ENSIGN GROUP, INC 10-Q

Item 1. FINANCIAL STATEMENTS THE ENSIGN GROUP, INC. UNAUDITED CONDENSED CONSOLIDATED BALANCE SHEETS (In thousands, except par values) March 31, 2024 December 31, 2023 ASSETS Current assets: Cash and cash equivalents $ 511,839 $ 509,626 Accounts receivable—less allowance for doubtful accounts of $ 9,463 and $ 9,348 at March 31, 2024 and December 31, 2023, respectively 519,439 485,039 Investments—current 14,459 17,229 Prepaid expenses and other current assets 42,451 35,036 Total current assets 1,088,188 1,046,930 Property and equipment, net 1,101,560 1,090,771 Right-of-use assets 1,821,024 1,756,430 Insurance subsidiary deposits and investments 107,666 92,687 Deferred tax assets 66,486 67,124 Restricted and other assets 39,686 40,205 Intangible assets, net 6,559 6,525 Goodwill 77,241 76,869 TOTAL ASSETS $ 4,308,410 $ 4,177,541 LIABILITIES AND EQUITY Current liabilities: Accounts payable $ 82,635 $ 92,811 Accrued wages and related liabilities 294,208 332,568 Lease liabilities—current 85,898 82,526 Accrued self-insurance liabilities—current 62,589 54,664 Other accrued liabilities 180,408 168,228 Current maturities of long-term debt 3,983 3,950 Total current liabilities 709,721 734,747 Long-term debt—less current maturities 144,533 145,497 Long-term lease liabilities—less current portion 1,701,652 1,639,326 Accrued self-insurance liabilities—less current portion 117,364 111,246 Other long-term liabilities 51,673 49,408 TOTAL LIABILITIES $ 2,724,943 $ 2,680,224 Commitments and contingencies (Notes 15 and 20) EQUITY Ensign Group, Inc. stockholders' equity: Common stock: $ 0.001 par value; 150,000 shares authorized; 60,294 and 56,904 shares issued and shares outstanding at March 31, 2024, respectively, and 59,987 and 56,597 shares issued and shares outstanding at December 31, 2023, respectively 60 60 Additional paid-in capital 486,336 465,707 Retained earnings 1,208,074 1,142,653 Common stock in treasury, at cost, 3,390 shares at both March 31, 2024 and December 31, 2023 ( 116,569 ) ( 116,555 ) Total Ensign Group, Inc. stockholders' equity 1,577,901 1,491,865 Non-controlling interest 5,566 5,452 Total equity $ 1,583,467 $ 1,497,317 TOTAL LIABILITIES AND EQUITY $ 4,308,410 $ 4,177,541 See accompanying notes to condensed consolidated financial statements. 1 Table of Contents THE ENSIGN GROUP, INC. UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF INCOME Three Months Ended March 31, 2024 2023 (In thousands, except per share data) REVENUE Service revenue $ 1,004,485 $ 881,918 Rental revenue 5,687 4,923 TOTAL REVENUE $ 1,010,172 $ 886,841 Expense: Cost of services 799,263 696,326 Rent—cost of services 51,876 46,637 General and administrative expense 57,158 51,891 Depreciation and amortization 19,657 17,112 TOTAL EXPENSES 927,954 811,966 Income from operations 82,218 74,875 Other income (expense): Interest expense ( 1,964 ) ( 2,036 ) Other income 9,344 5,543 Other income, net 7,380 3,507 Income before provision for income taxes 89,598 78,382 Provision for income taxes 20,638 18,413 NET INCOME 68,960 59,969 Less: Net income attributable to noncontrolling interests 125 117 Net income attributable to The Ensign Group, Inc. $ 68,835 $ 59,852 NET INCOME PER SHARE ATTRIBUTABLE TO THE ENSIGN GROUP INC. Basic $ 1.22 $ 1.08 Diluted $ 1.19 $ 1.05 WEIGHTED AVERAGE COMMON SHARES OUTSTANDING Basic 56,337 55,300 Diluted 57,921 57,098 See accompanying notes to condensed consolidated financial statements. 2 Table of Contents THE ENSIGN GROUP, INC. UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF STOCKHOLDERS' EQUITY Common Stock Additional Paid-In Capital Retained Earnings Treasury Stock Non-Controlling Interest (In thousands) Shares Amount Shares Amount Total BALANCE - JANUARY 1, 2024 56,597 $ 60 $ 465,707 $ 1,142,653 3,390 $ ( 116,555 ) $ 5,452 $ 1,497,317 Issuance of common stock to employees and directors resulting from the exercise of stock options 219 — 6,229 — — — — 6,229 Issuance of restricted stock, net of forfeitures 88 — 6,165 — — — — 6,165 Shares of common stock used to satisfy tax withholding obligations — — — — — ( 14 ) — ( 14 ) Dividends declared ($ 0.0600 per share) — — — ( 3,414 ) — — — ( 3,414 ) Employee stock award compensation — — 8,231 — — — — 8,231 Acquisition of noncontrolling interest shares — — ( 10 ) — — — — ( 10 ) Net income attributable to noncontrolling interest — — — — — — 125 125 Noncontrolling interests attributable to subsidiary equity plan — — 14 — — — ( 11 ) 3 Net income attributable to the Ensign Group, Inc. — — — 68,835 — — — 68,835 BALANCE - MARCH 31, 2024 56,904 $ 60 $ 486,336 $ 1,208,074 3,390 $ ( 116,569 ) $ 5,566 $ 1,583,467 Common Stock Additional Paid-In Capital Retained Earnings Treasury Stock Non-Controlling Interest (In thousands) Shares Amount Shares Amount Total BALANCE - JANUARY 1, 2023 55,661 $ 59 $ 415,560 $ 946,339 3,368 $ ( 114,626 ) $ 1,468 $ 1,248,800 Issuance of common stock to employees and directors resulting from the exercise of stock options 145 1 2,653 — — — — 2,654 Issuance of restricted stock, net of forfeitures 102 — 5,068 — — — — 5,068 Shares of common stock used to satisfy tax withholding obligations ( 1 ) — — — 1 ( 20 ) — ( 20 ) Dividends declared ($ 0.0575 per share) — — — ( 3,215 ) — — — ( 3,215 ) Employee stock award compensation — — 6,573 — — — — 6,573 Acquisition of noncontrolling interest shares — — ( 77 ) — — — — ( 77 ) Net income attributable to noncontrolling interest — — — — — — 117 117 Noncontrolling interests attributable to subsidiary equity plan — — 6 — — — ( 4 ) 2 Net income attributable to the Ensign Group, Inc. — — — 59,852 — — — 59,852 BALANCE - MARCH 31, 2023 55,907 $ 60 $ 429,783 $ 1,002,976 3,369 $ ( 114,646 ) $ 1,581 $ 1,319,754 See accompanying notes to condensed consolidated financial statements. 3 Table of Contents THE ENSIGN GROUP, INC. UNAUDITED CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS Three Months Ended March 31, (In thousands) 2024 2023 Cash flows from operating activities: Net income $ 68,960 $ 59,969 Adjustments to reconcile net income to net cash provided by operating activities: Depreciation and amortization 19,657 17,112 Amortization of deferred financing fees 266 269 Non-cash leasing arrangement 195 263 Impairment of long-lived assets 1,849 — Deferred income taxes 638 47 Provision for doubtful accounts 378 1,887 Stock-based compensation 8,238 6,573 Cash received from insurance proceeds 199 — (Gain)/loss on insurance claims, legal matters and asset disposals ( 171 ) 62 Change in operating assets and liabilities Accounts receivable ( 34,964 ) ( 37,136 ) Prepaid income taxes 3,830 4,643 Prepaid expenses and other assets ( 11,388 ) 3,444 Cash surrender value of life insurance policy premiums ( 9,678 ) ( 10,084 ) Deferred compensation liability 9,059 9,826 Operating lease obligations 606 ( 6,567 ) Accounts payable ( 10,376 ) 4,278 Accrued wages and related liabilities ( 38,978 ) ( 28,648 ) Income taxes payable 16,173 13,850 Other accrued liabilities ( 3,236 ) ( 813 ) Accrued self-insurance liabilities 14,055 9,369 NET CASH PROVIDED BY OPERATING ACTIVITIES $ 35,312 $ 48,344 Cash flows from investing activities: Purchase of property and equipment ( 29,437 ) ( 26,651 ) Cash payments for business acquisitions ( 494 ) — Cash payments for asset acquisitions ( 1,943 ) — Escrow deposits ( 486 ) — Cash proceeds from insurance proceeds and the sale of assets 536 13 Purchases of investments ( 12,815 ) ( 9,767 ) Maturities of investments 10,284 791 Other restricted assets ( 300 ) ( 357 ) NET CASH USED IN INVESTING ACTIVITIES $ ( 34,655 ) $ ( 35,971 ) Cash flows from financing activities: Payments on debt ( 975 ) ( 1,007 ) Issuance of common stock upon exercise of options 6,229 2,654 Repurchase of shares of common stock to satisfy tax withholding obligations ( 14 ) ( 20 ) Dividends paid ( 3,396 ) ( 3,201 ) Non-controlling interest distribution ( 278 ) ( 4 ) Purchase of non-controlling interest ( 10 ) ( 77 ) Payments of deferred financing costs — ( 19 ) NET CASH PROVIDED BY (USED IN) FINANCING ACTIVITIES $ 1,556 $ ( 1,674 ) Net increase in cash and cash equivalents 2,213 10,699 Cash and cash equivalents beginning of period 509,626 316,270 Cash and cash equivalents end of period $ 511,839 $ 326,969 4 Table of Contents Three Months Ended March 31, (In thousands) 2024 2023 SUPPLEMENTAL DISCLOSURES OF CASH FLOW INFORMATION Cash paid during the period for: Interest $ 1,729 $ 1,769 Lease liabilities $ 51,207 $ 46,420 Non-cash financing and investing activity Accrued capital expenditures $ 4,800 $ 4,900 Accrued dividends declared $ 3,414 $ 3,215 Right-of-use assets obtained in exchange for new and modified operating lease obligations $ 80,920 $ 351,100 See accompanying notes to condensed consolidated financial statements. 