ENSG - NASDAQ

Hello, and thank you for standing by. My name is Bella, and I will be your conference operator today. At this time, I would like to welcome everyone to The Ensign Group Q4 Earnings Call. [Operator Instructions] I would now like to turn the conference over to Mr. Keetch. You may begin.

Thank you, operator, and welcome, everyone. We filed our earnings press release yesterday, and it is available on the Investor Relations section of our website at ensigngroup.net. A replay of this call will also be available on our website until 5:00 p.m. Pacific on Friday, February 28, 2025. We want to remind anyone that might be listening to a replay of this call that all statements are made as of today, February 6, 2025, and these statements have not been nor will be updated subsequent to today's call. Also, any forward-looking statements made today are based on management's current expectations, assumptions or beliefs about our business and the environment in which we operate. These statements are subject to risks and uncertainties that could cause our actual results to materially differ from those expressed or implied on today's call. Listeners should not place undue reliance on forward-looking statements and are encouraged to review our SEC filings for a complete discussion of factors that could impact our results. Except as required by federal securities laws, Ensign and its independent subsidiaries do not undertake to publicly update or revise any forward-looking statements where changes arise as a result of new information, future events, changing circumstances or for any other reason. In addition, The Ensign Group, Inc. is a holding company with no direct operating assets, employees or revenues. Certain of our independent subsidiaries, collectively referred to as the service center, provide accounting, payroll, human resources, information technology, legal, risk management and other services to the other independent subsidiaries through contractual relationships. In addition, our captive insurance subsidiary, which we refer to as the insurance captive, provides certain claims made coverage to our operating companies for general and professional liability as well as for workers' compensation insurance liabilities. Ensign also owns Standard Bearer Healthcare REIT, Inc., which is a captive real estate investment trust that invests in health care properties and enters into lease agreements with certain independent subsidiaries of Ensign as well as third-party tenants that are unaffiliated with The Ensign Group. The words Ensign, company, we, our, and us refer to The Ensign Group, Inc. and its consolidated subsidiaries. All of our independent subsidiaries of Service Centers, Standard Bearer Healthcare REIT and the insurance captive are operated by separate independent companies that have their own management, employees and assets. References herein to the consolidated company and its assets and activities as well as the use of the words we, us and our and similar terms are not meant to imply nor should be construed as meaning that The Ensign Group has direct operating assets, employees or revenue or that any of the subsidiaries are operated by The Ensign Group. Also, we supplement our GAAP reporting with non-GAAP metrics. When viewed together with our GAAP results, we believe that these measures can provide a more complete understanding of our business, but they should not be relied upon to the exclusion of GAAP reports. A GAAP to non-GAAP reconciliation is available in yesterday's press release and is available in our Form 10-K. And with that, I'll turn the call over to Barry Port, our CEO. Barry?

