Thanks for standing by. My name is Mandeep, and I'll be your conference operator today. At this time, I would like to welcome everyone to the Ensign Group, Inc. First Quarter Fiscal Year 2024 Earnings Conference 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, May 31, 2024. We want to remind anyone that may be listening to a replay of this call that all statements made are as of today, May 2, 2024, and these statements have not been or will be updated subsequent to today's call. Also, any forward-looking statements made today are based on management's current expectations, assumptions and 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 more 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 with such subsidiaries. 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…

Thanks, Chad, and thank you, everyone, for joining us today. We're pleased with the continued and consistent performance that our local teams achieved again. After another record quarter, we're excited about the remarkable momentum our teams have created across our entire portfolio and look forward to seeing that continue throughout the year. As strong as our performance has been, we continue to see enormous opportunities inherent in our portfolio, both in existing operations and the growing number of new acquisitions. We were encouraged to see an increase in skilled mix during the quarter, with an increase in same-store skilled mix days of 5.6%, and an increase in same-store skilled mix revenue of 1.9% sequentially, over the fourth quarter. This continued strength in our skilled mix demonstrates the ongoing trend of increasing demand for skilled post-acute services. We are also excited to see same-store occupancy for the quarter reached 81%, which grew by 2.7% over the prior year quarter and surpassed pre-pandemic same-store occupancies, for the first time since first quarter of 2020. While we celebrate this milestone, our same-store portfolio still have an incredible amount of built-in upside as dozens of our most mature same-store operations operate in the 90-plus percent occupancy range. As our operators continue to build on a solid foundation of strong clinical results, cultural excellence and sustainable real estate costs, they will continue to realize the occupancy and skilled mix growth potential inherent in our same-store portfolio, which will allow us to continue achieving the consistent financial results that we have delivered over time without depending solely on acquiring new operations. That said, as you saw in our press release yesterday, we have been busy acquiring new operations and our transitioning and newly acquired buckets now represent over 25% of our total operational beds. We have…

Thank you, Barry. As we expected, we continue to add to our growing portfolio, and we are very excited about the 13 new operations and 6 real estate assets we added during the quarter and since, bringing the number of operations acquired since January 2023 to 39. These acquisitions span 8 of our 14 states and represent a significant opportunity to either strengthen our current clusters, or to establish new clusters and new markets. These new acquisitions include the following new operations, 3 in Tennessee, 1 in Iowa, 2 in Kansas, 1 in Texas, 2 in Colorado, 2 in Utah, 1 in Arizona and 1 in Nevada, totaling 1,216 new skilled nursing beds, 202 senior living units and 43 new LTAC beds. Of these 13 new operations, 6 of them included the real estate assets, which were acquired by Standard Bearer and will be leased to an Ensign-affiliated operator. Each of these additions were all carefully selected amongst the many opportunities available to us, and were chosen because of the huge clinical and financial potential. We continue to prioritize growth in our established geographies as it allows our clusters to work together with their acute care partners, and to provide a comprehensive solution to their healthcare needs. However, we are also excited to build clusters in new states or in markets where we have significant room to add more density. In particular, we are very excited to grow Nevada and to add our second and third operations in Tennessee which, along with the acquisition we completed earlier this year creates our first Tennessee cluster. We are very optimistic about our ability to continue growing in Nevada, Tennessee and the surrounding regions. We are also pleased to see some growth in the Midwest with the additions in Iowa and Kansas, and…

Thank you, Chad, and hello, everyone. Today, I'd like to share two examples that demonstrate how frontline teams throughout the organization are continuing to grow earnings, improve culture and elevate their clinical outcomes. The first facility is Olympia Transitional Care in Washington currently led by director [indiscernible] and Executive Director, Mindey Bradley. When it was acquired back in 2015, Olympia Transitional had low star ratings and a poor clinical reputation, with state regulators and with the local healthcare community. As a result, occupancy especially skilled payers was low, and the facility consistently lost money. Despite the enormous challenges, the local operators who make acquisition decisions recognize the latent potential that the facility had, especially given its discounted purchase price. And over the course of the past 9 years, the Olympia team has pushed relentlessly, transforming the culture of the facility and methodically adding clinical capacity. Today, Olympia Transitional is completely transformed as evident in its CMS 5-star rating for quality measures and overall. The local hospital and health system have embraced the change, and today, the facility actively participates in their ACO, and is a preferred provider for numerous managed care plans. As you'd expect, skilled mix has improved by 227% since acquisition, with a 37% increase since prior year quarter. Since acquisition, revenues have grown by 87%, and the facility has become one of the top EBIT producers in the state of Washington. The second facility example is Berthoud Care and Rehabilitation in Colorado. This operation currently led by COO, Emily McDonough and Executive Director, [ Andy Lafon ], was acquired in 2021 and exemplifies what typically happens in our transitioning category. Notably, this acquisition occurred in the midst of the COVID pandemic and staffing crisis. Yet during the past 3 years, enormous strides have been made. For example,…

