Ensign is America\u2019s largest operator of \u201cskilled nursing facilities\u201d (SNFs) \u2014\u00a0facilities designed to rehabilitate people who need less than hospital care, but more care than they can provide themselves.\u00a0<\/p>\n
According to April 2026 CMS dataCMS data<\/a>, The Ensign Group operates 334 CMS-certified nursing facilities across 17 states \u2014 larger than the market capitalization of its competitors PACS, National Healthcare Corporation, and Brookdale Senior Living. Ensign operates several types of nursing facilities, but we focus on their facilities that are CMS-certified, the vast majority of which are SNFs, and SNFs account for over 95% of Ensign\u2019s revenue.\n <\/p>\n Ensign boasts about its star ratings, \u201cindustry-leading\u201d clinical outcomes, and \u201cstrong history of quickly improving the quality of care in the facilities we acquire.\u201d A sell-side analyst referred to Ensign\u2019s quality star ratings as part of its \u201csecret sauce.\u201d And Ensign says it sets \u201cthe standard by which all others in our industry are measured.\u201d<\/p>\n But a five-month Hunterbrook investigation found that standard is tragically low \u2014\u00a0and fatal.<\/p>\n The investigation revealed Ensign\u2019s $10 billion empire is built on a dubious foundation: Its profits are heavily dependent on understaffing facilities. It performs better than average on self-reported quality metrics but worse on independently verifiable measures. It regularly violates state minimum staffing laws, and routes taxpayer dollars to its executives and to its own affiliates. Meanwhile, Ensign patients suffer and sometimes die.<\/p>\n \u201cWe could\u2019ve had so much more time,\u201d Weir\u2019s daughter, Hanneka White, told Hunterbrook in an interview. \u201cAnd it was taken away.\u201d\u00a0<\/p>\n Hunterbrook Media\u2019s reporting team \u2014 led by three journalists, as well as former financial analysts from Goldman Sachs and Magnetar Capital \u2014 examined millions of Center for Medicare & Medicaid Services (CMS) datapoints, reviewed thousands of pages of documents, and interviewed dozens of sources, including: attorneys, professors, healthcare professionals, ombudsmen, data analysts, and public advocates, as well as former employees of Ensign, residents of Ensign facilities, and family members of Ensign residents.\u00a0<\/p>\n Here\u2019s the story:<\/p>\n Ensign\u2019s profits can be traced to providing less care than its patients need \u2014\u00a0and less care than it is meant to provide based on the tax dollars it receives from the government. Government programs pay skilled nursing facilities based on \u201cacuity level,\u201d a measurement of how sick the residents are. Ensign says<\/a> it\u2019s focusing on high-acuity people in order to increase its revenue, the bulk of which comes from government programs. But then it staffs many facilities below the levels needed to provide the care those payment rates are calibrated to support. Using the formula from a 2025 peer-reviewed study<\/a>, Hunterbrook calculated a 5 million-hour gap between hours of nursing care needed and hours actually provided at Ensign facilities between July and November 2024, the period for which robust data is available. \u201cThe difference between those two numbers is fraud,\u201d opined Ernest Tosh, an attorney who litigates nursing home abuse and neglect cases. Hunterbrook estimates that closing that staffing gap would have cost Ensign about $161 million during the period studied \u2014 or roughly $386 million annualized. That\u2019s more than the company\u2019s entire reported net income that year of $298 million. Hunterbrook also found that the more a facility profited from understaffing, the worse its health survey scores, facility-reported incidents, complaint deficiencies, total penalties, staff turnover, and staffing ratings.\u00a0<\/p>\n The Ensign Effect. We found Ensign\u2019s growth strategy is to buy struggling nursing homes \u2014\u00a0then cut staff at those facilities and bank the savings, all while claiming quality improves. Ensign has rapidly built its $10 billion empire by rolling up distressed nursing homes, claiming to transform them into \u201cmarket leaders in clinical quality.\u201d But after Ensign acquires a facility, we found, nursing hours fall. Hunterbrook tracked 161 facilities before and after Ensign acquisition against roughly 15,000 other nursing facilities, controlling for industry trends. Bottom line: The quality of the facilities gets worse, not better, after Ensign acquires them.<\/p>\n Federal and state laws prohibit understaffing. Federal law<\/a> requires every Medicare- and Medicaid-funded nursing facility to keep \u201csufficient nursing staff\u201d to meet each resident\u2019s needs. The sicker the resident, the more staffing the law generally demands. Yet Hunterbrook found no consistent relationship between how sick Ensign\u2019s residents are and how many hours it staffs. Four states where Ensign operates impose numeric floors on the care that must be provided: California, Washington, Tennessee, and Kansas. Our analysis of CMS records from 2020 through 2025 found Ensign facilities falling below the legal floors in those states on more than 18,000 days cumulatively. \u201cYou have to staff to meet the needs of residents, and that consistently does not happen,\u201d said Ed Dudensing, an elder-abuse attorney, describing insufficient staffing. \u201cThat\u2019s illegal.\u201d<\/p>\n Ensign\u2019s superior \u201cstar\u201d ratings are largely built on an honor system the company appears to be gaming. The CEO emphasized Ensign facilities \u201coutperformed industry peers in 5-Star Quality Measure results\u201d in a recent press release<\/a>. He also highlighted \u201cthe highest quality clinical outcomes\u201d in an earnings call last year. What he didn\u2019t mention is that those measures are largely self-reported. We sorted CMS Provider Information performance metrics into three tiers: independently verified by unannounced government inspectors; self-reported but auditable via payroll records; or self-assessed and self-reported with no imposed documentation procedures. The result: Ensign performs worse when there is external verification.<\/p>\n Ensign paid more than $339 million to its own affiliates in 2024. That\u2019s about 8% of $ENSG revenue that year. The maneuver is known as tunneling<\/a>. Our cost-report analysis shows Ensign facilities pay hundreds of millions of dollars a year to entities also owned or controlled by Ensign. Think: Landlords. Insurance. Transportation. \u201cHome office\u201d management fees. Hunterbrook found that, across the industry, more money going to related parties correlates with fewer staffing hours, more staff turnover, and lower health inspection scores, among other metrics. A 2024 congressional letter<\/a> to Ensign\u2019s then-executive chairman identified the industry practice as a \u201cdeceptive tactic\u201d to hide profit. In an interview, Tosh, the attorney, shared his opinion of nursing homes tunneling money to related parties without any effective oversight: \u201cIt\u2019s just a huge menagerie of corporations to hide the money movement. In effect it\u2019s money laundering.