5 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (Dollars, shares and options in thousands, except per share data) 1. 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's independent subsidiaries provide health care services across the post-acute care continuum and engage in the ownership, acquisition, development and leasing of skilled nursing, senior living and other healthcare-related properties and ancillary businesses. As of March 31, 2024, the Company's independent subsidiaries operated 302 facilities and other ancillary operations located in Arizona, California, Colorado, Idaho, Iowa, Kansas, Nebraska, Nevada, South Carolina, Tennessee, Texas, Utah, Washington and Wisconsin. The Company's independent subsidiaries have a collective capacity of approximately 31,200 operational skilled nursing beds and 3,100 senior living units. As of March 31, 2024, the Company's independent subsidiaries operated 218 facilities under long-term lease arrangements and had options to purchase 11 of those 218 facilities. The Company's real estate portfolio consists of 114 owned real estate properties, which includes 84 facilities operated and managed by the Company's independent subsidiaries, 30 operations leased to and operated by third-party operators, and the Service Center (defined below) location. Of those 30 third-party operations, one senior living facility is located on the same real estate property as a skilled nursing facility that an independent subsidiary 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 independent subsidiaries through contractual relationships with such subsidiaries. The Company also has a wholly-owned captive insurance subsidiary that provides some claims-made coverage to the Company’s independent subsidiaries for general and professional liabilities, as well as coverage for certain workers’ compensation insurance liabilities. In 2022, the Company formed a captive real estate investment trust (REIT), which owns and manages its real estate business, called Standard Bearer Healthcare REIT, Inc. (Standard Bearer). The REIT structure provides the Company with an efficient vehicle for future acquisitions of properties that could be operated by Ensign's independent subsidiaries or other third parties. Standard Bearer has elected to be taxed as a REIT for U.S. federal income tax purposes. Refer to Note 6, Standard Bearer for additional information on Standard Bearer. Each of the Company's independent subsidiaries are operated by wholly-owned subsidiaries that have their own management, employees and assets. References herein to the consolidated “Company” and “its” assets and activities in this Quarterly Report are not meant to imply, nor should it be construed as meaning that The Ensign Group, Inc. has direct operating assets, employees or revenue, or that any of the subsidiaries, are operated by The Ensign Group, Inc. Other Information — The accompanying condensed consolidated financial statements as of March 31, 2024 and for the three months ended March 31, 2024 and 2023 (collectively, the Interim Financial Statements) are unaudited. Certain information and note disclosures normally included in the 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, 2023, 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. 2. 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 interests in its condensed consolidated statements of income. The Interim Financial Statements include the accounts of all independent subsidiaries controlled by the Company through its ownership of a majority voting interest. 6 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) The preparation of the 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, 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. Recently Issued Accounting Pronouncements — In October 2023, the Financial Accounting Standards Board (FASB) issued Accounting Standards Update (ASU) 2023-06 "Codification Amendments in Response to the SEC’s Disclosure Update and Simplification Initiative," which amends U.S. GAAP to include 14 disclosure requirements that are currently required under SEC Regulation S-X or Regulation S-K. Each amendment will be effective on the date on which the SEC removes the related disclosure requirement from SEC Regulation S-X or Regulation S-K. The adoption is not expected to have a material impact on the Company's Interim Financial Statements as these requirements were previously incorporated under the SEC Regulations. In November 2023, the FASB issued ASU 2023-07 " Segment Reporting (Topic 280): Improvements to Reportable Segment Disclosures, " which requires the Company to expand the breadth and frequency of segment disclosures to include additional information about significant segment expenses, the chief operating decision maker (CODM) and other items, and also require the annual disclosures on an interim basis. This guidance is effective for annual periods beginning after December 15, 2023, which will be the Company's fiscal year 2024, and in interim periods within fiscal years beginning after December 15, 2024, with early adoption permitted. The Company is currently evaluating the impact of the ASU on its Quarterly and Annual Reports. In December 2023, the FASB issued ASU 2023-09 " Income Taxes (Topic 740): Improvements to Income Tax Disclosures, " which requires the Company to disclose disaggregated jurisdictional and categorical information for the tax rate reconciliation, income taxes paid and other income tax related amounts. This guidance is effective for annual periods beginning after December 15, 2024, which will be the Company's fiscal year 2025, with early adoption permitted. The adoption is expected to enhance the Company's Notes to the Consolidated Financial Statements. The Company is currently evaluating the impact of the ASU on its Annual Report. 3. REVENUE AND ACCOUNTS RECEIVABLE The Company's service revenue is derived primarily from providing healthcare services to its patients. Revenue is recognized when services are provided to patients at the amount that reflects the consideration that 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. Disaggregation of Revenue The Company disaggregates revenue from contracts with its patients by payors. The Company has determined 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 rates, adjusted for estimates for variable consideration, on a per patient, daily basis or as services are performed. Revenue from the Medicare and Medicaid programs accounted for 71.6 % and 73.3 % of all service revenue for the three months ended March 31, 2024 and 2023, 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 revenue for the three months ended March 31, 2024 and 2023. 7 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) Service revenue for the three months ended March 31, 2024 and 2023 is summarized in the following tables: Three Months Ended March 31, 2024 2023 Revenue % of Revenue Revenue % of Revenue Medicaid (1) $ 390,163 38.8 % $ 340,264 38.6 % Medicare 265,583 26.4 247,723 28.1 Medicaid — skilled 63,309 6.4 57,927 6.6 Total Medicaid and Medicare 719,055 71.6 645,914 73.3 Managed care 188,104 18.7 156,663 17.8 Private and other (2) 97,326 9.7 79,341 8.9 SERVICE REVENUE $ 1,004,485 100.0 % $ 881,918 100.0 % (1) Medicaid payor includes revenue for senior living operations and revenue related to state relief funding . (2) Private and other also includes revenue from senior living operations and all revenue generated in other an cillary services. 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. Rental revenue was $ 5,687 and $ 4,923 , respectively, for the three months ended March 31, 2024 and 2023. State relief funding In 2023, the Company received state relief funding through Medicaid programs from various states, including healthcare relief funding under the American Rescue Plan Act (ARPA), increases in the Federal Medical Assistance Percentage (FMAP) under the Families First Coronavirus Response Act (FFCRA) and other state specific relief programs. The funding generally incorporates specific use requirements primarily for direct patient care including labor related expenses that are attributable to the COVID-19 pandemic or are associated with providing patient care. Due to the expiration of the COVID-19 Public Health Emergency on May 11, 2023, the Company did not receive additional funding during the three months ended March 31, 2024. The Company received $ 27,264 in state relief funding and recognized $ 26,358 as revenue during the three months ended March 31, 2023. 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 March 31, 2024 and December 31, 2023, or activity during the three months ended March 31, 2024 and 2023. 