By: Michelle Cera Andrew Ford Laura Wadsten
Editor: Jim Impoco Sam Koppelman
They beat the walls.
Cheryle Weir couldn’t breathe, her roommate recalled. Dependent on ventilators at an Ensign facility, they couldn’t talk. They couldn’t scream.
So they banged on the table, banged on the wall, desperate for anyone to hear. A nurse should have been there. No one was.
Eventually, Cheryle stopped banging.
Her family’s lawsuit blames her death on The Ensign Group ($ENSG).
Ensign is America’s largest operator of “skilled nursing facilities” (SNFs) — facilities designed to rehabilitate people who need less than hospital care, but more care than they can provide themselves.
Ensign boasts about its star ratings, “industry-leading” clinical outcomes, and “strong history of quickly improving the quality of care in the facilities we acquire.” A sell-side analyst referred to Ensign’s quality star ratings as part of its “secret sauce.” And Ensign says it sets “the standard by which all others in our industry are measured.”
But a five-month Hunterbrook investigation found that standard is tragically low — and fatal.
The investigation revealed Ensign’s $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.
“We could’ve had so much more time,” Weir’s daughter, Hanneka White, told Hunterbrook in an interview. “And it was taken away.”
Hunterbrook Media’s reporting team — led by three journalists, as well as former financial analysts from Goldman Sachs and Magnetar Capital — 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.
Here’s the story:
- Ensign’s profits can be traced to providing less care than its patients need — and 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 “acuity level,” a measurement of how sick the residents are. Ensign says it’s 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, 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. “The difference between those two numbers is fraud,” 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 — or roughly $386 million annualized. That’s more than the company’s 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.
- The Ensign Effect. We found Ensign’s growth strategy is to buy struggling nursing homes — then 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 “market leaders in clinical quality.” 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.
- Federal and state laws prohibit understaffing. Federal law requires every Medicare- and Medicaid-funded nursing facility to keep “sufficient nursing staff” to meet each resident’s needs. The sicker the resident, the more staffing the law generally demands. Yet Hunterbrook found no consistent relationship between how sick Ensign’s 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. “You have to staff to meet the needs of residents, and that consistently does not happen,” said Ed Dudensing, an elder-abuse attorney, describing insufficient staffing. “That’s illegal.”
- Ensign’s superior “star” ratings are largely built on an honor system the company appears to be gaming. The CEO emphasized Ensign facilities “outperformed industry peers in 5-Star Quality Measure results” in a recent press release. He also highlighted “the highest quality clinical outcomes” in an earnings call last year. What he didn’t 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.
- Ensign paid more than $339 million to its own affiliates in 2024. That’s about 8% of $ENSG revenue that year. The maneuver is known as tunneling. 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. “Home office” 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 to Ensign’s then-executive chairman identified the industry practice as a “deceptive tactic” to hide profit. In an interview, Tosh, the attorney, shared his opinion of nursing homes tunneling money to related parties without any effective oversight: “It’s just a huge menagerie of corporations to hide the money movement. In effect it’s money laundering.”
- Former employees in different states described systematic misrepresentations. Fabricated Google reviews; document falsification; falls downgraded to “slips;” 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: “The 30 would be erased and somebody would put in a 70.”
- 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 pro-Trump super PAC and Ensign gave $750,000 to MAGA Inc before the rule was rescinded. The now-defunct rule was estimated to save 13,000 lives a year.
- 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, “The patient’s demise was almost merciful.” A nonverbal resident with Alzheimer’s was found covered in ants with bites all over her body — 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.
- Ensign did not respond to multiple detailed requests for comment from Hunterbrook. Ensign CEO Barry Port did, however, tell The Arizona Republic in 2023 that staffing is decided by individual facility management, and the suggestion that his company siphons money to boost profit is “categorically false.” Other statements by the company seem to contradict that supposed distance between Ensign and its individual facilities. In a recent earnings call, for example, Port cited access to patient-level data and involvement in facility-level decisions. The most recent 10-K also suggested there was visibility over individual facilities: Ensign said they use specialized software to help caregivers “more accurately” capture services to “increase reimbursement,” and that the company had “installed software and touch-screen interface systems in each operation.”
To see our full methodology, click here.
If you or a loved one has been affected, or if you have any relevant information to share, please reach out at ideas@hntrbrk.com. This is part one of a series on Ensign and the industry.
“They’re The Model”
Most of us will require institutional care in our lifetime. We hope that care will be high quality.
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.
But Ensign has established something worse: a business model that seems to depend on eroding care for America’s sick and elderly.
“To take away resources from that is, I don’t even think that’s bad management. I think that’s just evil greed.”
Robert love, Former cook at Tennessee Nursing Facility Acquired by Ensign
Our investigation shows the company boomed in recent years by rolling up distressed homes, cutting high-skilled nursing staff, and gaming metrics.
“They’re the model,” said David Kingsley, a retired professor at the Kansas University Medical Center who researches corporations that depend on revenue from Medicare and Medicaid.
Ensign operates the most CMS-certified nursing facilities in America, with 334 locations across 17 states. They offer more than 38,000 skilled nursing beds, according to a March filing.
But these facilities have problems — and they seem to get worse after Ensign takes over. Conditions at several of its facilities are so severe that they are candidates on CMS’s “Special Focus Facility” list, 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.
And Ensign is coming for more. In the second quarter so far, it has announced purchases of 17 facilities in Texas, two in Wisconsin, and one each in Iowa and California (real estate only).
Ensign’s model is working. It grew rapidly after its current CEO took the helm in 2019. His $13.8 million in compensation last year — at a company whose revenue is largely derived from public funds — was mostly tied to company performance.
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’s normal to have financial performance incentives for cutting costs, it’s different when the incentive is to cut nursing hours — the results can be a matter of life and death.
For example, a lawsuit deposition shows the company tied a facility administrator’s 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.
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:
One source, a forensic accountant, likened the industry to the Sackler family’s opioid profiteering.
Full Article & Source:
Ensign: The Nursing Home Empire Built on Fatal Neglect