\u201d<\/p>\n Former employees in different states described systematic misrepresentations. Fabricated Google reviews; document falsification; falls downgraded to \u201cslips;\u201d improperly upcoded patient acuity; and retaliation against staff who refused to engage in these activities. Former employees also told Hunterbrook they were compelled to provide unnecessary care and exaggerate its duration. One former Ensign therapist described higher-ups encouraging higher billing via falsifying minutes of therapy: \u201cThe 30 would be erased and somebody would put in a 70.\u201d\u00a0<\/p>\n An industry lobbying group waged a multi-front campaign to kill a federal government rule meant to stop understaffing. In February of 2026, the Trump Administration rescinded a Biden-era rule setting a federal staffing minimum for nursing facilities, after the American Health Care Association (AHCA), an industry group, sued the government. Ensign and other operators backed<\/a> a pro-Trump super PAC and Ensign gave $750,000 to MAGA Inc before the rule was rescinded. The now-defunct rule was estimated<\/a> to save 13,000 lives a year.<\/p>\n Behind all the numbers, patients suffer and die. Thomas Scates died after an Ensign facility neglected him, according to his family. Herbert Howenstein died after a large pressure ulcer developed at an Ensign nursing home. Six inches long, an inch deep, blackened dead flesh, penetrating to muscle. An EMT report shows that facility staff were aware but nobody was treating him for it. An expert reviewing his death concluded, \u201cThe patient\u2019s demise was almost merciful.\u201d A nonverbal resident with Alzheimer\u2019s was found covered in ants with bites all over her body \u2014 an infestation discovered by her family, not the staff, according to an investigation report. Cheryle Weir died after begging for help that did not come in time, her daughter told Hunterbrook. These are just some of the stories Hunterbrook heard, which represent a fraction of the devastation in Ensign facilities around the country.<\/p>\n Ensign did not respond to multiple detailed requests for comment from Hunterbrook. Ensign CEO Barry Port did, however, tell The Arizona Republic in 2023<\/a> that staffing is decided by individual facility management, and the suggestion that his company siphons money to boost profit is \u201ccategorically false.\u201d Other statements by the company seem to contradict that supposed distance between Ensign and its individual facilities. In a recent earnings call<\/a>, for example, Port cited access to patient-level data and involvement in facility-level decisions. The most recent 10-K<\/a> also suggested there was visibility over individual facilities: Ensign said they use specialized software to help caregivers \u201cmore accurately\u201d capture services to \u201cincrease reimbursement,\u201d and that the company had \u201cinstalled software and touch-screen interface systems in each operation.\u201d<\/p>\n To see our full methodology, click here<\/a>.<\/p>\n If you or a loved one has been affected, or if you have any relevant information to share, please reach out at [email\u00a0protected]<\/a>. This is part one of a series on Ensign and the industry.<\/p>\n Most of us will require institutional care in our lifetime. We hope that care will be high quality.<\/p>\n Faced with an aging population and widespread nursing shortages, every American nursing facility must contend with infections, falls, and sometimes death. On an average day, a facility might smell like human waste cut with cleaning products. Easy listening music covers the croaking sounds of uncomfortable residents. Frontline staff do their best at difficult and low-paying jobs, in facilities lit fluorescently and decorated in liminal beige.<\/p>\n But Ensign has established something worse: a business model that seems to depend on eroding care for America\u2019s sick and elderly.<\/p>\n \u201cTo take away resources from that is, I don\u2019t even think that\u2019s bad management. I think that\u2019s just evil greed.\u201d<\/p>\n Robert love, Former cook at Tennessee Nursing Facility Acquired by Ensign<\/p>\n Our investigation shows the company boomed in recent years by rolling up distressed homes, cutting high-skilled nursing staff, and gaming metrics.<\/p>\n \u201cThey\u2019re the model,\u201d said David Kingsley, a retired professor at the Kansas University Medical Center who researches corporations that depend on revenue from Medicare and Medicaid.<\/p>\n Ensign operates the most CMS-certified nursing facilities in America, with 334 locations across 17 states.<\/p>\n Figures are from the April 2026 CMS archived data snapshot for \u201cnursing homes including rehab services.\u201d They may be incomplete. CMS archived data snapshot.<\/a> But these facilities have problems \u2014\u00a0and they seem to get worse after Ensign takes over. Conditions at several of its facilities are so severe that they are candidates on CMS\u2019s \u201cSpecial Focus Facility\u201d list<\/a>, a roundup of facilities with a pattern of serious problems that pose risks to resident health and safety. Facilities on the SFF list are at risk of being terminated from Medicare or Medicaid programs.<\/p>\n And Ensign is coming for more. In the second quarter so far, it has announced purchases of 17 facilities<\/a> in Texas, two<\/a> in Wisconsin, and one each in Iowa<\/a> and California<\/a> (real estate only).<\/p>\n Ensign\u2019s model is working. It grew rapidly after its current CEO took the helm in 2019. His $13.8 million in compensation last year \u2014\u00a0at a company whose revenue is largely derived from public funds \u2014\u00a0was mostly tied to company performance.\u00a0<\/p>\n And Ensign does not limit incentive-based compensation to its senior executives. Our investigation found that some individual facility administrators are compensated the same way, creating powerful incentives to cut costs. While it\u2019s normal to have financial performance incentives for cutting costs, it\u2019s different when the incentive is to cut nursing hours \u2014 the results can be a matter of life and death.<\/p>\n For example, a lawsuit deposition<\/a> shows the company tied a facility administrator\u2019s bonus directly to location profits, and by staffing below recommended levels, that administrator was able to boost a roughly $400,000 annual bonus to more than $800,000.<\/p>\n As a result of understaffing at that very same facility, the lawsuit claims, a resident died, his final moments captured on a recorded phone call provided to Hunterbrook:<\/p>\n One source, a forensic accountant, likened the industry to the Sackler family\u2019s opioid profiteering<\/a>.<\/p>\n To mask the sounds of screaming and crying, Doni Hunt Webb plays loud music.