Thank you, Spencer, and good morning, everyone. Detailed financials for the quarter are contained in our 10-Q and press release filed yesterday. Some additional highlights for the quarter compared to the prior year quarter include the following: GAAP diluted earnings per share was $1.19, an increase of 13.3%. Adjusted diluted earnings per share was $1.30, an increase of 15%. Consolidated GAAP revenue and adjusted revenues were both $1 billion, an increase of 13.9%. GAAP net income was $68.8 million, an increase of 15%, and adjusted net income was $75.4 million, an increase of 16.6%. Other key metrics as of March 31, 2024, include cash and cash equivalents of $512 million and cash flows from operations of $35.3 million. We also continued to delever our portfolio, achieving a lease-adjusted net debt-to-EBITDA ratio of 1.98x. This deleverage in a period of growth is particularly noteworthy and demonstrates our commitment for disciplined growth, as well as our belief that we can continue to achieve sustainable growth in the long run. In addition, we continue to have approximately $594 million of availability on our line of credit, which when combined with cash on hand on our balance sheet, give us over $1 billion in [ dry powder ] for future investments. We also own 119 assets, of which 114 are held by Standard Bearer and 95 of which are owned completely debt-free, and are gaining significant value over time, adding even more liquidity to help with future growth. In order to give you insight into our transformation of acquisitions, we have presented our skilled nursing operations into three buckets: same, transitioning and recently acquired facilities. You heard Barry refer to these different buckets earlier. And I thought it would be helpful to further explain what we mean when we are referencing to buckets and…

Thanks, Suzanne. As we wrap up, I need to reiterate again how incredibly -- we are to work alongside our facility leaders, field resources, clinical partners and service center team that are behind these record-setting results. We're always impressed by their incredible resiliency as they focus on supporting this mission in new and innovative ways. This commitment has blessed the lives of so many, including our own, and we're excited about our future because of these amazing partners. We have complete faith in them and the culture they have collectively built and continue to improve. So thank you to all of our field leaders and service center partners. And with that, we'll now turn it over to our Q&A portion of the call.

[Operator Instructions] Our first question comes from the line of Ben Hendrix with RBC Capital Markets.

Congratulations on the quarter. Appreciate all the color around the minimum staffing rule and I appreciate that you're not expecting any impact [indiscernible] through on 2024. But next year, it seems like the bit associated with the nurse aid minimum goes into effect. And I know it seems like there would be opportunities there to shuffle some staffing mix to -- especially with your LPN utilization to kind of help offset that. Just wondering mechanically what that looks like, how feasible that is? Is it something that could be done on a financial neutral basis and on a star ratings neutral basis?

Thanks, Ben. It's a good question. Just to be very clear, the staffing ratios that are specific to overall RNs and CNAs wouldn't go into effect for 3 years from when the rule is registered in the Federal Register. So 2025, there would be really no need for us to do any shuffling quite yet either 2026, really the same but that's a year we'd probably start gearing up and preparing and doing a little bit more -- you probably hear a little bit more from us on what we'd be doing in preparation for that to go into effect in 2027. So we don't anticipate doing a whole lot different operationally in the next couple of years other than focusing on the things that we know we can control and get better at, which really include all the different dynamics around labor control and also being an employee-centric kind of customer second environment, where we focus relentlessly on people systems and making sure we've got world-class orientation and training and support for our employees and also focus on eliminating registry as universally as we can, making sure that we're not relying on third-party staffing agencies for any staffing needs. And those are things that we can do a whole lot around to make sure that we're in a really strong and healthy place, when and if, those staffing ratios come into play.

Our next question comes from the line of Scott Fidel with Stephens.

First question, just wanted to talk about the deals you just announced and one nuance of them, and then put it in a longer-term perspective. Which was -- it was interesting how there was a bit of a higher mix of non-SNF beds that you acquired with some IL and AL and then even the LTAC, as Chad talked about. But that could have just been coincidence as well around some of the campuses that you acquired as part of this package. So my question is whether that was more of a coincidence or whether you are now looking to do more expansion in some of those adjacent lines of business outside of just SNF? And then if we do end up in a scenario where the staffing regs actually would go into effect in 3 years, whether that may further sort of influence your thinking on diversifying more beyond skilled nursing into some of those adjacent areas like IL, AL, LTAC and even theoretically IRFs down the road?

