The Ensign Group - Earnings Call - Q1 2025

Executive Summary

• Q1 2025 delivered record operational KPIs and a revenue beat, with total revenue of $1.173B, slightly above consensus, while GAAP diluted EPS of $1.37 missed consensus; adjusted diluted EPS was $1.52. Consensus: EPS $1.49*, Revenue $1.172B*.
• Management raised FY 2025 guidance: EPS to $6.22–$6.38 (from $6.16–$6.34) and revenue to $4.89–$4.94B (from $4.83–$4.91B), citing faster-than-expected contribution from new operations and strong occupancy/mix trends vs prior guidance.
• Same-store and transitioning occupancy hit new highs at 82.6% and 83.5%, respectively; skilled mix and managed care days improved across cohorts, supporting margin trajectory and multi-quarter momentum.
• Liquidity remains robust: $282.7M cash and $572.1M undrawn revolver; Q1 operating cash flow was $72.2M as the company deployed >$190M into real estate/operations and completed a $20M buyback; dividend $0.0625 was paid, continuing a 22-year increase streak.
• Near-term stock reaction catalysts: raised FY guidance, revenue beat, accelerating occupancy/mix, plus policy commentary (Medicaid and staffing rules) that management views as manageable given advocacy and portfolio mix.

What Went Well and What Went Wrong

What Went Well

• Record quarter across KPIs: “operators set several all-time highs,” with same-store and transitioning occupancy reaching 82.6% and 83.5%; skilled daily census up 7.6% and 9.9% YoY; managed care census up 8.9% and 15.6% YoY.
• Raised FY 2025 guidance (EPS to $6.22–$6.38; revenue to $4.89–$4.94B) on faster-than-expected contributions from newly acquired operations and strong operational momentum.
• Standard Bearer growth: rental revenue $28.4M (+27.9% YoY), FFO $17.1M (+21.1% YoY); added 13 owned properties in/around the quarter, reinforcing diversified earnings and real estate accretion.

Quotes:

• “We are thrilled to announce another record setting quarter… our results this quarter demonstrate that we’ve never been stronger” — CEO Barry Port.
• “We are raising our annual 2025 earnings guidance… [and] increasing our annual revenue guidance” — CEO Barry Port.
• “We continued our steady pace of growth by adding 19 new operations… across 8 states” — CIO Chad Keetch; call detail: 1,906 SNF beds and 200 senior living units added.

What Went Wrong

• EPS miss: GAAP diluted EPS of $1.37 fell short of consensus EPS $1.49*, though adjusted diluted EPS was $1.52; revenue slightly beat.
• Non-operating headwind: other income net declined YoY to $5.2M from $7.4M, partially offsetting operating gains; rent expense increased given portfolio growth.
• Policy overhang persists: investor concern around potential Medicaid-related changes and federal staffing minimums; management engaged in advocacy but flagged reconciliation timelines extending through July.

Transcript

Operator (participant)

Thank you for standing by. My name is Kate, and I'll be your conference operator today. At this time, I would like to welcome everyone to the Ensign Group First Quarter FY 2025 earnings conference call. All lines have been placed on mute to prevent any background noise. After the speaker's remarks, there will be a question-and-answer session. If you would like to ask a question during this time, simply press Star, followed by the number one on your telephone keypad. If you would like to withdraw your question, press Star one again. Thank you. I would now like to turn the call over to Mr. Keetch. Please go ahead.

Chad Keetch (CIO, Executive VP, and Secretary)

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 Saturday, May 31, 2025. We want to remind anyone that may be listening to a replay of this call that all statements made are as of today, April 30, 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, 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 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, which is a captive real estate investment trust that invests in healthcare 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 and its consolidated subsidiaries. All of our independent subsidiaries, the service center, 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 words we, us, and our in similar terms, are not meant to imply, nor should it 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 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-Q. With that, I'll turn the call over to Barry Port, our CEO. Barry?

Barry Port (CEO)

Thanks, Chad, and thank you, everyone, for joining us today. We are thrilled to announce another record-setting quarter achieved by our local teams. In spite of all the industry noise, our results this quarter demonstrate that we've never been stronger, showing yet again that sound fundamentals, coupled with an incredible passion, can forge consistency even in an ever-changing environment. Our operators set several all-time highs during the quarter, which are only made possible by strong clinical outcomes achieved by our dedicated team of caregivers and frontline staff. During the quarter, we saw substantial growth across all of our buckets and in almost every market we serve. More specifically, we achieved an all-time high in same-store and transitioning occupancy, which increased to 82.6% and 83.5%, respectively, over the prior year quarter.