Thanks, Chad, and thank you all for joining us today. Our leaders and their teams across the organization once again posted record clinical and financial results and continue to build remarkable momentum in each market across our portfolio. Our success is entirely due to the efforts and commitment of those leadership teams, caregivers, field resources and service center partners. One of our most important priorities is to support those that care for our patients every day. That core value of customer second is something our teams across the organization [indiscernible] as we attract and develop [indiscernible] and leaders. We are building a formidable bull pen of caring and passionate partners who are determined to live our mission to dignify post-acute care. After other another record year [indiscernible], we're excited about the many opportunities to continue to grow this effort by capturing the enormous upside in our portfolios, we relentlessly focus on fundamentals across the organization. We are pleased to see same-store and transitioning occupancy increased by 2.7% and 4.1% for the year and grew by 2.3% and 4.7% over the prior year quarter, respectively. We also saw skilled days increased by 3.8% for our same-store and 10.9% for transitioning operations over the prior year quarter. In addition, our managed care census grew by 6.6% and 27.7% for our same-store and transitioning operations, respectively, over the prior year quarter. These results demonstrate the exciting momentum even in our more mature operations. We are very pleased with these results, but even more excited about these outcomes because they were achieved while simultaneously adding 57 operations across almost every market we serve. When we look at the combination of organic growth and new acquisitions, we see a very bright future ahead. We are very humbled by what we were able to accomplish in 2024, and we're eager to continue to drive organic improvements and take advantage of the acquisition opportunities that we see on the horizon. We're issuing our 2025 earnings guidance of $6.16 to $6.34 per diluted share and annual revenue guidance of $4.83 billion to $4.91 billion. The midpoint of this 2025 earnings guidance represents an increase of 13.8% over our 2024 results is 31% higher than our 2023 results. We look forward to 2025 with confidence that our partners will continue to manage and innovate while balancing the addition of newly acquired operations. This annual guidance comes on top of the extraordinary growth we experienced in the last few years. To put this performance in perspective, over the last 5 years, our total revenue increased by $2.2 billion or 109.2%, representing a 15.9% compound annual growth rate, while our diluted GAAP earnings per share grew by $3.48 in 2019 to $5.12 in 2024, representing a 25.6% compounded annual growth rate. In addition, since we spun out the Pennant Group in 2019, we have seen adjusted EPS grow by 209% with a CAGR of 25.3%. This performance is not due to some large event or a single transformative transaction but instead is the result of steady and consistent growth and performance quarter after quarter, which comes from a collective belief and commitment held by all of our partners to expand our mission in a methodical and thoughtful way. We look forward to the upcoming year and are confident that our partners can reach new heights in clinical and financial performance as they apply our proven locally driven model. And as we evaluate our expanding portfolio, we are very excited about the continued growth in occupancy and skilled mix that we experienced last year, which is continuing so far into the first quarter of this year. There are so many opportunities in front of us to optimize operational efficiencies and drive occupancy and skilled mix as we continue to successfully unlock value and opportunity in the dozens of recently acquired operations. Our leaders are poised to again showcase our ability to find, acquire and transition performing and underperforming operations by applying proven Ensign principles developed over 25 years. Next, I'll ask Chad to add some additional insights regarding our growth. Chad?

