PACSグループ 2026年第3四半期決算説明会：調整後EBITDAは33.6%増、ガイダンス引き上げ

主要なポイント

• PACSグループが発表した2026年第3四半期の売上高は前年同期比11.5%増の15億ドルとなり、調整後EBITDAは33.6%増の1億7,570万ドルとなった。
• 売上高の伸びがサービス原価の9.2%増を上回ったことで、調整後EBITDAマージンは190ベーシスポイント拡大して11.7%となった。
• 既存の専門看護施設売上高は6.4%増の13億8,000万ドルとなった。既存施設の入居率は200ベーシスポイント上昇して91.3%となり、看護患者日数ベースのスキルド・ミックスは120ベーシスポイント改善して29.5%となった。
• PACSは2026年通期の売上高ガイダンスを59億5,000万〜60億5,000万ドルに、調整後EBITDAガイダンスを6億8,500万〜6億9,500万ドルに引き上げた。
• 新規取得施設は成熟施設に比べて入居率およびスキルド・ミックスが大幅に低い状態でポートフォリオに加わったため、短期的には統合コストが発生する一方で、長期的には改善の好機をもたらしている。
• 9月30日時点で利用可能流動性は7億740万ドル、現金および現金同等物は1億1,530万ドル、純レバレッジ比率は0.2倍となり、財務の柔軟性は引き続き高い水準を維持した。

主要財務データ

一般管理費は1億250万ドルから1億3,840万ドルに増加した。株式報酬費用は、役員の退職に伴う権利確定の前倒しや従業員向け株式付与の増加が一因となり、1,250万ドルから4,530万ドルに増加した。株式報酬費用を除く一般管理費は3.4%増となった。

事業および営業実績

PACSの既存施設ポートフォリオは284の専門看護施設で構成された。入居率は前年同期の89.3%に対して91.3%に達し、看護患者日数に基づくスキルド・ミックスは28.3%から29.5%に上昇した。

専門看護施設ポートフォリオ全体では、入居率は89.0%から90.2%に上昇し、スキルド・ミックスは28.2%から29.1%に拡大した。8月および9月に取得したAduroの31施設を除くと、入居率は91.0%、スキルド・ミックスは29.9%となっていた。

施設群（コーホート）間の運営格差は依然として顕著であった：

経営陣は、新規施設と成熟施設の間にある16.9ポイントの入居率格差および10.2ポイントのスキルド・ミックス格差について、買収した施設がPACSの臨床・運営システムを導入していく過程での改善余地を示していると述べた。

品質指標は引き続き運営上の中心的な注力分野となった。四半期末時点で、CMS（メディケア・メディケイド・サービスセンター）の品質評価が報告されている専門看護施設のうち78.9%にあたる250施設が4つ星または5つ星の評価を獲得した。成熟施設は平均4.5のCMS品質評価を維持した。

PACSは第3四半期中にAduroの取引に関連する31の専門看護事業の買収を完了した。四半期末後の10月1日にはフロリダ州で32の専門看護事業を買収し、新たな州へ進出した。また、11月1日にはテキサス州で10の専門看護事業と1つのアシステッド・リビング（生活支援型）施設事業を買収した。

2026年1〜9月期にPACSは、現金3億7,630万ドルおよび引き受けた負債2,750万ドルを含む、計4億380万ドルを施設運営および不動産の買収に投じた。同社はまた、第3四半期中に6物件の基礎不動産を購入した。

経営陣のガイダンス

PACSは2026年通期の見通しを引き上げた：

経営陣によると、この見通しの中央値は、2025年比で売上高が13%増、調整後EBITDAが37%増となる水準を表している。

このガイダンスには、10月1日に取得したフロリダ州の施設および11月1日に取得したテキサス州の施設について、PACSの所有下となる期間の業績寄与が含まれている。また、10月に受領したオハイオ州の品質インセンティブ遡及支払いに伴う500万ドルのEBITDA寄与も含まれる。