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. Accounts receivable as of March 31, 2024 and December 31, 2023, is summarized in the following table: March 31, 2024 December 31, 2023 Medicaid $ 188,524 $ 178,285 Managed care 135,691 125,907 Medicare 89,300 85,512 Private and other payors 115,387 104,683 528,902 494,387 Less: allowance for doubtful accounts ( 9,463 ) ( 9,348 ) ACCOUNTS RECEIVABLE, NET $ 519,439 $ 485,039 8 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) 4. COMPUTATION OF NET INCOME PER COMMON SHARE Basic 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 March 31, 2024 2023 NUMERATOR: Net income $ 68,960 $ 59,969 Less: net income attributable to noncontrolling interests 125 117 Net income attributable to The Ensign Group, Inc. $ 68,835 $ 59,852 DENOMINATOR: Weighted average shares outstanding for basic net income per share 56,337 55,300 Basic net income per common share: $ 1.22 $ 1.08 A reconciliation of the numerator and denominator used in the calculation of diluted net income per common share follows: Three Months Ended March 31, 2024 2023 NUMERATOR: Net income $ 68,960 $ 59,969 Less: net income attributable to noncontrolling interests 125 117 Net income attributable to The Ensign Group, Inc. $ 68,835 $ 59,852 DENOMINATOR: Weighted average common shares outstanding 56,337 55,300 Plus: incremental shares from assumed conversion (1) 1,584 1,798 Adjusted weighted average common shares outstanding 57,921 57,098 Diluted net income per common share: $ 1.19 $ 1.05 (1) Options outstanding which are anti-dilutive and therefore not factored into the weighted average common shares amount above were 1,143 and 1,178 for the three months ended March 31, 2024 and 2023, respectivel y. 5. FAIR VALUE MEASUREMENTS The Company's financial assets include the captive insurance subsidiary's deposits and investments designated to support long-term insurance subsidiary liabilities and are carried at amortized cost basis of $ 62,063 and $ 59,530 as of March 31, 2024 and December 31, 2023, respectively. As of March 31, 2024 and December 31, 2023, the amortized cost basis of the Company's financial assets included in the captive insurance subsidiary's investments are considered to approximate the fair value of these financial assets and are derived using Level 2 inputs. Also included are contracts insuring the lives of certain employees who are eligible to participate in non-qualified deferred compensation plans that are held in a rabbi trust. The cash surrender value of these contracts is based on funds that shadow the investment allocations specified by participants in the deferred compensation plan and are held at fair value. As of March 31, 2024, and December 31, 2023, the fair value of the investment funds was $ 50,894 and $ 41,216 , respectively, which are derived using Level 2 inputs. 9 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) Additionally, the Company has other investments held at historical cost basis, which are not material, for which the fair value is derived using Level 3 inputs. The Company believes its amortized cost basis investments that were in an unrealized loss position as of March 31, 2024 and December 31, 2023 do not require an allowance for expected credit losses, nor has any event occurred through the filing date of this report that would indicate differently. 6. STANDARD BEARER Standard Bearer's real estate portfolio consists of 109 of the Company's 114 owned real estate properties, of which 80 are operated and managed by the Company's independent subsidiaries and 30 are leased to and operated by third-party operators. Of those 30 operations, one senior living facility is located on the same real estate property as a skilled nursing facility that an independent subsidiary owns and operates. During the three months ended March 31, 2024, Standard Bearer acquired the real estate of one stand-alone skilled nursing operation for an aggregate purchase price of $ 1,604 . This facility is operated by one of the Company's independent subsidiaries . Refer to Note 7, Operation Expansions , for additional information. Subsequent to March 31, 2024, Standard Bearer acquired the real estate of two stand-alone skilled nursing facility, one long-term acute care hospital and two campus operations for an aggregate purchase price of $ 56,015 . The five additions are operated by certain of the Company's independent subsidiaries . Refer to Note 7, Operation Expansions , for additional information. As part of the formation of Standard Bearer, certain of the Company's independent subsidiaries, Standard Bearer and Standard Bearer's independent real estate subsidiaries entered into several agreements that include leasing, management services and debt arrangements between the operations . All intercompany transactions have been eliminated in consolidation. Refer to Note 8, Business Segments , for additional information related to these intercompany eliminations as well as Standard Bearer as a reportable segment. Intercompany master lease agreements Certain of the Company's independent subsidiaries and 80 Standard Bearer independent real estate subsidiaries have entered into five triple-net master lease agreements (collectively, the Standard Bearer Master Leases). The lease periods range from 15 to 19 years with three five-year renewal options beyond the initial term, on the same terms and conditions. The rent structure under the Standard Bearer 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 independent subsidiaries are required to pay the following: (1) all impositions and taxes levied on or with respect to the leased properties; (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. Rental revenue generated from Ensign affiliated operations for the three months ended March 31, 2024 and 2023 was $ 18,006 and $ 15,931 , respectively. Intercompany management agreement Standard Bearer has no employees. The Service Center provides personnel and services to Standard Bearer pursuant to the management agreement between Standard Bearer and the Service Center. The management agreement provides for a base management fee that is equal to 5 % of total rental revenue and an incentive management fee that is equal to 5 % of funds from operations (FFO) and is capped at 1 % of total rental revenue, for a total of 6 %. Management fee generated between Standard Bearer and the Service Center for the three months ended March 31, 2024 and 2023 was $ 1,332 and $ 1,182 , respectively, representing 6 % of total Standard Bearer rental revenue, as of each such date. Intercompany debt arrangements Standard Bearer obtains its funding through various sources including operating cash flows, access to debt arrangements and intercompany loans. The intercompany debt arrangements include mortgage loans and the Credit Facility to fund acquisitions and working capital needs. The interest rate under the Credit Facility is a base rate plus a margin ranging from 0.25 % to 1.25 % per annum or SOFR plus a margin ranging from 1.25 % to 2.25 % per annum. 10 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) In addition, as the Department of Housing and Urban Development (HUD) mortgage loans and promissory note are entered into by real estate subsidiaries of Standard Bearer, the interest expense incurred from these debts are included in Standard Bearer's segment income. Refer to Note 15, Debt , for additional information related to these debts. Equity Instrument Denominated in the Shares of a Subsidiary As part of the formation of Standard Bearer in 2022, the Company established the Standard Bearer Healthcare REIT, Inc. 2022 Omnibus Incentive Plan (Standard Bearer Equity Plan). The Company may grant stock options and restricted stock awards under the Standard Bearer Equity Plan to employees and management of Ensign's independent subsidiaries. These awards generally vest over a period of five years or upon the occurrence of certain prescribed events. The value of the stock options and restricted stock awards is tied to the value of the common stock of Standard Bearer, which is determined based on an independent valuation of Standard Bearer. The awards can be put to Standard Bearer at various prescribed dates, which in no event is earlier than six months after vesting of the restricted awards or exercise of the stock options. The Company can also call the awards, generally upon employee termination. During the three months ended March 31, 2024 and 2023, the Company did not grant any stock options nor restricted shares under the Standard Bearer Equity Plan. 7. OPERATION EXPANSIONS The expansion focus of the Company's independent subsidiaries is to purchase or lease operations that are complementary to the current operations, accretive to the business, or otherwise advance the Company's strategy. The results of all independent subsidiaries are included in the Interim Financial Statements subsequent to the date of acquisition. Acquisitions are accounted for using the acquisition method of accounting. The Company's independent subsidiaries also enter into long-term leases that may include options to purchase the facilities. As a result, from time to time, an independent real estate subsidiary will acquire the property of facilities that have previously been operated under third-party leases. 