Thank you, Barry. As we expected, we continue to add to our growing portfolio and are thrilled with the 12 new operations we added during the quarter and since. These include the following: one in Alabama, 8 in Tennessee, one in Wisconsin, one in Texas and one in Nebraska. In total, we added 1,147 new skilled nursing beds and 16 senior living units across 5 states. Of these new operations, 6 of them included the real estate assets, which were acquired by Standard Bearer and leased to an Ensign affiliated operator. This growth brings a number of operations acquired in 2023 and since to 64, 38 of which were acquired since January 2024. We are excited to add density in one of our newest markets in Tennessee, and look forward to deepening our relationships in the health care community and building upon the foundation of our strong local leadership. We are also eager to see our first operation in Alabama gained strength and look forward to bolstering our presence in that state over time. As we have talked about before, entering new states is a significant undertaking that for us, must be driven by a proven Ensign leader, who is committed to and has a connection with the new geography. As most of you know, the foundational principle of our entire strategy is the recognition that post-acute care is a locally driven business and the success or failure of any operation is largely determined by the quality of the leadership and the vision of the team leading each unique multimillion dollar business. In addition, having the support of local resources and experts from nearby states has also proven to be a successful model in opening a new market. Lastly, when we go into a new state, we typically look to start with 1 or 2 buildings so we can establish a solid launching point for more growth. With Alabama, we were able to check all those boxes and have an outstanding Ensign leader, who has relocated to direct our efforts there in our first building, with the support of our talent in Tennessee and South Carolina. Over time, as we gain strength in our first operation, we will look to add additional facilities to establish our first Alabama cluster. As we have seen recently with Tennessee, eventually, this will grow into multiple clusters, which will eventually comprise a sizable market. We can't wait to watch Alabama become another reflection of the template of growth and development we've seen across our footprint over the last 25 years. We remind you that we are now only in 15 states and have significant bandwidth to grow in the other 35 states. Looking forward, we have already announced a new transaction, which we expect to close in the next few months, that includes 2 new states: Alaska and Oregon. As with Alabama, each of these new states is driven by an Ensign leader and will represent a small investment with plans to build over time. With all that being said, during 2024 and since, we added new operations in all but 2 of our existing 15 states, spreading out the growth across many markets. While we will continue to evaluate new states that fit our criteria, we will prioritize growth in our established geographies. This not only allows us to deepen our commitment to these markets, but because our transitions do not rely on a centralized acquisition team our growth is not limited by typical corporate bottlenecks. Instead, we look to our local cluster partners to implement the transition plans. So while our rate of growth this year was strong, the distribution of our growth across many markets leaves us with significant bandwidth to grow in most of our markets. We still see significant opportunity to continue to add meaningful density in the markets we know best, and are making progress on several additions that we expect to close in the next few months. While we expect the current rate of acquisitions to continue this year, we remain committed to staying true to the proven deal criteria that have allowed us to grow in a healthy and sustainable way. We continue to see more and more opportunities to acquire new operations and our focus is to carefully choose the acquisitions that will be accretive to shareholders. Our local leaders continue to recruit future CEOs for Ensign affiliated operations. We have a deep bench of CEOs in training that are eagerly preparing for their opportunity to lead. We still see evidence that many operators in this industry are struggling, and we expect that the operating environment will translate into many near- and long-term opportunities to both lease and acquire post-acute care assets. However, we do not set arbitrary [indiscernible] and will remain true to our disciplined acquisition strategy. We only grow when we have the right leaders in place and pricing [indiscernible]. The scalability of our growth model, our healthy balance sheet, combined with the numerous opportunities we see in our existing footprint, give us enormous potential to continue to apply our proven acquisition and transition strategies in 2025. We are also providing additional disclosure on Standard Bearer, which added 13 new assets during the quarter and since and is now comprised of 129 owned properties. Of these assets, 97 are leased to an Ensign affiliated operator and 33 are leased to third-party operators. 10 of these 13 new real estate assets are operated by an Ensign affiliated operator and 3 of these properties are senior living assets that are operated by a high-quality third-party tenants under triple-net long-term lease. Going forward, Standard Bearer continues to work together with its operating partners at Ensign to acquire portfolios comprised of operations that Ensign would operate and facilities at third parties that are interested in operating under a lease. In addition, over the coming months, Standard Bearer also anticipates announcing more acquisitions of real estate that will be operated by third-party operators. Collectively, Standard Bearer generated rental revenue of $25.1 million for the quarter, of which $20.7 million was derived from Ensign affiliated operations. For the quarter, Ensign reported $15.3 million in FFO and as of the end of the quarter, had an EBITDAR to rent coverage ratio of 2.5x. And with that, I'll turn the call over to Spencer, our COO, to add more color around operations. Spencer?