We also saw skilled census increase for both our same-store and transitioning operations by 7.6% and 9.9%, respectively, over the prior year quarter. In addition, our managed care census grew by 8.9% and 15.6% for our same-store and transitioning operations, respectively, over the prior year quarter. All of these improvements are the result of many factors, including the relentless efforts by our local leaders to share and implement best practices that lead to stronger outcomes and earn the confidence from our residents, acute care partners, ACOs, and managed care networks. While the quarter was strong, we were even more excited about our results because they were achieved while simultaneously adding 47 new operations since January of 2024 across almost every market we serve, some of which are already performing at or above our expectations.

The combination of improvements in occupancy and skilled mix in our more mature operations and the long-term upside in our newly acquired operations shows the enormous organic growth potential in our existing portfolio. We continue to attract and develop caregivers and leaders and are building a formidable bullpen of caring and passionate partners who are determined to live our mission to dignify post-acute care. In addition, we continue to see improvements in turnover and limited use of agency staffing labor, all of which are critical to maintaining our cultural values and continuity of care. After such a strong first quarter, including some faster-than-expected contributions from some of our newly acquired operations, we are raising our annual 2025 earnings guidance to between $6.22 and $6.38 per diluted share, up from $6.16 to $6.34 per diluted share.

The new midpoint of this increased 2025 earnings guidance represents an increase of 14.5% over our 2024 results and is 32% higher than our 2023 results. We're also increasing our annual revenue guidance to $4.89 billion-$4.94 billion, up from $4.83 billion-$4.91 billion, to account for our current quarter growth and acquisitions we anticipate closing during the first half of 2025. We are excited about our start to the year and are confident that our partners will continue to manage and innovate while balancing the addition of newly acquired operations. We are eager to continue to drive organic improvements and take advantage of the acquisition opportunities that we see on the horizon. When we consider the current health of our organization combined with our culture and proven local leadership strategy, we are well-positioned to continue executing our operational model.

With all that said, we see so much more room for further improvement, and we continue to optimize operational efficiencies, expand services, and create new partnerships, all of which will drive further improvements in occupancy and skilled mix. We look forward to continuing to build on the momentum from the first quarter into the rest of the year as we continue to successfully unlock value and opportunity in the dozens of recently acquired operations. This performance is not due to some large event or 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 a commitment held by all of our partners to expand our mission in a methodical and thoughtful way. Next, I'll ask Chad to share some additional insights regarding our recent growth. Chad?

Chad Keetch (CIO, Executive VP, and Secretary)

Thank you, Barry. We continued our steady pace of growth by adding 19 new operations, including 8 real estate assets, during the quarter and since. These include the following: one in Alabama, one in Oregon, one in Washington, one in Texas, two in Alaska, two in Arizona, three in California, and eight in Tennessee. In total, we added 1,906 new skilled nursing beds and 200 senior living units across eight states. This growth brings the number of operations acquired during 2024 and since to 47. We are very excited to add density to one of our newest markets in Tennessee and to add our first operation in Alabama. When we enter into new states, we tend to see an uptick in opportunities in those geographies. We are seeing more opportunities to deepen our presence in the Southeast and expect to do so over time.

We're also excited to grow in Oregon and Alaska for the first time. As with our other new states, our entrance into these new markets has been driven by proven Ensign leaders who are committed to and have a connection with the new geography. As we have seen and said before, when we go into a new state, we typically look to start with one or two buildings so we can establish a solid launching point for more growth. This has played out time and time again, with our most recent example being Tennessee. These footholds eventually lead to growth into multiple clusters, which will eventually comprise a sizable market. We look forward to bolstering our presence in those markets over time.

In the meantime, we continue to prioritize growth in our established geographies as it allows our clusters to provide a comprehensive solution to the healthcare needs in those markets. While we 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 those 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 the local cluster partners to implement the transition plans. While our pace of growth remains 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. Our local leaders continue to recruit future CEOs for Ensign-affiliated operations, and we have a deep bench of CEOs in training that are eagerly preparing for an opportunity to lead. We still see evidence that many operators in this industry are struggling, and we expect the operating environment will translate into many near-term and long-term opportunities to both lease and acquire post-acute care assets. However, we do not set arbitrary growth goals and will remain true to our disciplined acquisition strategy. We only grow when we have the right leaders in place and the pricing is right.