\u00a0<\/p>\n \u201cI know this is neglect and abuse,\u201d she said.<\/p>\n She has lived in an Ensign facility in Utah for more than five years.\u00a0<\/p>\n \u201cI am a broken person now,\u201d she told Hunterbrook, her voice sounding heavy. \u201cI watch many people in here get broken.\u201d\u00a0<\/p>\n She described the daily reality of an Ensign facility, which she said was understaffed: persistent hygiene and medical failures.\u00a0<\/p>\n Hunt Webb said she suffers from extreme nerve damage, a condition she said does not get adequate treatment due to persistent understaffing, turnover, and a lack of training.\u00a0<\/p>\n At times, staff use wet paper towels in place of toilet paper, Hunt Webb said. She and other residents get recurring infections, she said, recalling that another patient cried and screamed after going a day without food, without being changed, left in a soaking wheelchair.<\/p>\n \u201cThe lack of staffing is the number one thing that affects residents\u2019 quality of life,\u201d the deputy state ombudsman in Texas, Alexa Schoeman, told Hunterbrook.<\/p>\n Dozens<\/a> of<\/a> studies<\/a> show<\/a> this<\/a> is true.<\/p>\n Public money flows to Ensign and other skilled nursing operators based on the needs of their residents. But many simply don\u2019t staff accordingly.<\/p>\n Each nursing facility funded by Medicare, Medicaid, or both is bound by federal law<\/a> to have \u201csufficient nursing staff\u201d to meet the needs of each resident, also referred to as patient \u201cacuity.\u201d The higher the acuity, the more staffing the law generally demands.<\/p>\n And Ensign residents tend to have higher needs than most.<\/p>\n That\u2019s by design, former Ensign employees told Hunterbrook. \u201cThey were seeking out people with more complex needs,\u201d said one former therapist. Administrators would deliberately \u201cfind the most complex diagnosis of that patient for the highest payback.\u201d\u00a0<\/p>\n Ensign\u2019s own financial filings indicate their patients are \u201coften high-acuity\u201d and that their \u201cbusiness model is based in part on serving higher acuity patients.\u201d As acuity goes up, so too should hours of care, according<\/a> to federal law. But Hunterbrook\u2019s analysis found no consistent relationship at Ensign.\u00a0<\/p>\n CMS commissioned research<\/a> to time how long it takes to care for residents at different acuity levels. It used this research to set Medicare payment rates, and it informed a federal rule requiring a minimum of 3.48 hours per resident day (HPRD) that was finalized but never put in force before industry lobbying<\/a> and lawsuits<\/a> helped convince the Trump administration to rescind<\/a> it.<\/p>\n The HPRD requirement was eliminated in two steps: 1) a federal court vacated the provision in April 2025, the Trump administration initially appealed but abandoned the appeal in September 2025; and 2) CMS then formally rescinded it by interim final rule in December 2025. The court did not question the validity of the 3.48 HPRD figure itself or the research behind it; it vacated the rule because CMS declared the standard would be \u201cimplemented and enforced independent of a facility\u2019s case-mix,\u201d which contradicted Congress\u2019s requirement that staffing be \u201csufficient to meet the nursing needs of its residents.\u201d Last year, researchers used<\/a> those findings to help facilities understand how many nursing hours they need to meet their residents\u2019 acuity \u2014 putting a number on the \u201csufficiency\u201d standard enshrined in federal and state law.\u00a0<\/p>\n Hunterbrook used this formula and worked with two of the researchers who developed it \u2014 Charlene Harrington, professor emerita of UCSF, and Robert McLaughlin, a healthcare data analyst \u2014 to calculate the expected number of hours Ensign residents should receive based on the acuity level they report to CMS. Harrington<\/a> is a leading scholar of nursing home policy, who has spent decades researching the staffing levels needed to ensure safe, quality care.\u00a0<\/p>\n Next, we calculated the difference between the hours of care patients should receive, based on reported acuity, and the number of hours Ensign actually paid nursing staff to work, according to Ensign\u2019s own filings with the government. In other words, we calculated the gap between what Medicare paid Ensign to provide care and how much Ensign actually spent on nursing staff to deliver that care.\u00a0<\/p>\n \u201cThe difference between those two numbers is fraud,\u201d elder care attorney Tosh said about this gap across the industry.<\/p>\n In 2025, the California Attorney General used a similar technique in a complaint<\/a> against the nursing home chain Sweetwater. In that case, California analyzed the same CMS database that Hunterbrook used here to allege that the chain systematically failed to meet resident care needs.\u00a0<\/p>\n Our analysis found Ensign residents were shorted more than 5 million hours in just five months of 2024 \u2014\u00a0that\u2019s more than 570 years of missing nursing time. The analysis is restricted to this time period due to data availability.\u00a0<\/p>\n We next sought to translate those hours into dollars, again using Ensign\u2019s own reports on its costs of staffing. We found that Ensign saved about $161 million during those five months by declining to staff its homes adequately. If the trend held across 2024, that\u2019s about $386 million annually in savings on staffing costs, representing profit to the company. For context: That year, Ensign\u2019s entire net income was $298 million.<\/p>\n Across all nursing facilities in CMS data, the profit from understaffing adds up to roughly $6.5 billion across the industry, just from July to November 2024.<\/p>\n Ensign ranks worse than peers: The spread is generally larger at Ensign facilities than the industry norm, according to Hunterbrook\u2019s analysis.<\/p>\n \u201cI think this work breaks ground and is really important because it puts a dollar figure on a staffing question that has been debated for decades,\u201d said McLaughlin, one of the authors of the formula we used in this analysis, who reviewed our work and validated our methodology.<\/p>\n Even these eye-popping figures are likely understated because nursing home operators can inflate the care hours they report to CMS and manipulate their cost reports, according to experts Hunterbrook interviewed. <\/p>\n A 2024 report by the Department of Health and Human Services Office of Inspector General also found that some nursing homes failed to accurately report related-party costs. 2024 HHS OIG report: SNF related parties.<\/a>\n <\/p>\n With federal rules in flux, some states where Ensign operates have their own minimum staffing laws. A separate Hunterbrook analysis of CMS records<\/a> suggests Ensign consistently violates the minimum hours-per-resident-day requirements of: California (3.5-hour)<\/p>\n California offers a waiver of the 3.5 HPRD minimum for workforce shortages, but a lawyer for California Advocates for Nursing Home Reform told Hunterbrook the waiver is \u201crarely granted.