Thank you, Chad, and hello, everyone. The incredible results, that we experienced this past quarter and year, were fueled by a combination of innovation and solid growth fundamentals in our more mature operations, along with exciting improvements being made in our newer acquisitions. The first example comes from our same-store category. Victoria Healthcare and Rehabilitation, a 79 bed skilled nursing facility located in Costa Mesa, California, became an Ensign affiliate back in 2003 and it has been a consistent performer every year for the past two decades. The facility's consistency is driven in part by committed, stable leadership. CEO Michael Yuhas has led the facility since completing his AIT program in 2015. And Joyce Camayo, the COO, has been part of Victoria since joining as a frontline RN eighteen years ago. Since then, she has systematically worked through most clinical leadership roles at the facility, including director of nursing. However, despite a legacy of excellence, 2024 was undeniably a breakout year for Victoria. Victoria team grew overall occupancy from an already strong 93% in Q4 of 2023 to 95.9% in Q4 of 2024. And skilled revenue mix increased to an astonishing 75.2% during that same period, an improvement of 420 basis points. This performance was fueled by strong growth both in Medicare and managed care days. Costa Mesa is a highly complex and competitive environment with deep saturation of managed care and hospital-based health plans. Victoria's census growth was only made possible by a consistent achievement of outstanding clinical outcomes. Victoria is currently rated five-star by CMS for health inspections, quality measures, and overall. Even more impressive, despite operating in a very rigorous state regulatory region, Victoria's state survey scores are fourteen times better than the California average. As you would expect, these clinical and occupancy results have led to growth in the business. Revenues increased 14% in Q4 over the prior year quarter and EBIT skyrocketed during that same period. Victoria is a prime example of the ongoing potential in legacy operations that can be kept a strong experienced teams build clinical excellence. Our second example comes from our transitioning facilities group. Boulder Canyon Health and Rehabilitation and Boulder, Colorado is a 140-bed SNF was acquired in 2021. It demonstrates how a turnaround occurs as local leaders apply proven enzyme suppose to their unique and often difficult circumstances. Like many of our acquisitions, as of the transition date, Boulder Canyon was a one-star facility with occupancy below 60%. The facility was losing money and was deeply dependent on nurse nursing agency just to meet basic patient needs. Despite these challenges, CEO Ray Lauritzen COO, Geralyn Lindsey. When do work? They methodically established a culture of love and high achievement. And actively recruited the top clinical talent in their area. They build an impressive leadership team and focused on elevating the experience of the frontline employees. As a result, in 2024, the facility completely eliminated nursing agency use. Despite growing their workforce to care for increased acuity and occupancy. While quality transformations were happening inside the facility, the Colorado resource team worked alongside facility leaders and cluster partners to transform Boulder Canyon's external reputation. Including winning over local hospital systems and key managed care organizations. Recently, one of Colorado's largest narrow network plans added Boulder Canyon as a preferred provider. Based on the changes in the facility's quality metrics, and the trust that they had built working with a sister facility over the years. Today, Boulder Canyon enjoys a newly remodeled physical plant. Great quality metrics, and an overall five-star rating from CMS. Total occupancy for Q4 of 2024 averaged 84.4%, with skilled Medicare days increasing by 70% and managed care days growing by over 200% compared to Q4 of 2023. This stability in labor and growth incentives has resulted in a 23% increase in net revenue and a 131% growth in EBIT over the prior year quarter. And if you ask the team of Boulder Canyon, they're just scratching the facility's potential. With that, I'll turn the time over to Suzanne Snapper to provide more detail on the company's financial performance and our guidance. And then we'll open up for questions. Suzanne Snapper?

Thank you, Victor, and good morning, everyone. Detailed financial for the year and the quarter are contained in our 10-Ks press release filed yesterday. Some additional highlights include the following for the year. GAAP diluted earnings per share was $5.12, an increase of 40.3%. Adjusted diluted earnings per share was $5.50, an increase of 15.3%. Consolidated GAAP revenues and adjusted revenues were both $4.3 billion, an increase of 14.2%. GAAP net income was $298 million, an increase of 42.3%. Adjusted net income was $320.5 million, an increase of 17.2%. For the quarter, GAAP diluted earnings per share was $1.36, an increase of 257.9%. Adjusted diluted earnings per share was $1.49, an increase of 16.4%. Consolidated GAAP revenue and adjusted revenues were both $1.1 billion, an increase of 15.5%. GAAP net income was $79.7 million, an increase of 267.4%. Adjusted net income was $87.6 million, an increase of 18.9%. Other key metrics as of December 31, 2024, include cash and cash equivalents of $464.6 million and cash flow from operations of $347.2 million. During the quarter, the company increased its dividend for the twenty-second consecutive year and paid a quarterly cash dividend of six and a quarter cent per common share. We have a long history of paying dividends. And as the company's liquidity remains strong, we plan to continue its long history of paying dividends due to the future. We also continue to delever our portfolio, achieving a record low lease adjusted net debt to EBITDA ratio of 1.9 times. Our ability to delever even during periods of significant growth is particularly noteworthy and demonstrates our commitment to disciplined growth, as well as our belief that we can continue to achieve sustainable growth in the long run. In addition, we currently have $572 million of available capacity on our line of credit. When we provide with our cash on our balance sheet, gives us over a billion dollars in dry powder for future investments. We also own 134 assets of which 129 are held by Center Bear. And 110 are owned completely debt-free and are gaining significant value over time, even adding more liquidity to the health with future growth. As Barry mentioned, we are providing our annual 2025 earnings guidance between $6.16 and $6.34 per diluted share. Our annual revenue guidance between $4.83 billion and $4.91 billion. We have evaluated multiple scenarios and based on the strength of our performance, and the positive momentum within our occupancy and field mix, as well as the continued progress on agency management and other operational initiatives, they're confident that we can achieve these results. Our 2025 guidance is based on diluted weighted average common shares outstanding of 59.5 million, a tax rate of 25%, the inclusion of acquisitions closed and expected to close to the second quarter of 2025. The inclusion of management's expectations for Medicare and Medicaid reimbursement rates net of provider tax, with this primary exclusion coming from stock-based compensation. Additionally, other factors that could impact quarterly performance include variations in reimbursement system, delays and changes in state budgets, seasonality in occupancy and skill mix, the influence of the general economy on census and staffing, the short-term impact of our acquisition activities, variations in insurance accruals, and other factors. And with that, I'll turn it back over to Barry Port. Barry Port?