2024 Expansions During the three months ended March 31, 2024, the Company expanded its operations and real estate portfolio through a combination of long-term leases and a real estate purchase , with the addition of five stand-alone skilled nursing operations. Of these additions, Standard Bearer acquired the real estate of one stand-alone skilled nursing operation, which was leased back to one of the Company's independent subsidiary. Refer to Note 6, Standard Bearer, for additional information on the purchase of real estate property. These new operations added a total of 591 operational skilled nursing beds to be operated by the Company's independent subsidiaries. In connection with the new operations obtained 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 each prior operator as part of each transaction. The Company also invested in new ancillary services that are complementary to its existing businesses. Subsequent to March 31, 2024, the Company expanded its operations through a combination of long-term leases and real estate purchases, with the addition of five stand-alone skilled nursing operations, one long-term acute care hospital and two campus operations. Of these additions, Standard Bearer acquired the real estate of five of these operations, which were leased back to the Company's independent subsidiaries. Refer to Note 6, Standard Bearer, for additional information on the purchases of real estate properties. These new operations added 625 operational skilled nursing beds, 43 long-term acute care beds, and 202 operational senior living units to be operated by the Company's affiliated operating subsidiaries. 2023 Expansions During the three months ended March 31, 2023, the Company expanded its operations through long-term leases , with the addition of 19 stand-alone skilled nursing operations. These new operations added a total of 1,764 operational skilled nursing beds operated by the Company's independent subsidiaries. In connection with the new operations obtained 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 each prior operator as part of each transaction. 11 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) 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 independent subsidiaries . The assets added during the three months ended March 31, 2024 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 condensed consolidated balance sheets of the Company, and the operating results have been included in the condensed consolidated statements of income of the Company since the date the Company gained effective control. 8. BUSINESS SEGMENTS The Company has two reportable segments: (1) skilled services, which includes the operation of skilled nursing facilities and rehabilitation therapy services and (2) Standard Bearer, which is comprised of selected real estate properties owned by Standard Bearer and leased to skilled nursing and senior living operators. As of March 31, 2024, the skilled services segment includes 264 skilled nursing operations and 27 campus operations that provide both skilled nursing and rehabilitative care services and senior living services. The Company's Standard Bearer segment consists of 109 owned real estate properties. The Company also reports an “All Other” category that includes results from its senior living operations, which includes 11 stand-alone senior living operations and the senior living operations at 27 campus operations that provide both skilled nursing and rehabilitative care services and senior living services. In addition, the "All Other" category includes mobile diagnostics, medical transportation, other real estate 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. Intercompany revenue is eliminated in consolidation, along with corresponding intercompany expenses. Segment income and loss is defined as profit or loss from operations before provision for income taxes, excluding gain or loss from sale of real estate, real estate insurance recoveries and impairment of long-lived assets. Included in segment income for Standard Bearer is expense for intercompany services provided by the Service Center as described in Note 6, Standard Bearer , as it is part of the CODM financial information. The following tables set forth financial information for the segments: Three Months Ended March 31, 2024 Skilled Services Standard Bearer All Other (1) Intercompany Elimination Total Service revenue (2) $ 969,602 $ — $ 39,626 $ ( 4,743 ) $ 1,004,485 Rental revenue (3) — 22,201 2,946 ( 19,460 ) 5,687 TOTAL REVENUE $ 969,602 $ 22,201 $ 42,572 $ ( 24,203 ) $ 1,010,172 Segment income (loss) 126,809 7,258 ( 42,620 ) — 91,447 Impairment of long-lived assets ( 1,849 ) Income before provision for income taxes $ 89,598 Depreciation and amortization 10,536 6,829 2,292 — 19,657 Interest expense (4) $ — $ 5,977 $ 272 $ ( 4,285 ) $ 1,964 (1) All Other primarily includes all ancillary operations, stand-alone senior living operations and the Service Center. (2) Intercompany service revenue represents service revenue generated by ancillary operations provided to the Company's independent subsidiaries and management service revenue generated by the Service Center with Standard Bearer. Intercompany service revenue is eliminated in consolidation along with corresponding intercompany cost of service. (3) All Other rental revenue includes rental revenue associated with the Company's subleases to third parties of $ 1,080 for the three months ended March 31, 2024. Intercompany rental revenue represents rental income generated by both Standard Bearer and other real estate properties with the Company's independent subsidiaries. Intercompany rental revenue is eliminated in consolidation along with corresponding intercompany rent expense. (4) Included in interest expense in Standard Bearer is interest expense incurred from intercompany debt arrangements between Standard Bearer and The Ensign Group, Inc. Intercompany interest expense is eliminated in the "Intercompany Elimination" column. 12 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) Three Months Ended March 31, 2023 Skilled Services Standard Bearer All Other (1) Intercompany Elimination Total Service revenue (2) $ 850,923 $ — $ 34,533 $ ( 3,538 ) $ 881,918 Rental revenue (3) — 19,717 2,563 ( 17,357 ) 4,923 TOTAL REVENUE $ 850,923 $ 19,717 $ 37,096 $ ( 20,895 ) $ 886,841 Segment income (loss) 113,345 7,219 ( 42,182 ) — 78,382 Depreciation and amortization 9,064 5,966 2,082 — 17,112 Interest expense (4) $ — $ 4,569 $ 311 $ ( 2,844 ) $ 2,036 (1) All Other primarily includes all ancillary operations, stand-alone senior living operations and the Service Center. (2) Intercompany service revenue represents service revenue generated by ancillary operations provided to the Company's independent subsidiaries and management service revenue generated by the Service Center with Standard Bearer. Intercompany service revenue is eliminated in consolidation along with corresponding intercompany cost of service. (3) All Other rental revenue includes rental revenue associated with the Company's subleases to third parties of $ 708 for the three months ended March 31, 2023. Intercompany rental revenue represents rental income generated by both Standard Bearer and other real estate properties with the Company's independent subsidiaries. Intercompany rental revenue is eliminated in consolidation along with corresponding intercompany rent expense. (4) Included in interest expense in Standard Bearer is interest expense incurred from intercompany debt arrangements between Standard Bearer and The Ensign Group, Inc. Intercompany interest expense is eliminated in the "Intercompany Elimination" column. Service revenue by major payor source were as follows: Three Months Ended March 31, 2024 Skilled Services All Other (3) Total Service Revenue Revenue % Medicaid (1) $ 382,118 $ 8,045 $ 390,163 38.8 % Medicare 265,583 — 265,583 26.4 Medicaid-skilled 63,309 — 63,309 6.4 Subtotal 711,010 8,045 719,055 71.6 Managed care 188,104 — 188,104 18.7 Private and other (2) 70,488 26,838 97,326 9.7 TOTAL SERVICE REVENUE $ 969,602 $ 34,883 $ 1,004,485 100.0 % (1) Medicaid payor includes revenue generated from senior living operations and revenue related to state relief funding. (2) Private and other also includes revenue from senior living operations and all revenue generated in other ancillary services. (3) All Other incorporates intercompany eliminations. Three Months Ended March 31, 2023 Skilled Services All Other (3) Total Service Revenue Revenue % Medicaid (1) $ 333,445 $ 6,819 $ 340,264 38.6 % Medicare 247,723 — 247,723 28.1 Medicaid-skilled 57,927 — 57,927 6.6 Subtotal 639,095 6,819 645,914 73.3 Managed care 156,663 — 156,663 17.8 Private and other (2) 55,165 24,176 79,341 8.9 TOTAL SERVICE REVENUE $ 850,923 $ 30,995 $ 881,918 100.0 % (1) Medicaid payor includes revenue generated from senior living operations and revenue related to state relief funding. (2) Private and other also includes revenue from senior living operations and all revenue generated in other ancillary services. (3) All Other incorporates intercompany eliminations. 