\u201d We are not aware of equivalent waivers in Kansas, Tennessee, nor Washington. California workforce shortage waiver.<\/a> From 2020 through 2025, in these four states cumulatively, Ensign facilities fell below state minimums on more than 18,000 days.<\/p>\n These minimums represent the lowest staffing level the laws permit.\u00a0<\/p>\n Ensign regularly fails to meet even that, despite serving residents who are sicker, on average, than those at peer facilities.<\/p>\n When asked directly about our findings regarding the staffing gap and failures to meet minimum staffing levels, Ensign didn\u2019t refute them or offer additional data. The company didn\u2019t respond at all.<\/p>\n There has been some conflicting research on the exact right level \u2014 a controversial<\/a> 2023 study commissioned by CMS declined to recommend a specific minimum HPRD, finding<\/a>, \u201cno obvious plateau at which quality and safety are maximized.\u201d But there\u2019s good reason for these minimums. That 2023 study still found higher staffing was associated with fewer hospitalizations and emergency room visits.<\/p>\n Understaffing hurts people.<\/p>\n In July 2025, a CMS report<\/a> shows, a nonverbal resident at an Ensign facility with Alzheimer\u2019s disease was found in her bed covered in ants.\u00a0<\/p>\n They crawled on her face, neck, legs, and swollen-shut eyes. They left bites all over her body.\u00a0<\/p>\n Her family said they discovered the infestation \u2014 not the staff.<\/p>\n We found a clear pattern across the industry: As spending on staffing decreased, quality metrics deteriorated significantly, including health survey scores, facility-reported incidents, complaint deficiencies, total penalties, staff turnover, and staffing ratings.<\/p>\n This table illustrates the strength of the relationship between quality metrics and the staffing gap, with longer bars indicating a stronger relationship. Source: Hunterbrook analysis\u00a0<\/p>\n Ensign trumpets the acronym CAPLICO across its internal communications, where the first \u201cC\u201d stands for \u201ccustomer second<\/a>.\u201d As they explain in the 2026 Code of Conduct<\/a>, \u201cThis means we put our employees first so that they are empowered and inspired to provide the best possible care to our residents\/patients.\u201d<\/p>\n A noble thought, perhaps. Yet in interview after interview with Hunterbrook, former employees recounted stories that contradicted Ensign\u2019s purported commitment to its workers.<\/p>\n Robert Love told Hunterbrook that he\u2019d worked as a cook at a Tennessee nursing facility for nine years before Ensign took over. After the sale went through in early 2025, he said, Ensign cut staff.<\/p>\n \u201cYou can\u2019t have that mentality in a nursing home setting,\u201d he said of the \u201ccustomer second\u201d motto. \u201cWe have to take care of them.\u201d<\/p>\n Love fed residents grappling with Alzheimer\u2019s disease and dementia. \u201cAnd to take away resources from that is, I don\u2019t even think that\u2019s bad management. I think that\u2019s just evil greed.\u201d<\/p>\n After Ensign took over, Love said he became one of only two cooks serving roughly 90 residents, his pay was cut, and his hours were slashed. \u201cThat\u2019s when I had to go look somewhere else,\u201d he said.\u00a0<\/p>\n The reduction in pay and hours led Love to take another job cooking fast food at a local gas station, where he made $5 more per hour than his wage at Ensign.<\/p>\n At an Ensign facility in San Antonio, the staffing shortfall was so severe that sometimes nurses would cook for residents, according to a former therapist.\u00a0<\/p>\n A former physical therapy director for Ensign in Costa Mesa, California, said they were regularly told Ensign could not afford the cost of care.\u00a0<\/p>\n \u201cWe don\u2019t have the means to pay you more, so here, have a pizza party,\u201d they recalled. \u201cIt\u2019s kind of become a meme or a joke at this point.\u201d<\/p>\n The data also undermines Ensign\u2019s claimed commitment to its staff. Our analysis showed that when it takes over a facility, Ensign almost invariably cuts staff hours and shifts what hours remain from more skilled, higher paid caregivers to less skilled, cheaper ones.<\/p>\n Again, when asked about these findings, Ensign did not\u00a0respond to repeated requests.<\/p>\n Staffing levels are not just words on a page or numbers on a spreadsheet \u2014 they have real, and sometimes fatal, consequences for Ensign residents.<\/p>\n In 2022, a resident<\/a> at Ensign\u2019s Clarion Wellness in Iowa was found suspended upside down between a bed rail and headboard, \u201ccompletely purple and black,\u201d a staff member recalled.\u00a0<\/p>\n The resident had suffocated.\u00a0<\/p>\n The facility had installed a grab bar on the resident\u2019s bed without assessing the risk of entrapment, obtaining consent, or evaluating the risks for the resident who had a history of falls, according to findings from Iowa\u2019s State Survey Agency.<\/p>\n Staff didn\u2019t check on the safety of the mattress and bed rails, but a facility maintenance supervisor admitted he marked them as complete anyway. The surveyors also found no evidence that visual wellness checks of the resident were completed.<\/p>\n Iowa regulators condemned the Ensign facility as strongly as they could<\/a>: They proposed a one-time $10,000 fine.\u00a0<\/p>\n The same year, Ensign collected more than $8 million in revenue per day.<\/p>\n Over and over, Ensign and its executives swear that they care about patients.\u00a0<\/p>\n \u201cOur consistent financial results would not be possible without a relentless, patient-focused culture that strives to deliver the highest quality clinical outcomes,\u201d the CEO said in an earnings call last year.\u00a0<\/p>\n As evidence, the company often cites CMS Star Ratings on quality metrics. For example, in its first-quarter 2026 earnings press release<\/a>, Ensign\u2019s CEO, Port, touted that facilities \u201coutperformed industry peers in 5-Star Quality Measure results by 24% nationally and 20% at the state level.\u201d<\/p>\n The catch: These ratings are largely based on the honor system, meaning they are self-reported. CMS<\/a> \u201cdoes not impose specific documentation procedures on nursing homes,\u201d for most of these metrics, relying instead on expectations of \u201cgood clinical practice.\u201d<\/p>\n While higher ratings don\u2019t necessarily mean better quality care<\/a>, they are likely to matter a lot to an ailing patient or their stressed loved one looking for a nursing facility. The government itself points<\/a> patients to a website<\/a> comparing the star ratings of different facilities in order to \u201ccompare nursing homes for quality.\u201d<\/p>\n When Hunterbrook first started looking at Ensign\u2019s operations in 2024, there was no obvious reason to doubt Ensign\u2019s quality of care, which appeared high based on its star ratings.