経営陣は、この見通しには、臨床システムの構築、現地のリーダーシップ支援、運営の強化など、フロリダ州およびテキサス州の施設統合に必要な短期的投資が織り込まれていると述べた。

PACSは2027年の正式なガイダンスを公表しなかった。経営陣は、2025年に関連するカリフォルニア州の別の品質インセンティブ支払いが2027年第1四半期に支払われる可能性があるものの、その金額は依然として不透明であり、ガイダンス公表前に受領しない限りガイダンスには織り込まないと言及した。

リスクと注力分野

• 買収後の統合：新規取得施設は入居率およびスキルド・ミックスが低い状態からスタートしており、大規模なポートフォリオ追加には臨床面および運営面での先行投資が必要となる。
• 政府による調査：過去に開示された調査は継続中である。PACSは協力を継続していると述べたが、経営陣はその時期や結果を予測することはできないとしている。
• 規制環境：経営陣は、最低人員配置要件に関する方針など、規制当局による監視が強化される可能性を認識している。
• 内部統制：PACSは重要な不備に関する改善計画を実質的に実行した。正式な改善の完了には十分な運用期間と有効性評価が必要であり、経営陣は年末までに完了する見込みとしている。
• 株式報酬：株式報酬の増加が、当四半期に報告された一般管理費を大幅に押し上げた。

アナリスト質疑応答のハイライト

• フロリダ州への事業展開：経営陣によると、PACSはフロリダ州について数年間調査を重ねており、規制、保険償還、事業環境の改善に伴い確信を深めたという。32施設を擁する規模での進出は、専任の地域リーダーシップと臨床インフラの構築にも寄与する。
• 労働環境：経営陣は、人材派遣費用の低下や、直近で買収した施設における割増人件費の削減が予想を上回るペースで進んでいることを挙げ、労働環境は良好であると説明した。
• M&Aパイプライン：PACSは、買収機会が過去のいかなる時期と比べても豊富に存在していると述べた。経営陣は、引受規律を維持しつつ、業績が中程度の施設、業績不振の施設、または経営難の施設を引き続き対象にしていくと強調した。
• キャッシュコンバージョン：経営陣は営業面の成長に加え、回収の改善と売掛金回収日数（DSO）の2〜3日短縮が堅調なキャッシュ創出に寄与したと説明した。
• 不動産への投資配分：PACSは、事業への投資や追加の施設買収と比べてリターンが有利な場合、機会を捉えて機動的に不動産を購入する計画である。
• 質に連動した保険償還：経営陣は、支払者や複数の州のメディケイドプログラムが、保険償還を医療の質の成果や重症度の高い患者への対応能力に連動させる動きを強めていると述べた。

決算説明会トランスクリプト全文

決算説明会の完全なトランスクリプト

経営陣による説明

Operator

Hello, and welcome to PACS Group Third Quarter 2026 Earnings Conference Call. [Operator Instructions] Speakers on today's call are Jason Murray, PACS Group's Chief Executive Officer; Carey Hendrickson, Chief Financial Officer; Josh Jergensen, President and Chief Operating Officer; and Ryan Welch, Director of Corporate Finance. The call today is being recorded, and a replay of the call will be available on the PACS Group Investor Relations website an hour after the completion of this call. A replay of this webcast will be available for 30 days. Information to access the replay is listed in yesterday's press release, which is available on our website under the Investor Relations section.

Before we begin, I would like to remind everyone that during today's call, we'll be making forward-looking statements regarding future events and financial performance. I would now like to turn the conference over to Ryan Welch, Director of Corporate Finance. Please go ahead.

Ryan Welch

Thank you, and good morning, everyone. Thank you for joining us for our earnings call. Before we begin the prepared remarks, we would like to remind you that yesterday, PACS Group issued a press release announcing its third quarter 2026 results. An investor presentation was published and is available on the Investor Relations section of px.com.

I'd also like to remind everyone that during the course of today's conference call, we will discuss certain forward-looking information, including our expectations for 2026 revenue and adjusted EBITDA. that is based on our current expectations, assumptions and beliefs about our business. Any forward-looking 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. You should carefully consider the risk factors that may affect our future results as described in our annual report on Form 10-K for the year ended December 31, 2025, and our other SEC filings.