13 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) 9. PROPERTY AND EQUIPMENT - NET Property and equipment, net consists of the following: March 31, 2024 December 31, 2023 Land $ 142,897 $ 142,656 Buildings and improvements 806,135 803,155 Leasehold improvements 177,697 172,064 Equipment 351,328 339,383 Furniture and fixtures 4,217 4,192 Construction in progress 32,404 25,563 1,514,678 1,487,013 Less: accumulated depreciation ( 413,118 ) ( 396,242 ) PROPERTY AND EQUIPMENT, NET $ 1,101,560 $ 1,090,771 Management evaluated its long-lived assets and recorded an impairment charge of $ 1,849 during the three months ended March 31, 2024. The Company determined there was no impairment during the three months ended March 31, 2023. See also Note 6, Standard Bearer and Note 7, Operation Expansions for information on acquisitions during the three months ended March 31, 2024. 10. INTANGIBLE ASSETS - NET March 31, 2024 December 31, 2023 Weighted Average Life (Years) Gross Carrying Amount Accumulated Amortization Gross Carrying Amount Accumulated Amortization Intangible Assets Net Net Assembled occupancy 0.3 $ 781 $ ( 781 ) $ — $ 781 $ ( 742 ) $ 39 Facility trade name 30.0 733 ( 445 ) 288 733 ( 439 ) 294 Customer relationships 18.4 4,582 ( 2,745 ) 1,837 4,582 ( 2,692 ) 1,890 TOTAL $ 6,096 $ ( 3,971 ) $ 2,125 $ 6,096 $ ( 3,873 ) $ 2,223 During the three months ended March 31, 2024 and 2023, amortization expense was $ 401 and $ 404 , respectively, of which $ 303 and $ 298 was related to the amortization of right-of-use assets, respectively. Estimated amortization expense for each of the years ending December 31 is as follows: Year Amount 2024 (remainder) $ 176 2025 234 2026 234 2027 234 2028 234 Thereafter 1,013 $ 2,125 Other indefinite-lived intangible assets consist of the following: March 31, 2024 December 31, 2023 Trade name $ 889 $ 889 Medicare and Medicaid licenses 3,545 3,413 TOTAL $ 4,434 $ 4,302 14 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) 11. GOODWILL Goodwill is subject to annual testing for impairment during the fourth quarter of each year. In addition, goodwill is tested for impairment if events occur or circumstances indicate that its carrying value may not be recoverable. There were no indicators of goodwill impairment noted during the three months ended March 31, 2024. The Company anticipates that the majority of goodwill recognized will be fully deductible for tax purposes as of March 31, 2024. Provided that goodwill corresponds to the acquisition of a business and not merely the acquisition of real estate property, the Company's Standard Bearer segment appropriately does not carry a goodwill balance. The following table represents activity in goodwill by skilled service segment and "all other" category as of and for the three months ended March 31, 2024: Goodwill Skilled Services All Other Total January 1, 2024 $ 67,886 $ 8,983 $ 76,869 Additions — 372 372 March 31, 2024 $ 67,886 $ 9,355 $ 77,241 12. RESTRICTED AND OTHER ASSETS Restricted and other assets consist of the following: March 31, 2024 December 31, 2023 Debt issuance costs, net $ 2,661 $ 2,883 Long-term insurance losses recoverable asset 15,901 15,913 Capital improvement reserves with landlords and lenders 5,198 4,870 Deposits with landlords 2,666 2,661 Escrow deposits 486 1,216 Other 12,774 12,662 RESTRICTED AND OTHER ASSETS $ 39,686 $ 40,205 Included in restricted and other assets as of March 31, 2024 and December 31, 2023 are anticipated insurance recoveries related to the Company's workers' compensation and general and professional liability claims that are recorded on a gross, rather than net, basis. 13. OTHER ACCRUED LIABILITIES Other accrued liabilities consist of the following: March 31, 2024 December 31, 2023 Quality assurance fee $ 10,380 $ 14,035 Refunds payable 52,887 51,248 Resident advances 8,582 10,834 Cash held in trust for patients 5,940 6,215 Dividends payable 3,414 3,396 Property taxes 9,605 12,875 Income tax payable 16,173 — Accrued litigation (Note 20) 51,734 51,734 Other 21,693 17,891 OTHER ACCRUED LIABILITIES $ 180,408 $ 168,228 15 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) Quality assurance fee represents the aggregate of amounts payable to Arizona, California, Colorado, Idaho, Iowa, Kansas, Nebraska, Nevada, Tennessee, 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. 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 condensed consolidated balance sheets. 14. INCOME TAXES The Company recorded income tax expense of $ 20,638 and $ 18,413 during the three months ended March 31, 2024 and 2023, respectively, or 23.0 % of earnings before income taxes for the three months ended March 31, 2024, compared to 23.5 % for the three months ended March 31, 2023. The effective tax rate for both periods is driven by the impact of excess tax benefits from stock-based compensation, offset by non-deductible expenses including non-deductible compensation. The Company is not currently under examination by any major income tax jurisdiction. During 2024, the statutes of limitations will lapse on the Company's 2020 federal tax year and certain 2019 and 2020 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 three months ended March 31, 2024 and 2023. 15. DEBT Debt consists of the following: March 31, 2024 December 31, 2023 Mortgage loans and promissory note $ 151,413 $ 152,388 Less: current maturities ( 3,983 ) ( 3,950 ) Less: debt issuance costs, net ( 2,897 ) ( 2,941 ) LONG-TERM DEBT LESS CURRENT MATURITIES $ 144,533 $ 145,497 Credit Facility with a Lending Consortium Arranged by Truist The Company maintains a revolving credit facility between the Company and its independent subsidiaries, including Standard Bearer as co-borrowers, and Truist Securities (Truist) (the Credit Facility) with a revolving line of credit of up to $ 600,000 in aggregate principal amount with a maturity date of April 8, 2027. 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 0.25 % to 1.25 % per annum or SOFR plus a margin ranging from 1.25 % to 2.25 % per annum, based on the Consolidated Total Net Debt to Consolidated EBITDA ratio (as defined in the Credit Facility). In addition, there is a commitment fee on the unused portion of the commitments that ranges from 0.20 % to 0.40 % per annum, depending on the Consolidated Total Net Debt to Consolidated EBITDA ratio. Borrowings made under the Credit Facility are guaranteed, jointly and severally, by certain of the Company’s wholly-owned subsidiaries, and are secured by a pledge of stock of the Company's material independent subsidiaries as well as a first lien on substantially all of such independent subsidiaries' personal property. The Credit Facility contains customary covenants that, among other things, restrict, subject to certain exceptions, the ability of the Company and its independent 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 terms of 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 March 31, 2024, there was no outstanding debt under the Credit Facility. The Company was in compliance with all loan covenants as of March 31, 2024. 16 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) Mortgage Loans and Promissory Note As of March 31, 2024, the Company has 23 subsidiaries that have mortgage loans insured with HUD in the aggregate amount of $ 149,416 , which subjects these subsidiaries to HUD oversight and periodic inspections. The mortgage loans bear effective interest rates in a range of 3.1 % to 4.2 %, including fixed interest rates in a range of 2.4 % to 3.3 % per annum. In addition to the interest rate, the Company incurs 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 through ten of the loan. There is no prepayment penalty after year ten. The terms for all the mortgage loans are 25 to 35 years. In addition to the HUD mortgage loans above, the Company has a promissory note of $ 1,997 that bears a fixed interest rate of 5.3 % per annum and has a term of 12 years. The note, which was assumed as part of 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 inputs, the carrying value of the Company's long-term debt is considered to approximate the fair value of such debt for all periods presented based upon the interest rates that the Company believes it can currently obtain for similar debt. Off-Balance Sheet Arrangements As of March 31, 2024, the Company had approximately $ 6,305 of borrowing capacity under the Credit Facility pledged as collateral to secure outstanding letters of credit, which increased by $ 50 from December 31, 2023. 