<\/p>\n It was only later that we realized that, to a large extent, the quality metrics Ensign likes to cite are largely self-reported and self-assessed.<\/p>\n So, relying on performance metrics documented in CMS Provider Information data<\/a> for Ensign\u2019s facilities from January 2020 to March 2026, we took a closer look.<\/p>\n This analysis accounted for Ensign\u2019s acquisitions from February 2016 to March 2026 through CMS\u2019s Change of Ownership dataset, and only included facilities previously owned by Ensign or newly acquired facilities. The analysis also includes a 12-month buffer period to exclude prior operators\u2019 performance data because CMS conducts health inspections roughly once a year. CMS\u2019s Change of Ownership dataset.<\/a>\n <\/p>\n Hunterbrook dove into performance metrics documented in CMS Provider Information data<\/a> for Ensign\u2019s facilities from January 2020 to March 2026. We separated the various available metrics into three tiers: Tier 1 \u2014 Independently verified by state survey agencies contracted by CMS who show up unannounced;<\/p>\n We organized the three tiers in this analysis according to how CMS describes the metrics it uses. Tier 1 metrics are generated by independent state survey agencies conducting unannounced inspections under contract with CMS. The Five-Star Technical Users\u2019 Guide confirms that health inspection ratings are based on the \u201cnumber, scope, and severity of deficiencies identified during the two most recent annual inspection surveys, as well as findings from the most recent 36 months of complaint investigations and focused infection control surveys\u201d \u2014 meaning total deficiency counts, standard survey deficiencies, complaint investigation deficiencies, and infection control citations originate from what state surveyors document on-site. The abuse icon is triggered by harm-level citations found during surveys. No Tier 1 metric relies on facility self-reporting. Five-Star Technical Users\u2019 Guide.<\/a> Tier 2 metrics \u2014 staffing ratings, reported nurse aide hours per resident day, RN hours, LPN hours, total nursing hours, nurse hours on the weekend, and turnover rates \u2014 are derived from Payroll-Based Journal (PBJ) submissions, which Section 6106 of the Affordable Care Act requires to be \u201cbased on payroll and other auditable data.\u201d While facilities self-report this data, it is anchored to payroll records that can be independently audited, and since October 2022 CMS has directed state surveyors to use PBJ staffing data during inspections. The number of facility-reported incidents is self-reported by facilities but is included in Tier 2 because federal regulations require skilled nursing facilities to report these incidents to state survey agencies, who then investigate and may conduct on-site surveys in response (State Operations Manual, Chapter 5). PBJ metrics are required to be \u201cbased on payroll and other auditable data.\u201d |<\/a> | CMS directed state surveyors to use PBJ staffing data during inspections. |<\/a> | State Operations Manual, Chapter 5.<\/a> Tier 3 metrics \u2014 the overall quality measure rating and the long-stay and short-stay QM ratings \u2014 are calculated largely from MDS assessments that the facility completes and submits. The MDS 3.0 Quality Measures User\u2019s Manual confirms that quality measures are calculated using MDS data, which is self-reported by the nursing homes. MDS 3.0 Quality Measures User\u2019s Manual |<\/a> | MDS data is self-reported.<\/a>\n <\/p>\n We found Ensign outperforms on the metrics the company controls, and underperforms on many of the metrics it has less influence over.<\/p>\n Compared to the national average on Tier 3 ratings, Ensign performed 22% better on the overall quality measure rating, 24% better on long-stays, and 16% better on short-stays \u2014 metrics that exist on the honor system. These numbers are unsurprising, given the statistically significant correlation between improved star ratings and profit, documented by<\/a> multiple<\/a> studies<\/a>, and accounts of multiple former employees who said the company underreported adverse events.<\/p>\n The picture looks a lot less rosy for Ensign on Tier 1 and Tier 2 metrics.<\/p>\n On Tier 2 (self-reported but auditable) metrics like registered nurse hours per resident day, Ensign was about 17% worse than the national average. Their staffing rating was 11% worse. And on facility-reported incidents, Ensign performed 38% worse.<\/p>\n Ensign also performed worse on many independently measured metrics (Tier 1): 20% worse on the number of complaint health deficiencies and more than 7% worse on infection control inspections.<\/p>\n Our conclusion: Ensign inflates its grades on metrics it controls, while a truer picture emerges when there is some level of independent verification.<\/p>\n For example, Park Village Healthcare and Rehabilitation in DeSoto, Texas, has five stars on Tier 3 quality measures on the CMS website<\/a> \u2014 a rating that might lead a family or potential resident to think the nursing home is high quality.\u00a0<\/p>\n The same facility\u2019s one-star (\u201cmuch below average\u201d) ratings for independently verifiable metrics like health inspections and staffing tell a very different story.\u00a0\u00a0<\/p>\n Once more, Ensign did not respond to our questions about its apparent manipulation of the quality rating system.<\/p>\n Misleading ratings can have consequences.\u00a0<\/p>\n At an Ensign facility in California, a patient had both legs amputated after staff ignored her doctor\u2019s orders to isolate her during chemotherapy, her husband told Hunterbrook. He said the facility placed her in a crowded room next to a resident with pneumonia, and let an infection spiral into sepsis.\u00a0<\/p>\n The patient\u2019s husband mentioned that they chose the nursing home after reading online reviews and seeing good ratings.<\/p>\n Multiple former employees across different Ensign facilities confirmed for Hunterbrook that ratings were an important internal focus for the company. They described everything from management compelling them to write fake Google reviews to retaliation against employees for not properly manipulating metrics.<\/p>\n \u201cEverything was done on paper,\u201d a former therapist who worked for Ensign told Hunterbrook. A form would go from the facility to building management, who ended up \u201cfalsifying before sending it.\u201d<\/p>\n Elizabeth Schlamann, a former certified medical aide for an Ensign nursing facility in Nebraska, told Hunterbrook that corporate directives to their staff were clear: Manipulate the resident assessments that inform star ratings.<\/p>\n \u201cThey would literally hold it against us as like a punishment,\u201d Schlamann said, noting that if metrics such as falls and bed sores weren\u2019t manipulated in the way corporate administration wanted them to be, promised perks were withheld.