The scalability of our growth model, our healthy balance sheet combined with numerous opportunities you see in our existing footprint give us enormous potential to continue to apply our proven acquisition and transition strategies in 2025. We anticipate the current rate of acquisitions to continue this year and remain committed to staying true to the proven deal criteria that has allowed us to grow in a healthy and sustainable way. We continue to see more opportunities to acquire new operations, and our focus is to carefully choose the acquisitions that will be accredited to our shareholders both in the near and long term. We are also providing additional disclosure on Standard Bearer, which added 13 new assets during the quarter and since and is now comprised of 137 owned properties. Of these assets, 104 are leased to an Ensign-affiliated operator, and 34 are leased to third-party operators.

Going forward, Standard Bearer will continue to work together with its operating partners at Ensign to acquire portfolios comprised of operations that Ensign would operate and facilities that third parties are interested in operating under a lease. Collectively, Standard Bearer generated rental revenue of $28.4 million for the quarter, of which $23.9 million was derived from Ensign-affiliated operations. For the quarter, Standard Bearer reported $17.1 million in FFO as of the end of the quarter and had an EBITDA to rent coverage ratio of 2.6 times. With that, I'll turn the call over to Spencer, our COO, to add more color around operations. Spencer?

Barry Port (CEO)

Thanks, Chad, and hello, everyone. Today, I'm excited to share two facility examples that illustrate the consistent operational momentum that we are seeing as local teams continue to respond to stakeholders in their communities. I hope that these real-life examples can help explain why we feel so encouraged by our Q1 results and confident in the ability of our model to continue to produce exceptional results going forward, regardless of the external forces or challenges that may exist. The first example comes from our transitioning bucket, Lomita Post-Acute Care Center, located in the Los Angeles, California area, and led by Executive Director Kyle Armstrong and Director of Nurses Carla Lomfueco. This 68-bed skilled nursing facility was acquired during Q1 of 2023. During the recently closed quarter, Lomita saw revenues increase by 17.7% and EBIT improve by an impressive 86.4% compared to Q1 of 2024.

Over the same period, occupancy grew by 2%, but the bigger story was the facility's strategic growth in skilled mix. For example, Medicare days increased by 19.8%, and managed care days grew by 85.7%. This growth in skilled census was made possible by the facility's commitment to quality, which is evident in it being the only skilled facility in its geography that carries a five-star quality measures and five-star overall rating from CMS. The five-star ratings have given the Lomita team strong credibility with the health plans, the hospitals, and discharging facilities in their area. Another major factor in Lomita's financial success has been their ability to improve the continuity of care and reduce labor costs through improved staff retention. During Q1, Lomita reduced its caregiver turnover by 36% compared to prior year quarter. This workforce stabilization directly decreased onboarding and overtime costs and, in turn, increased EBIT margin.

Most importantly, it's resulted in a healthy work environment where caregivers can trust their coworkers, build clinical competency, and achieve great healthcare outcomes for the residents they serve. The second facility highlight I want to share represents the exciting same-store growth that continues to occur in facilities that have been part of the organization for a long time. Copperfield Healthcare and Rehabilitation in Houston, Texas, is a 124-bed SNF that was acquired in 2016. During the period following transition, Copperfield made steady clinical and financial progress. However, during the past year, the facility has truly transformed into the community's facility of choice under the leadership of Ruhi Kapur, CEO, and Wanda Preston, Director of Nursing. For example, in Q1, Copperfield averaged 90.7% occupancy, an increase of 11% over prior year quarter. To give some context, the average occupancy for non-affiliated SNFs in the state of Texas is under 64%.

During that same period, skilled Medicare days grew by nearly 43%, while the already healthy managed care census improved by 14.8%. As you would expect, there's a clinical story behind the strong increases in skilled mix that Copperfield has achieved. In a medical hub like Houston, health plans and hospital systems demand quality from their post-acute partners, and Copperfield's ability to maintain CMS five-star quality measures and overall ratings has provided the facility access to contracts that are close to most providers. Notably, many of the Medicare lives in Houston are now being managed through ACOs, which means that the hospital systems can be at financial risk if the patients they discharge have poor health outcomes or have to return to acute hospitals.