During this call, we will discuss certain non-GAAP financial measures, including adjusted net income, adjusted earnings per share, adjusted EBITDA, adjusted EBITDAR and net leverage. These non-GAAP financial measures should be considered as a supplement to and not a substitute for measures prepared in accordance with GAAP. For a reconciliation of non-GAAP financial measures discussed during this call to the most directly comparable GAAP measure, please refer to the earnings release and the appendix included in the investor presentation, which are both published and available on the Investor Relations section of PAC Group's website. I'll now turn the call over to Jason Murray, Chairman and CEO.

Jason Murray

Thanks, Ryan, and thank you all for joining us this morning. We are very pleased to report another strong quarter for PACS, reflecting the dedication of our local teams and the continued progress we are making across the organization.

Throughout this year, our focus has remained on delivering high-quality care, strengthening the performance of our existing facilities and preparing our people and infrastructure to support the next phase of growth. We believe our third quarter results demonstrate the value of that work. Our existing portfolio continues to generate meaningful organic growth, and we're putting our operating capabilities and financial strength to work as we welcome new facilities and enter new communities and states. We see those priorities as closely connected. The same leadership and clinical resources and operating discipline that support performance in our established facilities provide the foundation for improving acquired operations over time.

The clearest evidence of our underlying progress this quarter is in our same-store results. Across our 284 skilled nursing facilities within our same-store portfolio, revenue increased 6.4% year-over-year. Occupancy improved by 200 basis points to 91.3% and skilled mix increased on both the revenue and per patient and per and patient day basis. These results demonstrate continued improvement within the facilities we already operate and reinforce our confidence in the organic growth opportunity across the platform.

At the same time, we began integrating a meaningful group of newly acquired facilities. During the quarter, we closed on 31 of 34 skilled nursing operations associated with the Aduro transaction, including 20 facilities in Texas on August 1st, and 11 facilities across South Dakota, North Dakota, New Mexico, and Montana on September 1st. These additions entered PACs at lower occupancy and skilled mix levels than our established portfolio, bringing down certain consolidated averages this quarter. We believe it is important to understand that acquisition mix alongside the continued improvement in our same-store results.

For us, these facilities' initial operating metrics represent the baseline from which we intend to grow. Our objective is to advance their occupancy and skilled mix toward the levels demonstrated by our mature facilities through strong local leadership, clinical support and consistent execution. We've seen this progression across prior acquisitions and the opportunity to repeat that work is central to our growth strategy. Our acquisitions team has continued to refine the process we use to evaluate opportunities. Based on that work and our operating experience, we believe the growth profiles of these newly acquired facilities are consistent with the growth patterns we have seen across prior acquisitions.

We're excited to be replenishing our new cohort with facilities where we see meaningful potential for improvement. As earlier acquisitions progress through ramping an into mature status, adding new operations creates the next set of opportunities for organic growth within the portfolio. Realizing that opportunity requires sustained work. Our teams are focused on supporting local leaders, implementing our clinical and operating systems, strengthening referral relationships and building accountability inside each facility. We believe those efforts can translate the gap between starting performance and mature operating levels into meaningful value over time, and Carey will provide more detail on the operating metrics in a few moments.

As of September 30, PACS operates 355 health care facilities across 20 states with 38,774 total beds, including 34,933 skilled nursing beds and 2,841 assisted living beds. As our footprint expands, our focus remains on helping each facility deliver consistent high-quality care. That work begins with local leadership. Our administrators and facility teams understand the needs of their patients and communities, while PAC services and our regional teams provide the clinical expertise, education, systems and support to help improve them. This relationship supports both the continued progress of our established facilities and the integration of newly acquired operations.

We also continue to invest in that leadership pipeline through our administrator and training or AIT program. We currently have 54 AITs in the program, developing the skills and operating experience to lead facilities with impacts. Building that bench of future administrators supports our existing operations and helps prepare us to bring our operating model to additional facilities as we grow. We believe the value of investing in both current and future facility leaders is most evident in the continued improvement in the quality of care across the organization.