<\/p>\n Staff were also \u201cheavily urged or encouraged\u201d to engage in upcoding, according to Schlamann, a practice where residents are coded as more medically complex than they actually are to increase reimbursement from the government.<\/p>\n Twice when it was scrutinized by regulators, Ensign paid<\/a> settlements<\/a> topping $40 million to conclude claims it ripped off the government by billing Medicare for unnecessary treatment and for allegedly paying illegal kickbacks for patient referrals.<\/p>\n If Ensign has continued these behaviors, then some percent of the apparent understaffing in the data may actually be due to upcoding, which can also be illegal.\n <\/p>\n A former speech language pathologist remembered receiving an exit survey before leaving the Ensign nursing home they worked at. The survey asked them if they had seen any unethical behavior or fraud, and promised a follow up call within 24 to 48 hours. They checked yes.<\/p>\n \u201cI didn\u2019t get a phone call,\u201d they said.<\/p>\n Ensign is known for its aggressive acquisition strategy.\u00a0<\/p>\n In financial filings, the company attributes much of its historical growth to acquiring SNFs. Ensign\u2019s 2025 10-K<\/a> claims a \u201cstrong history of quickly improving the quality of care in the facilities we acquire.\u201d They point to \u201cconsistent improvement\u201d in star ratings post-acquisition as evidence.<\/p>\n In reality, does the quality of care improve in the facilities Ensign acquires?<\/p>\n The data answers with a resounding \u201cNo.\u201d<\/p>\n In fact, the analysis revealed what we\u2019re calling \u201cThe Ensign Effect.\u201d\u00a0<\/p>\n When Ensign acquires a facility, the acuity \u2014 a measure of how sick residents are \u2014 stays higher than the national average, while care provided by higher-skilled registered nurses drops sharply, and total nursing hours go down noticeably too.\u00a0<\/p>\n \u201cThe regulation is that you have to staff to meet the needs of the residents, and that consistently does not happen,\u201d said Ed Dudensing, an elder abuse attorney for 23 years. \u201dThat\u2019s illegal.\u201d<\/p>\n We used 72 months of CMS Provider Information records<\/a> spanning January 2020 to March 2026 and tracked 161 facilities before and after Ensign acquired them, verified by CMS Change of Ownership<\/a> records.\u00a0<\/p>\n We then compared the changes at Ensign facilities to what was happening nationally at roughly 15,000 other facilities over the same time periods, using a technique called difference-in-differences that helps sift the Ensign Effect from broader industry trends.<\/p>\n The result? After Ensign takes over, total nursing hours fall at a statistically significant rate, and continue to fall over time.\u00a0<\/p>\n The Ensign Effect is especially visible among their higher-paid and most highly skilled employees.\u00a0<\/p>\n Before acquisition, the registered nurse hours of the facilities hover around the national average. After, a steady decline sets in and widens over the following years.<\/p>\n The drop in RN hours also leads to a change in the overall staffing mix.\u00a0<\/p>\n An increased share of care hours are provided by Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs), who are less highly trained than RNs and generally cannot provide complex medical assessments or treatments independently.\u00a0<\/p>\n And yet, while overall nursing care hours and the share of those hours being provided by the most highly skilled professionals is dropping precipitously, somehow Ensign\u2019s overall star ratings consistently improve at facilities it acquires.\u00a0<\/p>\n How can that be?<\/p>\n Overall ratings \u2014 featured prominently on CMS\u2019s Care Compare site<\/a> where families shop for nursing homes \u2014 are built<\/a> by starting with the health inspection score and then adding up to one star each for staffing and quality measures, including self-reported numbers. Under this methodology, self-reported data can lift a facility\u2019s overall rating by as many as two stars: a 2-star health inspection can become a 4-star overall, and a 3-star can become a 5-star.<\/p>\n Staffing cuts and pushing work onto lower-skilled employees can have serious consequences, according to our sources.\u00a0<\/p>\n Dominique Haynes, a former CNA at an Ensign facility in Texas, mentioned uncertified staff providing care.<\/p>\n \u201cI constantly saw residents passing away,\u201d she said, referring to the result of dialysis procedures performed by staff she thought were unqualified to do so.<\/p>\n Haynes also described chronic supply shortages. Each morning, she said she went \u201cEaster egg hunting\u201d for scarce supplies. She hoarded wet wipes. Catheters went unchanged, and residents were regularly left sitting in urine.\u00a0<\/p>\n \u201cThey\u2019re scared that they won\u2019t be changed, or that they\u2019re not going to get water, or they\u2019re not going to be taken care of,\u201d Haynes said.<\/p>\n Ensign\u2019s staffing cuts might make sense if the overall patient population at facilities acquired by Ensign also had lower acuity over time. But because the government pays more for higher acuity populations, Ensign actually seeks to acquire facilities where patients are sicker than the national average, Hunterbrook found. Ensign says as much in their public communications, highlighting the sicker-than-average populations in their facilities and telling shareholders that while these struggling nursing homes might negatively affect margins at first, they typically contribute \u201cto earnings within 12 to 18 months.\u201d\u00a0<\/p>\n The numbers suggest Ensign accomplishes this primarily by cutting down on the staff tasked with the survival of some of the nation\u2019s sickest and most vulnerable people.<\/p>\n But it\u2019s more than just numbers. Reverend Michael Southcombe routinely visited the Pine Crest nursing home in Merrill, Wisconsin. Then he learned the county-owned facility was slated to sell to Ensign. He grew worried about the quality of care under a corporate newcomer.\u00a0<\/p>\n Driven by a zeal for justice, he became a leader of the grassroots group People for Pine Crest, protesting its sale.<\/p>\n They took their fight to county board meetings, with a self-described \u201cfive foot nothing, crippled little old lady,\u201d<\/a> in fierce opposition.\u00a0<\/p>\n They got crushed.<\/p>\n The sale went through in 2025, and a group member told a local newspaper<\/a> that 15 to 20 positions had already been eliminated, employees had their pay cut, and others lost hours.<\/p>\n Nurses are now stretched thin, response time has bloated, and staff that survived the cuts are working harder but getting paid less, Southcombe told Hunterbrook.\u00a0<\/p>\n \u201cThe only way these companies make money is to not provide the care that they\u2019re being paid to provide,\u201d Southcombe said.<\/p>\n Some residents have loved ones who can care for them in the absence of Ensign staff, he added.