Similarly, managed care plans in the area have narrowed their networks and are guiding their members needing post-acute care to providers like Copperfield that score high on quality outcomes. As acuity has increased, Copperfield's multidisciplinary clinical team has partnered with and even received training from their acute hospital partners, which has empowered Copperfield to confidently care for patients with medical conditions and equipment that would overwhelm most SNF-level care teams. As demonstrated by both Lomita and Copperfield, it's a very exciting time to be in post-acute care. There continues to be strong demand for quality care, and as facilities like Lomita and Copperfield demonstrate clinical competency and willingness to partner with hospitals and health plans, they are rewarded with higher occupancy, improved payer mix, and the ability to provide life-changing outcomes for more and more patients and staff.

With that, I'll turn the time over to Suzanne to provide more detail on the company's financial performance and our guidance, and then we'll open up for questions. Suzanne?

Suzanne Snapper (CEO)

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 include the following: GAAP diluted earnings per share was $1.37, an increase of 15.1%. Adjusted diluted earnings per share was $1.52, an increase of 16.9%. Consolidated GAAP revenue and adjusted revenues were both $1.2 billion, an increase of 16.1%. GAAP net income was $80.3 million, an increase of 16.6%. Adjusted net income was $89 million, an increase of 18%. Other key metrics as of March 31st include cash and cash equivalents of $282.7 million and cash flow from operations of $72.2 million. During the quarter, we spent more than $190 million to execute our strategic growth plan, most of which has been in the works for months.

We made this investment from a position of strength, as shown by our latest adjusted net debt to EBITDA ratio of 2.13 times after taking these investments into consideration. Our continued ability to maintain low leverage, 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 approximately $572 million of available capacity under our line of credit, which, when combined with cash and investments on our balance sheet, gives us over a billion dollars in dry powder for future growth. We also own 143 assets, of which 137 are held by Standard Bearer and 119 are owned completely debt-free and are gaining significant value over time, adding even more liquidity to help with future growth.

The company paid a quarterly cash dividend of $0.0625 per common share. We have a long history of paying dividends and have increased the annual dividend for 22 consecutive years. In addition, as one of our many ways to deploy capital, we recently completed a $20 million stock repurchase program we believe at attractive prices. As we've done in the past, we'll always consider stock repurchases when we feel the market is undervaluing our shares. As Barry mentioned, we are increasing our annual 2025 earnings guidance to between $6.22-$6.38 per diluted share, and our annual revenue guidance to $4.89 billion-$4.94 billion.

We have evaluated multiple scenarios, and based on the strength in our performance and positive momentum we have seen in occupancy and skilled mix, as well as the continued progress on labor, agency management, and other operational initiatives, we have confidence that we can achieve these goals. Our 2025 guidance is based on diluted weighted average common shares outstanding of approximately $59.5 million, a tax rate of 25%, the inclusion of acquisitions closed or expected to be closed through the second quarter of 2025, the inclusion of management's expectations on Medicare and Medicaid reimbursement rates, and the provider tax, with the primary exclusion coming from stock-based compensation.

Additionally, other factors that can impact the quarterly performance include variations in reimbursement systems, delays and changes in state budgets, seasonality in occupancy and skilled mix, the influence on our general economy and census and staffing, the short-term impact of our acquisition activities, variations in insurance and close, and other factors. With that, I'll turn it back to Barry. Barry?

Barry Port (CEO)

Thanks, Suzanne. As we wrap up, we can't emphasize how, again, incredibly honored and grateful we are to work alongside our operational leaders, our field resources, our clinical partners, and our service center team that are behind these record-setting results. We never cease to be amazed by their impressive resiliency, innovation, and passion. Their 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 in the culture that they have collectively built. Now we'll take some questions. Kate, can you instruct us on the Q&A procedure?

Operator (participant)

At this time, I would like to remind everyone, in order to ask a question, please press star and then the number one on your telephone keypad. We will pause for just a moment to compile the Q&A roster. Your first question comes from the line of Ben Hendricks with RBC Capital Markets. Please go ahead.

Ben Hendrix (Analyst)

Great. Thank you very much, guys. Thank you for the color on Lomita and Copperfield. I wanted to follow up on a couple of points there, specifically the comments you made around managed care contracting and the narrowing of networks. Maybe you can give us an overview of what you're seeing broadly in terms of the appetite for value-based and outcome-based contracts and how that's helping you guys gain a little confidence in supporting this guidance raise. Thanks.

