The Ensign Group (NASDAQ:ENSG) told investors at Oppenheimer’s 36th Annual Healthcare MedTech & Services Conference that it exited the fourth quarter with what management described as broad-based operational momentum, improving labor trends, and an active acquisition environment—though pricing has moved higher. CEO Barry Port was joined by Chief Investment Officer Chad Keetch, Flagstone President Adam Willits, and Chief Accounting Officer Suzanne Snapper for a wide-ranging discussion covering 2026 guidance, deal activity, occupancy and acuity trends, reimbursement and regulation, and the company’s real estate strategy through Standard Bearer.
Operations: occupancy gains and easing labor pressure
Port said the company was “pretty pleased” with consistency of execution across the year, pointing to occupancy growth that was not limited to a few markets but spread across all markets. He also cited continued improvement in labor fundamentals, including better wage inflation trends and improving retention and turnover.
2026 guidance: growth outlook and key assumptions
Snapper said the company is “really excited” about its 2026 guidance and characterized it as healthy and achievable based on historical performance. From the midpoint of guidance, she said Ensign is targeting approximately a 15% increase in revenue and a 14% increase in EPS.
On the revenue drivers behind the outlook, management discussed occupancy, mix, and rate expectations. Snapper said that in 2025 the company saw its highest occupancy and skilled mix in same-store, and cited a strong summer-month occupancy gain that was about 90 basis points stronger from Q2 to Q3 compared with the prior year’s entry into summer. She said the company expects similar growth in 2026.
Snapper outlined expected organic growth across Ensign’s three operating “buckets”:
- Same-store: 2% to 4% revenue growth
- Transitioning: 4% to 5% revenue growth
- Recently acquired: 9% to 10% revenue growth
On rates, Snapper said Ensign anticipates continued increases in line with prior years, citing single-digit growth in Medicare and Medicaid. She also said the company expects a similarly constructive wage environment in 2026, along with control of agency costs, overtime/double time, and continued lower turnover—trends she said were already visible in the first two months of 2026.
Keetch added that the guidance does not assume acquisitions. He noted that while acquisitions can lift revenue, large turnaround-heavy deals can sometimes be a drag on EPS.
Acquisitions: higher pricing, more supply, and leadership capacity
Port said pricing has increased and that sellers appear to be finding the environment attractive, contributing to more opportunities coming to market. He described the current task as “sifting through” numerous potential deals to find those that fit strategically.
As an example, Port referenced Ensign’s Utah Stonehenge acquisition, describing it as “pretty pricey” relative to historical price per bed, but said the deal was performing well only a few months after closing. He argued that higher prices can sometimes be justified, particularly when real estate is included and assets are newer or higher quality, and noted that investors may not always see the capital expenditure required to rehabilitate older physical plants.
On capacity to execute deals, management emphasized the importance of local leadership. Port said Ensign had 60 administrators-in-training (AITs) in its pipeline “as of yesterday,” spread across the company, after what he described as a year with nearly 50 acquisitions. He said the first question on any deal is who will lead it, and that leadership depth is a primary constraint on growth. Port also said the company continues to attract recruits, adding that Ensign’s existing team serves as its best recruiting channel.
New geographies, limited new supply, and reimbursement/regulatory themes
Willits provided integration updates on recent activity, including 17 acquisitions in California—highlighting an 11-building Covenant Care transaction that expanded Ensign into California’s Central Valley. He said early census gains and earnings performance in that geography had been strong. Willits also said Ensign entered Alaska through a Providence Health & Services portfolio that included an assisted living facility and a skilled nursing facility, and described census and earnings performance in the first 10 months as “remarkable.” He also cited expansion in Oregon and Washington through the Providence portfolio and continued growth in Tennessee, with strong occupancy, earnings, and regulatory performance.
Port said Ensign’s approach to larger deals is to break them into “bite-sized pieces” using local leadership, and said the company is confident it can replicate that model outside California. He identified the Southeast as a focus area and said Florida, Georgia, and North Carolina are states Ensign “wouldn’t be surprised” to enter within the next couple of years, while emphasizing that new-state entry requires trusted Ensign leadership on the ground.
On longer-term fundamentals, Port pointed to demographics and said Ensign is likely at “the doorway” to tailwinds that may show up as a steady, consistent benefit rather than a single step-change. He cited expectations that the 80+ population will triple over the next three decades, while the caregiver ratio declines by 40% over that same period. Management also said it does not see meaningful new skilled nursing construction, and suggested bed supply may be shrinking rather than growing, particularly in highly regulated states such as California.
On reimbursement and regulation, Port said the company has “pretty good visibility” into state rates through the end of 2027, while acknowledging risks tied to state Medicaid budgets. He said Ensign is working to be in state-level discussions, including with governors’ offices, and argued that cutting skilled nursing funding for seniors is politically unpopular. Port also said Ensign was “built for times of uncertainty,” citing prior transitions in payment systems and the ability of operators to adjust to headwinds. He referenced Idaho as an example where a Medicaid decrease was reflected operationally even as the legislature later voted against it, saying the company’s leaders adjusted without skipping a beat.
In California, Willits addressed the WQIP program and said it is not currently in the 2027 budget, but that Ensign is lobbying to restore it, including partnering with SEIU and other stakeholders and conducting more than 100 legislative visits. He said the state deficit that influenced prior cuts has improved due to tax revenues, increasing the chance of reinstatement. Snapper noted that Ensign’s 2026 numbers still include a full year of WQIP revenue and said the company expects California to continue using value-based frameworks, though there may be a gap period before a replacement program is implemented.
Port also discussed Standard Bearer, describing Ensign’s real estate portfolio as a strong collection of skilled nursing assets and emphasizing that facility value is closely tied to operational quality. He said Ensign prefers to own and operate real estate when possible, followed by long-term lease-and-operate structures, and lastly owning and leasing to third parties. As an example, he described using Standard Bearer in the Providence deal to buy a portfolio where some assets were not a fit for Ensign operations, and leasing those assets to a third party.
Closing the discussion, Port said investor concerns about regulation may be “overblown,” arguing that while skilled nursing is highly regulated, Ensign was built within that environment and sees broad-based support among policymakers. He suggested that over time the sector has been treated with relative consistency despite periodic “ups and downs,” and said Ensign’s model is designed to operate through those fluctuations.
About The Ensign Group (NASDAQ:ENSG)
The Ensign Group, Inc is a diversified provider of post-acute healthcare services in the United States, operating a network of skilled nursing, assisted living, independent living, home health and hospice care centers. The company’s model emphasizes integrated care by employing multidisciplinary teams—including nursing staff, therapists and physicians—to deliver personalized rehabilitation and long-term care services for seniors and other patients recovering from injury, illness or surgery.
Through its owned and managed centers, The Ensign Group offers a broad spectrum of rehabilitation services such as physical, occupational and speech therapy.