Thanks, Suzanne Snapper. As we wrap up, I must reemphasize as I always do how incredibly honored and grateful that we all are to work alongside our operational leaders, field resources, clinical partners, and service center team that are behind these record-setting results. We are completely amazed by their impressive resiliency as they focus on elevating and loving everyone around them. Their collective commitment is truly a blessing. Our future is bright and we're excited for a busy year ahead. And with that, we'll now turn it over to the Q&A portion of our call. Bella, can you please instruct the audience on the Q&A procedure?

At this time, I would like to remind everyone in order to ask a question, press star. Then the number one on your telephone keypad. We will pause for just a moment. To compare the Q&A roster. Your first question comes from the line of Ben Hendrix from RBC Capital Markets. Your line is now open. Please go ahead.

Thank you very much, guys, and congratulations on the results. I just wanted to get your latest thoughts on the Medicaid reimbursement backdrop. Clearly, you guys have had great luck bridging from the COVID era FMAP payments through the end of the public health emergency. But looking forward, are there any specific programs or aspects of programs, supplemental quality and incentive or otherwise that you're exposed to that might be at particularly high risk for cost savings cuts under the new administration versus others? Thanks. Look, you know, it's hard to know exactly where things are gonna go during the reconciliation process and what will actually become a priority with in terms of legislation. I can tell you that you know, we are prepared through our industry association and our lobbyists there to help educate members of congress on any one of the scenarios that might be further explored. Our association has been really nimble and good at having language and legislative options prepared and really just a robust kind of education effort around impacts to the Medicaid program as it relates to seniors. But for us, it's not clear as to what will become a priority. All we can really do is just make sure that we're part of the education process in the meanwhile. We can also, you know, just kinda reiterate what we know about the Trump administration that they're committed to the Medicaid program. He said that publicly. He said it as recently as Friday. As he's committed to the senior industry as well. Senior care industry. So I think having Medicaid be impacted in a broad-based way is gonna be a pretty difficult task for congress during the reconciliation process. But as for now, no. None of our programs are really at risk that we are aware of.

And I would just add, you know, you typically and a Republican control, you definitely usually see lighter regulations. Well, there might be some things on the rate. And so, like, as you stated in the question, we really try to be nimble during these times and really utilize that. So if there's regulatory, you know, relief, there's some flexibility in our operating model with that. And then our involvement at the state level is very deep. From the legislative side as well as to all the associations that we have at each individual.

Thanks a lot. And if I could just follow-up real quick specifically on Tennessee, just given your M&A acquisition there. I just wanna get your thoughts on kind of the overall backdrop both from a Medicaid perspective but also just, what you're seeing on the horizon in terms of opportunities for preferred provider relationships, kinda like what you called out for Boulder Canyon. Thank you.