Yes. Thanks for that question. So I would say that it certainly wasn't something we set out to do this quarter and acquiring more senior living or independent living beds. We are always looking for what we call consider healthcare campuses, which are primarily skilled nursing operations that happen to have those other offerings on the campus. And I think in every case, that was what was going on. And so from that point of view, no, our strategy really hasn't changed. We've always liked those. We'll continue to seek those. It just happened to be that we had more of those kinds of deals this particular quarter. So I don't think you'll see us look to go acquire lots of stand-alone assisted living and independent living. As again, our focus would be on primarily SNF that has those service offerings on the campus. As for the LTAC, I mean, as I said, we're really excited about that service offering. It's only 43 beds. But operationally, we already operate sub-acutes and very high acuity skilled nursing facilities in many states. And so it doesn't feel very different from a lot of what we already do. There are clear differences though in the regulatory environment, some of the technical aspects of billing with the [ DRG ] kind of coding system and those sorts of things will be new to us. But this is what we call a small bullet type of investment that, again, is part of a larger skilled nursing campus and certainly, hope that it goes really well. And to the extent we -- we can learn that business and show that Ensign operating principles apply and work, which we think they will in a beautiful way that's certainly something we -- like we've done in other cases, right, in other lines of business certainly could expand it both LTAC and IRF, but not saying that, that's like comprise a big chunk of our investment dollar. But it is something that as we learn and get good at, that we certainly can expand into. As for the diversification question, again, I would say that the staffing stuff really, if anything, it probably just creates even more opportunities for -- for us to continue doing what we've done. And so I don't think that, that will impact our overall strategy to the extent we do decide to go down some of these other paths, it will be much more driven by sort of the operational dynamics and the local dynamics in those healthcare markets that -- that are responding to the needs of our acute partners in those areas. That will drive it much more than any sort of regulation would.

Okay. Got it. Next question, just wanted to get, I guess, sort of in the updated guidance, which is obviously reaffirmed, but now you have visibility into the first quarter. How you're thinking about both occupancy and skilled mix as sort of thinking about trending in the second quarter? And then in the back half of the year, just when considering things like historical seasonality, the fact that you have now eclipsed the pre-pandemic same-store occupancy but then you also have over 25% of operational beds in the transitional and new bucket where there's obviously a lot of opportunity to harvest improvements there.

Yes. Great question, Scott. I mean, we obviously feel pretty bullish about our occupancy trends as they've been really strong lately, certainly in the times we'd expect them to be, but even as we are looking at trends now, we feel like demand is really, really strong, and we feel like we've got -- we're poised to -- in spite of seasonality have a pretty strong summer. Certainly, that can change. And as we get into the -- deep into the summer months, we could see a little bit more of a drop off, which is usually more evidenced in our skilled mix. And I think if there is some seasonality to be seen, it will probably be more evident there than it will be in our overall occupancy, which might just go sideways for a little while. But as is typical, that should start picking up as we get it late into the third quarter and then starting into the fourth quarter. But we don't anticipate anything unusual or abnormal. And nor do we feel like getting to pre-pandemic occupancy as some kind of artificial ceiling or target, our expectation is that we continue to grow and we -- the trends that we've seen are great indications of that.

And I would add, Scott, that when you kind of look at the guide, really on the low end of the guide, we've factored in a higher level of seasonality and then kind of moving up the guide would be less seasonality, as Barry was talking about. And so as we continue to have the year play out, that seasonality aspect of historically having lower occupancy lower skilled mix in Q2, Q3 would really play into that lower end of the guide. And as -- if we end up experiencing better seasonality, less seasonality in other words, we would kind of guide to the high end of the guide with that. And it's -- right now, we feel pretty strong about where we're at in the less seasonality than we've experience historically right now in the quarter.

Okay. Great. And then I'm going to just sneak one more question here, and that would be around -- if you could update us on the visibility that you feel you have now into rates over the course of the full year? It seems like the rate backdrop has developed pretty favorably for '24 when we think about the rebasing that have gone on in Medicaid in a number of key states and then we already do have visibility into the proposed FY '25 rates for Medicare coming in a little bit over 4%. But maybe just sort of help us fill us in, in terms of the overall picture and any sort of emerging insight that you have into FY '25 Medicaid rates. I know it's early here, but just any visibility would be helpful.

Scott. So just one reminder, when you're looking at the numbers in our rate tables. Remember that if you're going to compare last year to this year, last year's numbers would not include the FMAP dollars. And so you're going to see some pretty big increases in those rate tables that might not look like they're translating into the overall impact. But what we feel about the current year's rates is that they're very strong, very solid. As you mentioned, the Medicare rate came out. We're very pleased with where that came out as a preview. I'm excited to have that come in. That doesn't come in until the beginning of Q4. So October 1, everything else is really panning out to be pretty nice overall, really having all of those states as we were talking about through all of 2023, really roll those FMAP dollars into the underlying rates. States did in a very different way, some built it into the base rate, some put it into supplemental -- some put it into supplemental programs, including quality programs. But we're very, very pleased with where everything landed. I mean, that's why you see those large jumps when you look at our rate table is because now they're included in base rate, which is way more stable for us and create long-term visibility for us, to continue to be successful.

That concludes today's Q&A session and today's conference. You may now disconnect.