<\/p>\n \u201cI worry about the ones who are laying there in bed at some end stage of dementia who don\u2019t have family coming to visit them,\u201d Southcombe said.<\/p>\n \u201cWho puts the straw in their mouth when they\u2019re thirsty?\u201d<\/p>\n For years, patient advocates have pointed to understaffing as the single biggest driver of bad clinical outcomes at nursing facilities, and have pushed for regulatory reform in this area. The industry\u2019s main lobbying group aggressively fights any movement toward mandated levels of staffing by claiming they would cause financial ruin.\u00a0<\/p>\n That group, the American Health Care Association (AHCA), most recently took aim at a federal staffing requirement<\/a> published in May 2024. It would have required all nursing facilities certified by CMS to provide a minimum of 3.48 nursing hours per resident per day, a level estimated<\/a> to save 13,000 lives per year. AHCA filed a federal lawsuit<\/a> the same month, claiming (among other things) that a majority of nursing homes have \u201cnegative operating margins\u201d and that the rule would \u201cforce them to close their doors for good.\u201d<\/p>\n The AHCA features a rotating cast of characters \u2014\u00a0and deep ties to Ensign. Ensign\u2019s CEO Barry Port sits<\/a> on the board of the AHCA, and a former president and CEO of the AHCA, Mark Parkinson, is now<\/a> on Ensign\u2019s board of directors.<\/p>\n In a 2025 earnings call, Port shared that he had also met with Congressional leadership regarding the staffing minimum. He said it was \u201cto make sure they\u2019re fully educated and understanding of what\u2019s good for funding.\u201d\u00a0<\/p>\n Around then, Ensign and other major nursing home operators also contributed to a super PAC devoted to President Trump, according to a New York Times report<\/a>.\u00a0<\/p>\n And a Federal Election Commission filing<\/a> showing contributions to MAGA Inc. confirms Ensign donated $750,000 to the president\u2019s super PAC on August 8, 2025.\u00a0<\/p>\n Continuing their full court press, industry representatives met with the president for lunch at his golf club in the summer of 2025, the Times article said.<\/p>\n By December 2025, the staffing rule was gone.<\/p>\n In 2024, CMS published a final rule setting a minimum 3.48 hours-per-resident-day (HPRD) total nurse staffing requirement and a 24\/7 onsite RN requirement, to be phased in over several years. The 3.48 HPRD floor and the 24\/7 RN requirement were scheduled to take effect for non-rural facilities on May 11, 2026, and for rural facilities on May 10, 2027. They never took effect. CMS issued an interim final rule in December 2025 rescinding the HPRD and 24\/7 RN provisions, effective February 2, 2026 \u2014 roughly three months before the 3.48 HPRD and 24\/7 RN requirements would have first applied to non-rural facilities. Congress also enacted a moratorium on enforcing the HPRD and 24\/7 RN requirements until 2034, in Section 71111 of the One Big Beautiful Bill Act. CMS\u2019s Final rule setting a minimum 3.48 hours-per-resident-day (HPRD) total nurse staffing requirement and a 24\/7 onsite RN requirement. |<\/a> CMS\u2019s interim final rule in December 2025 rescinding the HPRD and 24\/7 RN provisions. |<\/a> | Congressional Research Service Report on Health Provisions of One Big Beautiful Bill Act.<\/a>\n <\/p>\n Of course, the poverty narrative the industry relied on for its lobbying win is at least somewhat contradicted by the company\u2019s own public statements when talking to another audience: Wall Street.<\/p>\n While AHCA was claiming financial hardship in court filings, Ensign\u2019s CEO was trumpeting \u201crecord\u201d and \u201cextraordinary\u201d growth in earnings calls in 2024.<\/p>\n \u201cThis plea of poverty when the CEOs are flying around on their private jets is a little hard to bear,\u201d said geriatrician and director of the National Center on Elder Abuse, Dr. Laura Mosqueda.<\/p>\n How can Ensign report individual facilities struggling to make ends meet and massive profits at the corporate level?\u00a0<\/p>\n One answer: A financial arrangement known as \u201ctunneling.\u201d\u00a0<\/p>\n Here\u2019s how it works: Ensign\u2019s facilities pay separate companies that Ensign also owns or controls for functions like real estate, insurance, and administrative services. Many of these services are necessary to operate the business and each facility would have to pay someone for them. But experts told Hunterbrook that nursing home operators regularly charge themselves excessive, above-market rates when their own affiliates are involved \u2014 draining money that could go to staffing while making the facilities appear too financially strapped to provide adequate care.<\/p>\n For the executives at the top, this system works out rather well. Ensign\u2019s CEO took home<\/a> over $13 million in compensation in 2025. The CFO, almost $12 million. And more than $9 million went to the COO.<\/p>\n More than two-thirds of nursing home profits are tunneled to related parties, a study<\/a> revised last year found. Another study<\/a> based on data from 2019 found $1.95 billion in excessive related-party payments across the industry.\u00a0<\/p>\n \u201cThe government is forking over billions of dollars to take care of older and disabled adults,\u201d said Tony Chicotel, an attorney for California Advocates for Nursing Home Reform. \u201cThe owners are taking that money and spending the very minimum they can on care.\u201d\u00a0<\/p>\n A congressional letter<\/a> sent in 2024 directly to Ensign\u2019s executive chairman at the time, Christopher Christensen, cites these related-party schemes as a \u201cdeceptive tactic\u201d the nursing home industry uses to hide profit.<\/p>\n Ensign facilities tunneled about $339 million in total to related parties in 2024, which made up about 8% of the company\u2019s consolidated revenue that year, Hunterbrook found. That\u2019s larger than Ensign\u2019s net income, according to a 2024 financial filing, precisely what the congressional letter warned about.<\/p>\n And this figure is likely understated, given improper reporting<\/a> to CMS.\u00a0<\/p>\n \u201cIt\u2019s just a huge menagerie of corporations to hide the money movement,\u201d said Tosh. \u201cIn effect, it\u2019s money laundering.\u201d<\/p>\n The government prohibits<\/a> excessive charges, but even when unreasonable costs are caught, CMS doesn\u2019t claw back the money<\/a>.\u00a0<\/p>\n And as with understaffing, the data show a consistent pattern: The more nursing facilities pay related parties, the worse their outcomes across some measured dimensions \u2014 nurse hours, staffing ratings, turnover, and health inspection scores.<\/p>\n \u201cIf we weren\u2019t funding all of this extra expense that comes out of the buildings to all these third parties,\u201d a former Ensign administrator said, \u201cthen we would be able to operate and give very, very amazing care to these residents.\u201d\u00a0<\/p>\n Ensign did not respond to Hunterbrook\u2019s repeated questions regarding its related party transactions.