Yeah. So just taking a step back and looking at the overall Tennessee market that we're new to, obviously, they have and there's a lot of noise in the press just because of all the hospitals. And the larger reimbursement amounts that they receive in Tennessee. Obviously, the amount of supplemental issue is associated with our operations is substantially less than that. And really, it is carried all the way through and approved all the way through. July first of this year. And then they're looking to and working with the legislation there in Tennessee to actually continue that on with the letter portion there as it relates to skilled nursing. But, again, it's not the amount you're seeing with other large hospitals. With regards to networking, obviously, we've been in that state. I think we talked about this when we any anytime we enter a new state, we are doing a lot of preparation. The operator who is kind of had founded that state has been there for a very long time and has established great relationships over this period of time. Not only that individual, but others that we have worked on from the acquisition and others that we actually had as resources in that have great connections out there.

Great. Thank you.

Everybody. First question just to ask maybe a little bit about labor cost trends. What are you seeing there? I know it's been moving more favorable in the last year or so. What do you see as you move into 2025? And is there anything specific around the workforce standards program in California that you're factoring into your outlook and how that might impact just the maybe starting with the general labor environment. We're not seeing massive changes but we're seeing very gradual improvements that continues you know, quarter to quarter recently. We expect that to continue. Some of that's just environmental. You know, the labor markets have stabilized more and more since COVID. And part of it is we're relentlessly working on new ways to attract labor, retain, you know, the best nurses, the best CNA, the best frontline workers, and then also we're looking for leadership development opportunities because there's you know, our business is very locally driven. And if you have a great local leadership that's really the key to having a healthy frontline workforce. And so as we continue to do those things, we think a combination of you know, environmentally, you know, the markets are a little bit better. And as we get better, that bodes well for the 2025.

And the California workforce standard is all baked into the guidance for 2025. We've already included that. We also have is gonna be the second year that we're gonna be going through that program. And so, like, we've got a good handle on expectations associated with that program based upon what the state has published.

Okay. And maybe just a follow the follow-up question be on the deal pipeline. What are you seeing or the terms on the deals that you're doing changing in any way? What is the competitive landscape around acquisitions look like right now? A great question. You know, as we

kinda said in the prepared remarks, we're seeing a lot of deal flow and you know, we actually you know, we've acquired a lot this in the last eighteen months, and we expect to continue kind of on the same pace in 2025. So we've got a lot of deals lined up that will be closing over the next several months. As Suzanne Snapper mentioned earlier, you know, we are seeing some some you know, the ways that, you know, the change of ownership from the state and granting licenses and stuff like that that are you know, really, like, the deals are locked up. We're just waiting to get those licenses. So you'll see us start announcing, you know, more closings over the next few months. In terms of competitive landscape, there are way more deals on our desks than we could ever dream of doing. So we are able to be very, very selective and, you know, we often talk about this disciplined growth and you know, and then that that's a lot of things. You know, making sure we have leaders in the markets, leaders that are ready to go to assume, you know, the responsibility to transition these buildings. That's obviously the first thing, but also the terms of the acquisitions, we're really particular about making sure if it's a lease, that there's plenty of coverage and we're not, you know, stretching and looking at pro forma results and establishing the rents. We're pretty, you know, firm on using the trailing twelve and not paying for performance we're gonna create, and, you know, when we're buying the real estate, you know, we're really, you know, focused on, you know, price per bed and making sure it's in line with kind of what we see as sustainable prices that will allow us to have, you know, the balance sheet that we do. And, you know, you can't grow as quickly as we have over time. And have a healthy balance sheet if you overpay on things. So you know, that's all kind of know, how we look at it. But with all that said, you know, there's many opportunities for us as we're going through that disciplined analysis on deals. You know, we tend to win the deals that we want and that we're ready to move forward with. And expect that to continue. Okay. Great. Thanks.