employee service share-based compensation, nonvested awards, total compensation cost not yet recognized	29,021		$ 29,021
Employee service share-based compensation, nonvested awards, total compensation cost not yet recognized, period for recognition			3 years 7 months 6 days
Stock options and Restricted stock awards to non-employee directors
Employee Service Share-based Compensation, Allocation of Recognized Period Costs [Line Items]
Share-based compensation expense	$ 494	$ 260	$ 1,508	$ 684

Leases - Lessee Narrative (Deta

Leases - Lessee Narrative (Details) $ in Thousands	1 Months Ended	3 Months Ended			9 Months Ended
	Oct. 27, 2021USD ($)bedoperation	Sep. 30, 2021USD ($)agreementbedrenewalfacilitybusiness	Jun. 30, 2021USD ($)business	Sep. 30, 2020USD ($)bed	Sep. 30, 2021USD ($)agreementbedrenewalfacility	Sep. 30, 2021agreementbedrenewalfacilityoperation	Sep. 30, 2021ownedPropertyagreementbedrenewalfacility	Sep. 30, 2020USD ($)bedoperation
Lessee, Lease, Description [Line Items]
Master lease agreements | agreement		8			8	8	8
Lessee, operating lease, term of contract		10 years			10 years	10 years	10 years
Facilities under master lease arrangement | facility		43			43	43	43
Operating lease, weighted average remaining lease term		14 years 10 months 24 days			14 years 10 months 24 days	14 years 10 months 24 days	14 years 10 months 24 days
Operating lease, weighted average discount rate, percent		7.70%			7.70%	7.70%	7.70%
Operational skilled nursing beds | bed		24,700			24,700	24,700	24,700
Right-of-use assets obtained in exchange for new and modified operating lease obligations					$ 175,617			$ 14,669
Subsequent Event
Lessee, Lease, Description [Line Items]
Right-of-use assets obtained in exchange for new and modified operating lease obligations	$ 22,828
Skilled Nursing Operations | Subsequent Event
Lessee, Lease, Description [Line Items]
Number of businesses acquired | operation	3
Operational skilled nursing beds | bed	328
Cost of Sales and General and Administrative Expense
Lessee, Lease, Description [Line Items]
Rent expense		$ 35,646		$ 32,520	$ 103,598			$ 97,366
Skilled Nursing Operations
Lessee, Lease, Description [Line Items]
Number of businesses acquired						14	1	3
Operational skilled nursing beds | bed		1,504		303	1,504	1,504	1,504	303
Minimum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, renewal term		10 years			10 years	10 years	10 years
Maximum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, renewal term		15 years			15 years	15 years	15 years
CareTrust REIT
Lessee, Lease, Description [Line Items]
Skilled nursing, assisted living and independent living facilities | facility		95			95	95	95
Master lease agreements | agreement		9			9	9	9
Lessee, operating lease, renewal term		5 years			5 years	5 years	5 years
Operating lease, increase in right-of-use assets		$ 63,374	$ 54,716
Operating lease, increase in liabilities		$ 63,374	$ 54,716
Operating leases of lessee, contingent rentals, basis spread on variable rate		2.50%			2.50%	2.50%	2.50%
Rent expense		$ 15,445		$ 13,139	$ 43,944			$ 39,394
CareTrust REIT | Third Party Tenants Under Triple Net Lease Arrangements
Lessee, Lease, Description [Line Items]
Skilled nursing, assisted living and independent living facilities | facility		94			94	94	94
CareTrust REIT | Purchase Option
Lessee, Lease, Description [Line Items]
Skilled nursing, assisted living and independent living facilities | facility		4			4	4	4
CareTrust REIT | Master Leases
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term extension		17 years	15 years		17 years	17 years	17 years
CareTrust REIT | Skilled Nursing Operations
Lessee, Lease, Description [Line Items]
Number of businesses acquired | business		2	4
CareTrust REIT | Minimum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract		13 years			13 years	13 years	13 years
Lessee leasing arrangements, operating leases, number of renewal terms | renewal		2			2	2	2
CareTrust REIT | Maximum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract		20 years			20 years	20 years	20 years
Lessee leasing arrangements, operating leases, number of renewal terms | renewal		3			3	3	3
Various Landlords
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract		15 years			15 years	15 years	15 years
Lessee leasing arrangements, operating leases, number of renewal terms | renewal		2			2	2	2
Lessee, operating lease, renewal term		5 years			5 years	5 years	5 years
Various Landlords | Minimum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract		5 years			5 years	5 years	5 years
Various Landlords | Minimum | Equipment
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract		3 years			3 years	3 years	3 years
Various Landlords | Maximum
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract		20 years			20 years	20 years	20 years
Various Landlords | Maximum | Equipment
Lessee, Lease, Description [Line Items]
Lessee, operating lease, term of contract		5 years			5 years	5 years	5 years

Leases - Lessee Lease Cost (Det

Leases - Lessee Lease Cost (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Lessee, Lease, Description [Line Items]
Operating lease expense	$ 39,517	$ 36,038	$ 115,186	$ 107,991
Amortization of deferred rent	125	101	346	337
Rent - cost of services
Lessee, Lease, Description [Line Items]
Operating lease expense	35,623	32,504	103,534	97,318
Variable lease, cost	1,127	567	2,543	1,781
General and administrative expense
Lessee, Lease, Description [Line Items]
Operating lease expense	23	16	64	48
Depreciation and amortization
Lessee, Lease, Description [Line Items]
Operating lease expense	289	289	869	933
Variable lease costs
Lessee, Lease, Description [Line Items]
Variable lease, cost	$ 3,582	$ 3,229	$ 10,719	$ 9,692