16. 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 months ended March 31, 2024 and 2023 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. 2022 Omnibus Incentive Plan (2022 Plan) — The Company has one active stock incentive plan, the 2022 Omnibus Incentive Plan (the 2022 Plan). Including the shares rolled over from the 2017 Omnibus Incentive Plan, the 2022 Plan provides for the issuance of 3,452 shares of common stock. The number of shares available to be issued under the 2022 Plan will be reduced by (i) one share for each share that relates to an option or stock appreciation right award and (ii) two shares for each share which relates to an award other than a stock option or stock appreciation right award (a full-value award). Non-employee director options, to the extent granted, will 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. At March 31, 2024, the total number of shares available for issuance under the 2022 Plan was 1,106 . 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. 17 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) Stock Options The Company used the following assumptions for stock options granted during the three months ended March 31, 2024 and 2023: Grant Year Options Granted Weighted Average Risk-Free Rate Expected Life Weighted Average Volatility Weighted Average Dividend Yield 2024 181 4.3 % 6.1 years 40.9 % 0.2 % 2023 222 4.1 % 6.3 years 41.6 % 0.2 % For the three months ended March 31, 2024 and 2023, 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 2024 181 $ 122.69 $ 56.23 2023 222 $ 89.84 $ 41.60 The weighted average exercise price equaled the weighted average fair value of common stock on the grant date for all options granted during the three months ended March 31, 2024 and 2023 and therefore, the intrinsic value was $ 0 at the date of grant. The following table represents the employee stock option activity during the three months ended March 31, 2024: Number of Options Outstanding Weighted Average Exercise Price Number of Options Vested Weighted Average Exercise Price of Options Vested January 1, 2024 3,991 $ 62.65 1,887 $ 39.58 Granted 181 122.69 Forfeited ( 25 ) 83.01 Exercised ( 219 ) 28.48 March 31, 2024 3,928 $ 67.19 1,808 $ 43.49 The aggregate intrinsic value of options outstanding, vested, expected to vest and exercised as of March 31, 2024 and December 31, 2023 is as follows: Options March 31, 2024 December 31, 2023 Outstanding $ 224,818 $ 197,819 Vested 146,313 137,048 Expected to vest 73,361 56,759 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 three months ended March 31, 2024 and 2023 was $ 7,382 and $ 5,337 , respectively. The total intrinsic value of options exercised during the three months ended March 31, 2024 and 2023 was $ 19,959 and $ 10,950 , respectively. Restricted Stock Awards The Company granted 95 and 105 restricted stock awards during the three months ended March 31, 2024 and 2023 , 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 three months ended March 31, 2024 and 2023 ranged from $ 116.65 to $ 122.69 and $ 89.83 to $ 94.63 , respectively. The fair value per share includes quarterly stock awards to non-employee directors. 18 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) A summary of the status of the Company's non-vested restricted stock awards as of March 31, 2024 and changes during the three months ended March 31, 2024 is presented below: Non-Vested Restricted Awards Weighted Average Grant Date Fair Value Nonvested at January 1, 2024 431 $ 78.91 Granted 95 119.57 Vested ( 89 ) 101.18 Forfeited ( 7 ) 81.64 Nonvested at March 31, 2024 430 $ 83.28 During the three months ended March 31, 2024, the Company granted 4 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 $ 116.65 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 of The Pennant Group, Inc. (Pennant) from the Company in 2019 (spin-off) were granted shares of restricted stock upon 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 are entirely forfeited. The total stock-based compensation related to the 2019 LTI Plan was approximately $ 206 and $ 191 for the three months ended March 31, 2024 and 2023, respectively. Stock-based compensation expense Stock-based compensation expense recognized for the Company's equity incentive plans and long-term incentive plan for the three months ended March 31, 2024 and 2023 was as follows: Three Months Ended March 31, 2024 2023 Stock-based compensation expense related to stock options $ 4,988 $ 3,425 Stock-based compensation expense related to restricted stock awards 2,727 2,728 Stock-based compensation expense related to restricted stock awards to non-employee directors 516 420 TOTAL $ 8,231 $ 6,573 In future periods, the Company expects to recognize approximately $ 72,032 and $ 30,655 in stock-based compensation expense for unvested options and unvested restricted stock awards, respectively, that were outstanding as of March 31, 2024. Future stock-based compensation expense will be recognized over 3.9 and 3.5 weighted average years for unvested options and restricted stock awards, respectively. There were 2,120 unvested and outstanding options as of March 31, 2024, of which 1,952 shares are expected to vest. The weighted average contractual life for options outstanding, vested and expected to vest as of March 31, 2024 was 6.8 years. 19 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) 17. LEASES The Company leases from CareTrust REIT, Inc. (CareTrust) real property associated with 99 independent skilled nursing and senior living facilities used in the Company’s operations, 98 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 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 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 99 facilities leased from CareTrust include an option to purchase that the Company can exercise starting on December 1, 2024. During three months ended March 31, 2024, the Company added two operations and extended the term for one of the Master Leases to 20 years. As a result, the total lease liabilities and right-of-use assets increased by $ 48,112 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 $ 16,800 and $ 16,283 for the three months ended March 31, 2024 and 2023, 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 March 31, 2024. In connection with the spin-off that occurred in 2019, the Company guaranteed certain leases of Pennant based on the underlying terms of the leases. The Company does not consider performance under these guarantees to be probable and the likelihood of Pennant defaulting is remote, and therefore no liabilities have been accrued. The Company leases facilities where its independent subsidiaries operate and certain administrative offices under non-cancelable operating leases, most of which have initial lease terms ranging from five to 20 years. In addition, the Company leases certain of its equipment under non-cancelable operating leases with initial terms ranging from three to five years . Most of these leases contain renewal options, certain of which involve rent increases. Eighty-two of the Company’s independent subsidiaries, excluding the subsidiaries that are operated under the Master Leases with CareTrust, are operated under 13 separate master lease arrangements. During the three months ended March 31, 2024, the Company amended one of the separate master lease arrangements to add two stand-alone skilled nursing operations operated by the Company's independent subsidiaries. The amended master lease increased the lease liabilities and right-of-use assets by $ 30,980 to reflect the new lease obligations and extended the term to 20 years. Under the master leases, a default 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. 