At the end of the third quarter, 250 facilities or 78.9% of our skilled nursing facilities with reported CMS quality measure ratings held 4 or 5-star ratings. Our mature facilities maintained an average CMS quality measure rating of 4.5, well above industry averages. These measures reflect the work our caregivers and clinical leaders do every day. Stronger outcomes help facilities earn the trust of patients, families, hospitals and payers. Over time, that trust supports admissions, occupancy, patient mix and the financial performance needed to continue investing in care.

One example I'm particularly proud of this quarter is the progress at one of our newly acquired facilities in Tennessee. The facility faced significant clinical, operational and physical plant challenges and was formally designated by CMS as a special focus facility, a designation reserve for nursing homes with a history of serious quality concerns. Our regional leaders recognized committed people already within the building and invested in their development. With new administrative leadership and dedicated regional clinical support, the local team strengthened clinical oversight, infection prevention, employee education, accountability and follow-through in daily care.

The work was hands-on and sustained. Employees completed more than 25 in-service training sessions and regional clinical leaders worked alongside the team to reinforce standards and turn recommendations into everyday practice. The team then successfully completed its first two standard surveys under PAC's ownership in March and July 2026. Those were the two qualifying surveys needed for graduation and the facility officially graduated from the special focus facility program effective September 16, 2026. That is a meaningful accomplishment and a credit to the global team and the PACs resources supporting them.

While addressing those clinical and regulatory challenges, the team also continued to strengthen the operation. They met regularly with hospital partners, communicated openly with the improvements underway and continue working to earn trust in their market. During the special focus facility period, occupancy increased from approximately 70% to nearly 85%. What stands out to me is the combined -- the combination of committed people, education support and accountability. The facility's progress demonstrates what can happen when local team take ownership and have the resources to support and to succeed.

This is what we do. While some operators may shy away from facilities facing these types of challenges, we have confidence in our people, our operating model and our ability to take on these opportunities when we believe we can make a meaningful difference. We empower local leaders, we provide the tools and support they need and work together to improve the lives of the patients and communities we serve. This is how we advance our mission as an organization. Experience like this also inform how we think about growth.

When we evaluate an acquisition, we look beyond where a facility stands today and consider what its team can accomplish with the leadership, clinical resources and operating support available through PACS. Our experience improving facilities across different markets gives us confidence as we bring that approach to new communities and states. With that perspective, we have continued to expand our footprint.

Following quarter end, on October 1, we completed the acquisition of 32 skilled nursing operations in Florida, adding 4,049 skilled nursing beds and establishing our presence in a new state. We're particularly excited about this expansion. Entering Florida with 32 facilities gives us a meaningful presence from the outset and an opportunity to build regional leadership, clinical support and operating resources around a substantial group of local teams. We look forward to developing relationships across these communities and bringing the resources of PACs to support the caregivers serving them.

As we welcome these facilities, our first priority is getting to know the people inside each building and understanding the needs of their patients, employees and referral partners. We want to identify the strengths already in place, understand where additional support make the greatest difference and work alongside local leaders to establish clear priorities for improvement. We believe Florida represents an important next step for PAC and a compelling opportunity to extend our operating model into a new market. We're excited to welcome these teams and look forward to sharing their progress as they become established within our platform.

We also completed the acquisition of 10 skilled nursing operations and 1 assisted living operation in Texas on November 1. These additions deepen our presence in a market we know well, where our established regional leadership, clinical resources and operating infrastructure provide a foundation for supporting the incoming teams. We're excited about the opportunity to build on that presence and strengthen our relationship across these communities. Across both new and existing markets, our approach to growth remains disciplined. We pursue facilities where we believe our people and operating model can make a meaningful difference, and we evaluate opportunities with a focus on clinical capability, integration capacity and long-term value creation.