Spencer Burton (COO)

Great question. We really have had a long history of this. Managed care isn't new to us. I think a lot of others might have shied away from managed care, but we've embraced it from the get-go. I think when you really try and strive to have partnerships with the MCOs and create a different level of relationship locally because we have local leadership, it allows us to have a different connection to them and allows us to actually drive and create the ability to have success together with them. I think those examples that Spencer shared are really just what we're trying to do throughout the organization of having that partnership at a deeper level for us to make it a win-win for both the MCO as well as our local facilities. As we go through that, that's how it works.

It's really that discussion at the local level, how can we help each other really get their members, our patients, in a better spot clinically? When you go with that clinical focus, the financial return usually typically comes along with that. That's what we strive for, and having those relationships continue to develop and enhance with our resources from the managed care team and the SGR team really pushing on that, as well as that local partnership with the facilities.

Barry Port (CEO)

Yeah. I think just to add a tiny bit more color on that is that what's important is that you combine all of that, the relationships, the drive, the understanding of the market and the environment with a sophisticated back office that allows leaders to see real-time metrics and share some of those metrics with their partners and work in collaboration with them to achieve the outcomes for the members that they're driving and hoping for. It creates an opportunity where you have a partnership between local leaders and those managed care plans that ultimately drives volume because of their ability to take a sicker patient profile and achieve what's expected.

Ben Hendrix (Analyst)

Great. Thank you for that. In light of the guidance raise, we just get lots and lots of questions on your positioning against policy. Forgive me for the requisite policy question, but just how are you guys? What are your latest thoughts on what could come out of Washington, how you're positioned, and specifically around the potential for supplemental Medicaid cuts? Thanks.

Barry Port (CEO)

Yeah. No problem. We're totally transparent and open about our thoughts on this. We are approaching this in very much the same way we did with the staffing minimum issue that we've dealt with over the last year or so, which is to say that we are actively involved in the advocacy process. I've personally met with leadership in both the House and the Senate. Our association has been enormously efficient and effective at setting up meetings to educate members of Congress and help them understand the implications of any potential changes or discussions around certain funding aspects, whether it be provider tax-related or directed payments to states. They've been great meetings.

There's been some light bulb moments where we've had members of Congress come into a new understanding of how some of these programs that have been around for 30-plus years that are CMS-approved every rate cycle, how they work and why they work the way they do. There's certainly opportunity for change in the Medicaid program, and we know that and they know that. Our approach right now is to make sure they're fully educated and understanding of what's good for funding to the industry and what is potentially harmful because they don't always necessarily see how everything trickles down and functions, and they've been incredibly receptive. I'd highlight that President Trump has been very direct about his both view of the Medicaid program and his protection of it. I think members of Congress are hearing that loud and clear.

As we sit here today, what we feel like as far as the direction things are headed is that there's more of a focus on the expansion population. Even news you heard about yesterday on per capita caps and other ideas are all primarily targeted towards the expansion population and not who the original recipients of the Medicaid program were intended for. That's what we see. The trends, at least in the last week or two, are positive. This won't be done soon. The reconciliation process will probably continue through July at least, and we'll continue to stay very active and involved in the process and make sure that we continue to make sure our voices are heard on all of these issues.

Spencer Burton (COO)

Just as an add, as you remember, we were not a big beneficiary of that expansion population. So that part of it bodes well for us if that's the continued focus.

Ben Hendrix (Analyst)

Thanks, guys.

Operator (participant)

Your next question comes from the line of Tauchi with Macquarie Capital. Please go ahead.

Thank you. Good morning. First question. The $200 million investment spent this quarter sets a record in company history. I think it was mainly from one health system seller. There was another billion-dollar portfolio transaction in February. Are you seeing any changes in deal volume, market dynamics, or any seller mentality changes? In other words, how sustainable do you think the current pace of investment is in the next 12 months? If you could comment on kind of the mix between real estate versus lease deals in your investment pipeline.