Leases - Lessee Future Minimum

Leases - Lessee Future Minimum Lease Payments (Details) - USD ($) $ in Thousands	Sep. 30, 2021	Dec. 31, 2020
Year
2021 (remainder)	$ 34,660
2022	138,592
2023	136,845
2024	135,889
2025	135,813
2026	135,708
Thereafter	1,201,777
Total lease payments	1,919,284
Less: present value adjustment	(774,058)
Present value of total lease liabilities	1,145,226
Less: current lease liabilities	(52,050)	$ (48,187)
Long-term operating lease liabilities	$ 1,093,176	$ 950,320

Leases - Lessor Narrative (Deta

Leases - Lessor Narrative (Details)	Sep. 30, 2021facilityoperation	Mar. 31, 2020facility	Oct. 31, 2019facility
Lessor, Lease, Description [Line Items]
Number of real estate properties	95
Spinoff | Minimum
Lessor, Lease, Description [Line Items]
Lessor, operating lease, term of contract			14 years
Spinoff | Maximum
Lessor, Lease, Description [Line Items]
Lessor, operating lease, term of contract			16 years
The Pennant Group, Inc. | Senior Living Facilities
Lessor, Lease, Description [Line Items]
Number of real estate properties		2
The Pennant Group, Inc. | Spinoff | Senior Living Facilities
Lessor, Lease, Description [Line Items]
Number of real estate properties	31		29

Leases - Lessor Rental Income (

Leases - Lessor Rental Income (Details) - USD ($) $ in Thousands	3 Months Ended		9 Months Ended
	Sep. 30, 2021	Sep. 30, 2020	Sep. 30, 2021	Sep. 30, 2020
Lessor, Lease, Description [Line Items]
Operating lease, lease income	$ 3,933	$ 3,914	$ 11,837	$ 11,196
The Pennant Group, Inc.
Lessor, Lease, Description [Line Items]
Operating lease, variable lease income	301	312	881	909
The Pennant Group, Inc.
Lessor, Lease, Description [Line Items]
Operating lease, lease income	3,468	3,443	10,396	9,675
Other third-party
Lessor, Lease, Description [Line Items]
Operating lease, lease income	$ 465	$ 471	$ 1,441	$ 1,521

Leases - Lessor Future Minimum

Leases - Lessor Future Minimum Lease Payments Receivable (Details) $ in Thousands	Sep. 30, 2021USD ($)
Leases [Abstract]
2021 (remainder)	$ 3,900
2022	15,238
2023	14,937
2024	14,249
2025	13,911
2026	13,700
Thereafter	84,838
Total	$ 160,773

Commitments and Contingencies (

Commitments and Contingencies (Details) $ in Thousands	3 Months Ended		9 Months Ended		12 Months Ended
	Sep. 30, 2021facility	Sep. 30, 2020	Sep. 30, 2021facility	Sep. 30, 2020	Dec. 31, 2020	Oct. 22, 2021USD ($)
Concentration Risk [Line Items]
Facilities under Medicare probe reviews | facility	7		7
Subsequent Event
Concentration Risk [Line Items]
Cash, uninsured amount | $						$ 677
Customer Concentration Risk | Total Medicaid and Medicare | Accounts Receivable
Concentration Risk [Line Items]
Concentration risk			53.70%		58.30%
Customer Concentration Risk | Total Medicaid and Medicare | Revenue Benchmark
Concentration Risk [Line Items]
Concentration risk	73.60%	75.50%	73.60%	74.00%

Common Stock Repurchase Progr_2

Common Stock Repurchase Program (Details) shares in Thousands	Oct. 21, 2021USD ($)	Mar. 13, 2020USD ($)repurchaseProgram	Mar. 04, 2020USD ($)	Aug. 26, 2019USD ($)	Mar. 31, 2020USD ($)shares	Dec. 31, 2019USD ($)shares
Equity, Class of Treasury Stock [Line Items]
Number of stock repurchase programs | repurchaseProgram		2
Repurchase of common stock					$ 25,000,000
March 4, 2020 Repurchase Program
Equity, Class of Treasury Stock [Line Items]
Stock repurchase program, authorized amount			$ 20,000,000
Stock repurchase program, period in force			12 months
Repurchase of common stock (in shares) | shares					503
Repurchase of common stock					$ 20,000,000
March 13, 2020 Repurchase Program
Equity, Class of Treasury Stock [Line Items]
Stock repurchase program, authorized amount		$ 5,000,000
Stock repurchase program, period in force		12 months
Repurchase of common stock (in shares) | shares					189
Repurchase of common stock					$ 5,000,000
August 26, 2019 Repurchase Program
Equity, Class of Treasury Stock [Line Items]
Stock repurchase program, authorized amount				$ 20,000,000
Stock repurchase program, period in force				12 months
Repurchase of common stock (in shares) | shares						138
Repurchase of common stock						$ 6,406,000
October 21, 2021 Repurchase Program | Subsequent Event
Equity, Class of Treasury Stock [Line Items]
Stock repurchase program, authorized amount	$ 20,000,000
Stock repurchase program, period in force	12 months