20 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) The components of operating lease expense are as follows: Three Months Ended March 31, 2024 2023 Rent - cost of services (1) $ 51,876 $ 46,637 General and administrative expense 153 124 Depreciation and amortization (2) 303 298 Variable lease costs (3) 5,770 4,832 $ 58,102 $ 51,891 (1) Rent- cost of services includes deferred rent expense adju stments of $ 195 and $ 263 for the three months ended March 31, 2024 and 2023, respectively. Additionally, rent- cost of services includes other variable lease costs such as CPI increases and short-term leases of $ 3,057 and $ 2,060 for the three months ended March 31, 2024 and 2023, 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 third-party leases as of March 31, 2024 are as follows: Year Amount 2024 (remainder) $ 147,657 2025 196,805 2026 196,598 2027 196,009 2028 194,981 2029 191,269 Thereafter 1,651,949 TOTAL LEASE PAYMENTS 2,775,268 Less: present value adjustment ( 987,718 ) PRESENT VALUE OF TOTAL LEASE LIABILITIES 1,787,550 Less: current lease liabilities ( 85,898 ) LONG-TERM OPERATING LEASE LIABILITIES $ 1,701,652 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 March 31, 2024, the weighted average remaining lease term is 15.1 years and the weighted average discount rate used to determine the operating lease liabilities is 6.4 %. Subsequent to March 31, 2024, the Company expanded its operations through long-term leases with the addition of three standalone skilled nursing operations. The aggregate impact to the carrying value of lease liabilities and right-of-use assets related to the long-term leases is estimated to be approximately $ 39,689 . Lessor Activities The Company leases its owned real estate properties to third-party operators, of which 29 senior living operations are operated by Pennant. All of these properties are triple-net leases, whereby the respective tenants 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 from 14 to 16 years. During the first quarter of 2023, the Company entered into a sublease agreement for three stand-alone skilled nursing operations with a third-party operator with an initial lease term of 18 years. 21 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) Total rental income from all third-party sources for the three months ended March 31, 2024 and 2023 is as follows: Three Months Ended March 31, 2024 2023 Pennant (1) $ 3,820 $ 3,742 Other third-party (2) 1,867 1,181 TOTAL $ 5,687 $ 4,923 (1) Pennant rental income includes variable rent such as property taxes of $ 318 and $ 325 during the three months ended March 31, 2024 and 2023, respectively. (2) Other third-party includes rental revenue associated with the Company's subleases to third parties of $ 1,080 and $ 708 for the three months ended March 31, 2024 and 2023. Future annual rental income for all third-party leases as of March 31, 2024 were as follows: Year Amount (1) 2024 (remainder) $ 16,589 2025 21,569 2026 21,269 2027 21,176 2028 21,151 2029 21,109 Thereafter 108,459 TOTAL $ 231,322 (1) Annual rental income includes base rents and variable rental income pursuant to existing leases as of March 31, 2024. 18. DEFINED CONTRIBUTION PLANS The Company has a 401(k) defined contribution plan (the 401(k) Plan), whereby eligible employees may contribute up to 90 % of their annual basic earnings, subject to applicable annual Internal Revenue Code limits. Additionally, the 401(k) Plan provides for discretionary matching contributions (as defined in the 401(k) Plan) by the Company. The Company has a non-qualified deferred compensation plan (DCP), whereby certain highly compensated employees who are otherwise ineligible to participate in the Company's 401(k) plan, may defer the receipt of a portion of their base compensation and, for certain employees, up to 100 % of their eligible bonuses. Additionally, the DCP 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 fund savings plans of this nature. The Company paid for related administrative costs, which were not significant during the three months ended March 31, 2024 and 2023. As of March 31, 2024 and December 31, 2023, the Company accrued $ 51,478 and $ 49,201 , respectively, as long term deferred compensation in other long term liabilities on the consolidated balance sheet. Cash surrender value of the contracts is based on investment funds that shadow the investment allocations specified by participants in the deferred compensation plan. Refer to Note 5, Fair Value Measurements for more information on the funds. For the three months ended March 31, 2024 and 2023, the Company recorded gains related to its DCP of $ 2,394 and $ 1,239 , respectively, which are included in other income, net, and recorded offsetting expenses of $ 2,488 and $ 1,280 , respectively, which are allocated between cost of services and general and administrative expenses. 22 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) 19. SELF INSURANCE LIABILITIES 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 for the Company's independent subsidiaries in California is $ 750 per claim, subject to an additional one-time deductible of $ 1,500 . For the independent subsidiaries not in California, the self-insured claim is $ 650 per claim, subject to an additional one-time, deductible of $ 1,350 . For all independent subsidiaries, except those located in Colorado, the third-party coverage above these limits is $ 1,000 per claim, $ 3,000 per operation, with a $ 10,000 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 insurance subsidiary, the related assets and liabilities of which are included in the accompanying condensed consolidated balance sheets. The captive insurance subsidiary 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 $ 116,892 and $ 105,729 as of March 31, 2024 and December 31, 2023, respectively. The Company’s independent 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 independent 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 independent 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 $ 30,765 and $ 29,454 as of March 31, 2024 and December 31, 2023, respectively. In addition, the Company has recorded an asset and corresponding liability of $ 15,901 and $ 15,913 as of March 31, 2024 and December 31, 2023, 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 for 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 $ 525 for each covered person for fiscal year 2024. As of March 31, 2024 and December 31, 2023, the Company’s accrued liability under these plans recorded on an undiscounted basis in the accompanying condensed consolidated balance sheets was $ 16,395 and $ 14,814 , 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. 23 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) 20. COMMITMENTS AND CONTINGENCIES 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 obligations 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 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 based on 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 consolidated balance sheets for any of the periods presented. In connection with the spin-off in 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 transaction. 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. Litigation and 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. 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 us. The Company and its independent subsidiaries are party to various legal actions and administrative proceedings and are subject to various claims arising in the ordinary course of business, including claims that services provided to patients by the Company’s independent subsidiaries have resulted in injury or death, and claims related to employment and commercial matters. For example, in a four-week medical negligence trial in the State of Arizona, the jury returned a verdict against one of the Company’s independent subsidiaries in late November 2023. The Company intends to appeal the verdict. The Company has in the past appealed similar decisions and has, in some circumstances, received returned decisions in its favor. Although the Company intends to vigorously defend against these claims and in general these types of claims and cases, there can be no assurance that the outcomes of these matters will not have a material adverse effect on operational results and financial condition. Additionally, in certain states in which the Company has or has had independent subsidiaries, insurance coverage for the risk of punitive damages arising from general and professional liability litigation may not be available due to state law and/or public policy prohibitions. There can be no assurance that the Company or its independent subsidiaries will not be liable for punitive damages awarded in litigation arising in states for which punitive damage insurance coverage is not available. The skilled nursing and post-acute care industry is heavily regulated. As such, the Company and its independent subsidiaries are continuously subject to state and federal regulatory scrutiny, supervision and control in the ordinary course of business. Such regulatory scrutiny often includes inquiries, investigations, examinations, audits, site visits and surveys, some of which are non-routine. In addition to being subject to direct regulatory oversight from state and federal agencies, the skilled nursing and post-acute care industry is also subject to regulatory requirements which, if noncompliance is identified, could result in civil, administrative or criminal fines, penalties or restitutionary relief, and reimbursement; authorities could also seek the suspension or exclusion of the provider or individual from participation in their programs. The Company believes that there has been, and will continue to be, an increase in governmental investigations of post-acute providers, particularly in the area of Medicare/Medicaid false claims, as well as an increase in enforcement actions resulting from these investigations. Adverse determinations in civil legal proceedings or governmental investigations, whether currently asserted or arising in the future, could have a material adverse effect on the Company’s financial position, results of operations, and cash flows. Additionally, such proceedings and/or investigation can be a distraction to the business. 