Now before I turn the call over, I'd like to briefly address our previously disclosed government investigations. These matters remain ongoing, and we continue to engage constructively and cooperate fully with the government as we work towards a resolution. We believe the constructive engagement to date has provided a productive foundation for continuing to work through these matters. While we cannot predict the timing or ultimate outcome of these processes, we remain confident in our approach and in our ability to bring these matters to an appropriate resolution.

Importantly, we're doing so from a position of strength. Our business continues to perform exceptionally well. Our teams are executing at a high level and the momentum across our organization reinforces our confidence in the strength and sustainability of our operating model. We remain firmly focused on supporting our local leaders and caregivers, delivering high-quality care and executing on the significant opportunities ahead of us. We're proud of the progress our teams have made this year and excited about the opportunity ahead. So with that, I'll turn the call over to Carey.

Carey Hendrickson

Thank you, Jason. Our third quarter results demonstrate continued growth in the earnings power of our platform. We delivered strong same-store performance. We increased revenue, and we expanded our adjusted EBITDA margin while investing in the next phase of acquisition growth.

For the third quarter of '26, revenue was $1.5 billion, an increase of $154 million or 11.5% growth year-over-year. Our net income was $60.8 million, an increase of $8.5 million or 16.2% from $52.3 million in the third quarter of 2025. Our diluted earnings per share was $0.37, 15.6% higher than the $0.32 we reported in the prior year. Our adjusted net income was $104 million, a 37% increase from $75.9 million in the prior year. Our adjusted earnings per share was $0.63, 37% higher than our $0.46 of adjusted EPS in the prior year. Our adjusted EBITDA was $175.7 million, an increase of $44.2 million or 33.6% from $131.5 million in the prior year. This includes approximately $4.4 million of net EBITDA benefit from a payment received under California's Workforce and Quality Incentive Program, or Debbie CIP.

Adjusted EBITDAR was $273.9 million. Our adjusted EBITDA margin increased to 11.7% compared with 9.8% in the prior year, which is an expansion of 190 basis points, which reflects our ability to translate revenue growth into stronger profitability across the platform.

Turning to our operating results. Our same-store portfolio includes 284 skilled nursing facilities that we operated as of the beginning of 2025. This consistent base provides the clearest year-over-year view of our underlying operating performance, particularly as acquisitions and facility maturation changed the composition of our total portfolio and our new ramping and mature cohorts.

Our same-store skilled nursing revenue increased 6.4% to $1.38 billion compared with $1.30 billion in the prior year, accelerating from 5.8% year-over-year growth that we had in the second quarter. Our same-store occupancy increased to 91.3% compared with 89.3% in the prior year, an improvement of 200 basis points. Same-store skilled mix by nursing patient days increased to 29.5% from 28.3%, an improvement of 120 basis points. For the total skilled nursing portfolio, occupancy was 90.2% compared with 89.0% in the prior year and an industry average of 80.2%. Skilled mix by nursing patient days increased to 29.1% compared with 28.2% in the prior year.

As Jason noted, these consolidated results include the Aduro facilities that we acquired during August and September, which entered our portfolio at lower occupancy and skilled mix levels. Excluding those 31 Aduro facilities, our third quarter occupancy would have been 91.0% compared with reported occupancy of 90.2% and up from our total occupancy of 90.4% that we reported in the second quarter of 2026. Skilled mix by nursing patient days would have been 29.9% compared with reported 29.1%. This comparison highlights the effect of acquisition mix on our consolidated results and provides context for the improvement opportunity within our newly acquired facilities.

At quarter end, our skilled nursing portfolio included 196 mature facilities, 90 ramping facilities and 35 new facilities. The new cohort also included all 31 Aduro facilities acquired during the quarter. Mature facilities operated at 93.1% occupancy with skilled mix of 31.3%. Our ramping facilities operated at 87% occupancy with skilled mix of 25.7% and our new facilities operated at 76.2% occupancy with skilled mix of 21.1%.