Barry Port (CEO)

Yeah. Thanks, Tal. It certainly was a strong quarter from a perspective of putting capital to work, for sure. In terms of the deal flow, I would say it's really just a continuation of what we've seen over the last year to 18 months, and that's just a lot of stuff for sale all the time. There are more deals out there than we could ever do. As I said in my prepared remarks, we're sticking to our principles and our disciplined approach there and remain very selective in the deals that we underwrite and ultimately consummate. The $200 million-ish in investment in the quarter was mostly driven by the fact that a lot of our deals were real estate.

As you know, and those that have been following us know well, if we have a wish list, our first desire would be to own the real estate and operate it with an Ensign-affiliated operator. Our second priority would be to enter into a lease and have an Ensign-affiliated operator operate it. The third would be to buy the real estate and then have a third party enter into a lease with our real estate entity. I think the deal flow, and as you look through our press release, you'll kind of see how those priorities lay out. This particular quarter, there was more real estate than I would say is usual, but we're always trying to achieve that.

Certainly, our cash position and the amount of liquidity we have from, as Suzanne mentioned, our revolving line of credit, we have tons of dry powder to continue on that pace. I will say that the deals that we have for the remainder of the year, at least the ones that we have visibility into right now, are probably more lease-focused than real estate. Again, we're just opportunistic about how that mix plays out. Certainly excited about the opportunities that are in front of us. The real focus and the real question is making sure that we have a leadership pipeline that's ready to go to take on these operations. That still remains kind of our most important, I guess, limiter on growth is talent, less so on capital.

Ben Hendrix (Analyst)

Appreciate the comment. My second question is on staffing. Your portfolio outcome is at a record high. I think it's 200 basis points above pre-pandemic levels. Skill mix is also higher than 2019. If we look at nursing facility jobs broadly, they haven't fully recovered, and there are intense competitions with other healthcare settings, particularly for skilled staff. I'm wondering if you could comment on, number one, whether there are skilled staffing constraints or pressure points that limit admissions, particularly around skilled patients. Second, where do you think outcomes need to be when we will see accelerating operating leverage, assuming it is not a linear relationship?

Barry Port (CEO)

Yeah. It's a great question, Tal. From a macro perspective, certainly, when you look at the amount of workers that left our sector during COVID, our sector itself has not fully recovered yet. There are fewer workers in post-acute care than there were, and specifically skilled nursing care than there were prior to the pandemic, while all other sectors have recovered and then some. That said, we're probably an anomaly when it comes to that. Our recovery, while I would never say it's always completely finished, we're somewhere near pre-pandemic levels in agency staffing. Our turnover is consistently improving. Our pace of wage inflation has moderated to pre-pandemic levels.

We, and I say we, referring to our operators and leaders in the field, have been very successful at staying ahead of the curve when it comes to finding talent and recovering enough to be able to do what they've been doing, which is to continue to see occupancy rise without any compromise in how they staff. They've been able to fill positions in order to do so. We have a high level of confidence that they'll continue to be able to remain on that path without having to compromise in some way by adding agency staffing. We feel confident in that just in seeing what the trends have been over the last many months, which is to say that agency staffing continues to decrease while our overall occupancy continues to increase. You are right to point out that the demand is there.

I wouldn't say we're limiting admissions because of staffing, because our leaders have found ways to fill positions and keep the flywheel moving.

Ben Hendrix (Analyst)

If I may, just on the second part of my question, I know that some senior living operators, they call 85% occupancy kind of a magic number where they will see increasing operating leverage. I mean, are you seeing is there a magic number in skilled nursing in your experience?

Barry Port (CEO)

No. No, we do not see some magic number. In fact, I think we see the organic upside as something that has always been an opportunity that we have been deliberate in explaining to folks that even if we had to stop growing through acquisitions because of pricing or leadership concerns, we see facilities with all of that upside to take advantage of that could keep our growth moving for several years even. No, we do not see a cap. We do not see a sweet spot. We see facilities that continuously move. If you were to take our same store operations and examine them closely, you would see a pathway or a movement kind of to higher and higher occupancy over many, many, many years. That is why we have that confidence because we see how that has played out over the course of our history.

Spencer Burton (COO)

Yeah. On the leveraging question, I think we have seen kind of that stability. I think during COVID, we were playing catch-up. First was trying to add for agency. Second was then trying to right-size where the wages were at on an individual basis. I think you saw that through last year. All of our commentary through last year was, "Hey, we're still having to have we're running after wages." This year, what we're saying is that we see stability now. I think stability after stability becomes the ability to leverage on the leveraging points. I would say right now we're in stability phase, and then I think there's an ability for us to continue to leverage, especially if there's recession, right?