\u00a0<\/p>\n Riverbend Post Acute Rehabilitation<\/a> illustrates the dark side of this model.<\/p>\n The 131-bed Ensign nursing home in Kansas City, Kansas, was scarlet-lettered as a \u201cspecial focus facility\u201d by CMS, meaning it\u2019s among the worst-performing and at risk of losing public funding.<\/p>\n Riverbend is so bad, CMS doesn\u2019t acknowledge it with a rating, but with a warning.<\/p>\n The Ensign facility has been the subject of multiple federal complaint investigations and health inspections. Riverbend was cited for \u201cimmediate jeopardy\u201d \u2014 the most severe<\/a> level \u2014 after a 2024 investigation<\/a> found inadequate care led to a maggot infestation inside a resident\u2019s body.\u00a0<\/p>\n The facility has the money to care for its patients, Hunterbrook found, bringing in nearly $18 million in patient revenue in 2024. But the facility tunnels a massive portion of the money to other Ensign affiliates.\u00a0\u00a0<\/p>\n \u201cHow do you explain having that much revenue,\u201d Kingsley said, \u201cand yet they can\u2019t take care of a special focus facility?\u201d<\/p>\n Here\u2019s how: In just one year, this nursing home reported more than $2 million in related-party transactions in its cost report to CMS.<\/p>\n Riverbend, meanwhile, has technically lost money in three of the last five years with available data. On paper, it\u2019s barely staying afloat.<\/p>\n But this picture is misleading. Riverbend\u2019s losses are a fraction of the $2 million it sent to Ensign. And this is the crux of the related-party scheme: make the nursing home appear poor on paper while the parent organization extracts its revenue.\u00a0<\/p>\n In another example of prioritizing profit over care, Riverbend\u2019s cost report shows it relies heavily on lower-cost certified nursing assistants (CNAs) over more expensive and skilled registered nurses.\u00a0<\/p>\n The theme of replacing more skilled, higher paid workers with lower-skill, lower-cost workers came up twice in interviews with former employees.\u00a0<\/p>\n A former therapist who worked for Ensign told Hunterbrook they were fired because their position meant they had to be paid more than others.\u00a0<\/p>\n One former Ensign administrator in training, responsible for tracking expenses, confirmed the pursuit of lower-skilled labor.\u00a0<\/p>\n \u201cIf we can get it cheaper from somewhere else, let\u2019s get it cheaper,\u201d they said, describing their view of Ensign\u2019s mentality. \u201cIt doesn\u2019t matter the quality.\u201d<\/p>\n The dollars on Ensign\u2019s balance sheet are abstractions. But behind them are real people who have been neglected, suffer, and sometimes die in Ensign facilities.\u00a0\u00a0<\/p>\n Take the story of Thomas Scates.<\/p>\n Air Force veteran, truck driver, firebrand minister. He thundered in church as he did in cheering his grandson on in football: \u201cI\u2019ll fly away,\u201d\u00a0he cried from the pulpit, \u201cI\u2019ll fly away.\u201d<\/p>\n When his body started failing, he put his faith in an Ensign nursing facility. Ensign let him fall.\u00a0<\/p>\n Overburdened nurses didn\u2019t give him enough attention, his daughter, Sharon Thompson, told Hunterbrook. One misdosed his insulin, she said. Then he tumbled out of bed and called for help, but no one came.<\/p>\n \u201cI don\u2019t know how long he was on the floor before somebody showed up,\u201d Thompson recalled.<\/p>\n Ensign staff just put him back in bed, Thompson said. The Scates family filed a lawsuit, later dismissed on technical grounds rather than the merits of the case,\u00a0claiming he died because Ensign\u2019s facility in Peoria, Arizona neglected him.<\/p>\n \u201cThey did not take him to the hospital,\u201d Thompson added. \u201cThey did not call a paramedic.\u201d\u00a0<\/p>\n The family\u2019s complaint claimed Scates\u2019 injuries were preventable, yet the facility was chronically understaffed and undertrained in an effort to maximize profit.<\/p>\n Scates\u2019 experience seems to reflect patterns Hunterbrook found across Ensign\u2019s facilities. Our analysis concluded that Ensign has turned the suffering and neglect of the nation\u2019s most vulnerable into a lucrative business model: seeking out medically complex residents to extract as much revenue as possible, siphoning hundreds of millions of dollars to Ensign\u2019s own affiliates, pocketing vast sums by staffing below the level their residents need, and showcasing self-reported quality metrics to investors and the public.<\/p>\n The ethical conclusion is simple in the eyes of a professor widely known for her research and advocacy in this area, Charlene Harrington.<\/p>\n \u201cWhen you have a multibillion-dollar corporation,\u201d Harrington said, \u201cThere\u2019s no excuse for killing people.\u201d<\/p>\n If you or a loved one has been affected, or if you have any relevant information to share, please reach out at [email\u00a0protected]<\/a>. This is part one of a series on Ensign and the industry.<\/p>\n Michelle Cera trained as a sociologist specializing in digital ethnography and pedagogy. She completed her PhD in Sociology at New York University, building on her Bachelor of Arts degree with Highest Honors from the University of California, Berkeley. She has also served as a Workshop Coordinator at NYU\u2019s Anthropology and Sociology Departments, fostering interdisciplinary collaboration and innovative research methodologies.<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/06\/image-1024x683.jpeg\")
One of Cheryle Weir\u2019s daughters, Hanneka White, with a photo of her mother. Source: Hunterbrook Media<\/p>\n
\n They offer more than 38,000 skilled nursing beds, according to a March filing<\/a>.<\/p>\n
\n \u00a0<\/p>\n
\n , Kansas (1.85-hour), Tennessee (2-hour), and Washington (3.4-hour).<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/06\/image-4-1024x536.png\")
Ensign mission statement. Source: Ensign Group<\/a><\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/06\/image-5-861x1024.png\"){kind=spacer}
Love\u2019s picture of his employee badge at an Ensign facility in Parsons, Tennessee. <\/p>\n
\n Tier 2 \u2014 Self-reported but based on verifiable payroll records and auditable by CMS;<\/p>\n
\n and Tier 3 \u2014 Self-assessed and self-reported with no specific documentation procedures.<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/06\/image-1-1024x603.png\")
Screenshot of Riverbend Post Acute Rehabilitation profile. Source: Screenshot from Medicare.gov<\/a><\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/06\/image-2-1024x768.jpeg\")
Rev. Thomas Scates at the pulpit. Source: Hunterbrook Media<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/06\/image-1-1024x682.jpeg\")
Sharon Thompson holding photos of her parents, Rev. Thomas and Janetta Scates. Source: Hunterbrook Media<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/06\/image-3-1024x575.jpeg\")
Gravestone of Thomas Scates. Source: Sharon Thompson\u00a0<\/p>\n