24 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) For example, 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 and its independent subsidiaries received a document and information request from the House Select Subcommittee. The Company and its independent subsidiaries cooperated in responding to this inquiry. In July 2022 and thereafter, the Company and its independent subsidiaries received follow up requests for additional documents and information. The Company and its independent subsidiaries responded to these requests and cooperated with the House Select Subcommittee in connection with its investigation. On December 9, 2022, the House Select Subcommittee issued its final report summarizing its investigation and related recommendations designed "to strengthen the nation's ability to prevent and respond to public health and economic emergencies." According to the information provided by the House Select Subcommittee, the issuance of this report was the House Select Subcommittee's final official act in connection with their assigned responsibilities. Also , the Company, on behalf of its independent subsidiaries, received a Civil Investigative Demand (CID) from the U.S. Department of Justice (DOJ) in January of 2024 indicating that the DOJ is investigating the Company to determine whether it has caused the submission of claims to Medicare and Texas Medicaid for services which were unnecessary or otherwise not consistent with existing reimbursement requirements. The CID covers the period from January 1, 2016, to the present. As a general matter, the Company's independent subsidiaries maintain policies and procedures to promote compliance with all applicable Medicare and Medicaid requirements, including but not limited to those relating to the presentation of claims for reimbursement for services provided . The Company is fully cooperating with the DOJ in response to the CID. However, the Company cannot predict the outcome of the investigation or its potential impact on the consolidated financial statements. In addition to the potential lawsuits and claims described above, the Company and its independent subsidiaries are also subject to potential lawsuits under the FCA 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. In addition, and pursuant to the qui tam or "whistleblower" provisions of the FCA, 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, on May 31, 2018, the Company, on behalf of its independent subsidiaries, received a CID from the DOJ stating that it was investigating to determine whether there had been a violation of the False Claims Act (FCA) and/or the Anti-Kickback Statute (AKS) with respect to the relationships between certain of the Company’s independent subsidiaries and persons who serve or have served as medical directors. The Company fully cooperated with the DOJ and promptly responded to its requests for information. In April 2020, the Company was advised that the DOJ declined to intervene in any subsequent action filed in connection with the subject matter of this investigation. Despite the decision of the DOJ to decline to participate in litigation based on the subject matter of its previously issued CID, the involved qui tam relator moved forward with the complaint in December 2020. From that time until December 2023, and notwithstanding the Company's success in early pre-trial motions, the Company continued to incur legal defense costs and fees, including significant amounts as part of discovery in the fourth quarter of 2023. In early January 2024, the Company entered into mediation with the involved parties and on January 19, 2024, the parties agreed to settle the civil case for $ 48,000 , subject to the review of the DOJ and other relevant government entities. The settlement does not include admissions on the part of the Company or its independent subsidiaries and the Company maintains that it has and continues to comply with all applicable State and Federal statutes (including but not limited to the FCA and the AKS). In addition to the FCA, 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 FCA. As such, the Company and its independent 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 subsidiaries do business. Under the Fraud Enforcement and Recovery Act of 2009 (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 an FCA 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. 25 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) 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 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 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 authorize 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 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 subsidiaries are subjected to, alleged to be liable for, or agree to a settlement of, claims or obligations under federal Medicare statutes, the FCA, or similar state and federal statutes and related regulations, or if the Company or its independent 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 independent subsidiaries under a Corporate Integrity Agreement and/or other such arrangement. 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. Medicare Revenue Recoupments — The Company's independent subsidiaries 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 (TPE) Program. Beginning in August 2020, CMS resumed TPE 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 March 31, 2024 and through the filing date of this report, 22 of the Company's independent subsidiaries had Reviews scheduled or in process. In June 2023, CMS announced a new nationwide audit, the “SNF 5-Claim Probe & Educate Review,” in which the Medicare Administrative Contractors (MACs) will review five claims from each SNF to check for compliance. In implementing this SNF 5-Claim Probe & Educate Review, CMS acknowledged that the increase in observed improper payments from 2021 to 2022 may have arisen from a "misunderstanding" by SNFs about how to appropriately bill for claims of service after October 1, 2019. All facilities that are not undergoing TPE reviews, or have not recently passed a TPE review, will be subject to the nationwide audit. MACs will complete only one round of probe-and-educate for each SNF, rather than three rounds that typically occur in the TPE. Additionally, CMS's education for each SNF will be individualized and based on observed claim review errors, with rationales for denial explained to the SNF on a claim-by-claim basis. This program applies only to claims submitted after October 1, 2019, and will exclude claims containing a COVID-19 diagnosis. 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. 26 Table of Contents THE ENSIGN GROUP, INC. NOTES TO THE UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS - (Continued) The Company’s receivables from Medicare and Medicaid payor programs accounted for 52.5 % and 53.4 % of its total accounts receivable as of March 31, 2024 and December 31, 2023, respectively. Revenue from reimbursement under the Medicare and Medicaid programs accounted for 71.6 % and 73.3 % of the Company's revenue for the three months ended March 31, 2024 and 2023, respectively . 21. COMMON STOCK REPURCHASE PROGRAM On August 29, 2023, the Board of Directors approved a stock repurchase program pursuant to which the Company could repurchase up to $ 20,000 of its common stock under the program for a period of approximately 12 months from September 1, 2023. 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 share repurchase program does not obligate us to acquire any specific number of shares. The Company did not purchase any shares pursuant to this stock repurchase program during the three months ended March 31, 2024.