One of the things that happens for us is when there's recession, we definitely see more opportunity on the nursing front and other things where people come back into the workforce, which creates even more leverageability, and that costs us service money.

Ben Hendrix (Analyst)

That's super helpful. Thank you.

Operator (participant)

Your next question comes from the line of AJ Rice with UBS. Please go ahead.

A.J. Rice (Analyst)

Thanks. Hi, everybody. Maybe just first to ask about a little further on your deal activity. It seems like your enthusiasm level for what you're seeing in the pipeline and all is even a little increased. I wonder two aspects to that. Is the competitive landscape from your perspective, who you're seeing when you're looking at properties, is it somehow easing? Are you seeing a little less competition for deals right now? You mentioned moving into some new markets, particularly I noted the Southeast. I know the payment rates are generally for Medicaid lower down there, but the labor rates are also lower. Can you get the same economics in some of those newer markets that you've gotten historically in some of your more established markets?

Barry Port (CEO)

Yeah. Great question. In terms of the competition for deals, I would tell you that we haven't really seen that change. It's kind of the same usual suspects that we keep bumping into. Most of that, I would say, is probably private equity and other sort of family-based funds and groups like that that are frequently looking to buy in our space. This last deal that involved eight buildings in the Northwest as an example, that was a process that the Providence Health System was very, very selective in choosing who the buyer would be. Of course, the economics were part of it, but they did several interviews and came to tour our buildings and met with our leadership team.

They selected us as the buyer because of our operational history and reputation and our track record on closing successfully, especially deals from nonprofit faith-based sellers. That is an example of one that we tend to win, the deals that we want and that we think are fair. Competition is really kind of the same, I would say. In terms of kind of the Southwest or the Southeast, we are really excited about the market there, and certainly labor dynamics play into that. That is where, as Barry was talking about earlier, having the local operators boots on the ground in those markets, having their input and their heavy involvement in underwriting all these acquisitions is really a key to how we evaluate these.

Those dynamics of the labor environment and the rate environment and really all of it, which is so unique by market, we do not have to be the experts on that necessarily here because they are. They are the experts in their particular market. With those folks out that have kind of gone to the Southeast to help plant a flag there, leading the way, I fully expect that we can accomplish there what we have in some of our most mature states.

A.J. Rice (Analyst)

Okay. Maybe just one follow-up. I appreciate your comments earlier about all the noise out of Washington and how to think about that. I wondered in your discussions with states right now and what you're hearing with regard to rate updates and so forth on the Medicaid side, is any of that discussion or overhang of what's going on in Washington seeping into those discussions? Do you have a thought on what your anticipated composite Medicaid rate update across your portfolio might look like? I know there's a lot of mid-year updates. How are they thinking about contingency planning for the discussion around all these variables, provider taxes, etc., that are under review in Washington?

Barry Port (CEO)

It's a great question. There's an assumption there that the states act proactively when it comes to discussions around Medicaid funding. I think for the most part, we have not heard any proactive discussions nor had an invitation to be involved in any. I think most of that is justified. This environment around Medicaid discussions in Washington, it changes literally daily. Where their focus and attention is changes almost daily. Because of that, I think people are pretty slow to want to overly anticipate or overly react to one narrative or another that may or may not be included in the reconciliation process.

To answer your question, generally, no, there really hasn't been any meaningful discussion with the states, and nor do I feel like many of them are doing a whole heck of a lot to make adjustments until they have more clarity on what could be the potential changes for them. As for rate visibility, luckily, most of our rate cycles are kind of determined ahead of the year. And so throughout this year, we've got really good visibility into where things are headed regardless of what happens. Suzanne, anything you want to add to that?

Spencer Burton (COO)

I'd say when you start priorities to talk about the states, we're always actively involved in talking to them about what's happening in their next rate-setting year, continuously educating them of what's going on at our local facilities and kind of the pressures that we have or don't have in particular markets. I think that's a continuous process that we're actively involved in at the state level with the state rates that come kind of in early Q3 and late Q3. Still, those discussions are going overall very well and just helping folks understand the environment.

A.J. Rice (Analyst)

Okay. Thanks a lot.

Operator (participant)

Ladies and gentlemen, that concludes today's call. Thank you all for joining. You may now disconnect.