As Jason noted, our new facility performance is the starting baseline for improvement. This quarter, the gap between new and mature facilities was 16.9 percentage points in occupancy and 10.2 percentage points in skilled mix. Those differences between new and mature illustrate the operating opportunity within this group as our teams implement the PACS model and work toward mature levels of performance. We expect that progress to come through stronger clinical execution, increased admissions and the development of our referral relationships that support occupancy and patient mix. The pace and extent of improvement will vary by facility, but we have proven our ability to advance our acquired operations through this life cycle, and we're confident in the significance of this opportunity. Replenishing the new cohort with the 78 facilities we've added in the last several months strengthens the organic growth potential within our portfolio. Our focus is on converting that potential into sustained operating improvement and stronger earnings over time.

From a cost perspective, cost of services was $1.14 billion, an increase of 9.2% compared with revenue growth of 11.5%. Our general and administrative expense was $138.4 million compared with $102.5 million in the prior year. That increase included higher stock-based compensation expense, which totaled $45.3 million this quarter compared with $12.5 million in the prior year. That increase in stock-based compensation reflected accelerated vesting of an executive's awards upon retirement as well as increased equity awards to employees. Excluding stock-based compensation expense, general and administrative expense increased only 3.4% year-over-year. This comparison also benefited from lower professional fees, including lower investigation-related legal expense.

One additional point on the relationship between our reported earnings and cash expenses. Our adjusted EBITDA reflects GAAP rent expense. And in the third quarter, GAAP rent expense exceeded our actual cash rent payments by $10.1 million, and we show that on the additional information that's accompanying our non-GAAP reconciliation.

Turning to cash flow. We generated $583.1 million for operating activities during the first 9 months of 2026. This cash generation supports our ability to invest in the business and pursue acquisitions while maintaining financial flexibility. During the first nine months of 2026, we deployed $403.8 million of capital for acquisitions of facility operations and real estate, including $376.3 million in cash and $27.5 million of assumed debt. Our third quarter activity included the purchase of underlying real estate for 6 properties in Oregon, Nevada, Texas and Montana. Selectively increasing real estate ownership remains an important part of our capital allocation approach. We evaluate these investments based on their economics and their potential to create long-term value alongside opportunities to invest in operations and acquire additional facilities with a focus on identifying the highest and best use of capital.

Following this investment activity, we ended September with $707.4 million of available liquidity, including $115.3 million of cash and cash equivalents and net leverage of 0.2x. That financial position provides flexibility to support integration to invest in our facilities and to continue pursuing disciplined growth. We also retain the ability to repurchase shares opportunistically if and when that makes sense, with the full $250 million under our remaining authorization available at quarter end.

Before turning to guidance, I'd also like to provide an update on our internal control remediation efforts. We've substantially completed the implementation of our remediation plan related to the material weaknesses in our internal controls and the redesigned controls are functioning as expected. The remaining step is for the controls to operate for a sufficient period of time to allow us to complete effectiveness testing and formally conclude that the material weaknesses have been fully remediated, which we fully expect to occur by the end of this year.

Turning now to our full year outlook. For full year 2026, we are increasing our revenue guidance to $5.95 billion to $6.05 billion and our adjusted EBITDA guidance to $685 million to $695 million. That's a $200 million increase in our revenue guidance range and a $40 million increase in the midpoint of our adjusted EBITDA guidance range. At the midpoint, these ranges represent revenue growth of 13% and adjusted EBITDA growth of 37% over 2025. Our updated outlook reflects the continued strength of our existing portfolio and includes $5 million of EBITDA contribution from retroactive quality incentive payments in Ohio that we received in October.

Our revenue outlook also includes the contribution from the 32 Florida facilities that we acquired on October 1 and the 11 Texas facilities that we acquired on November 1 for the portion of the year that will operate those facilities. As we bring larger groups of facilities into PACs, the initial lift required to establish our clinical systems to support local leadership and strengthen operations can be substantial. That work requires investment early in the integration process ahead of the operating improvements that we expect to achieve over time. Our outlook incorporates these planned and expected near-term integration investments for the Florida and the newly acquired Texas facilities required to position them for sustained improvement.

We evaluate acquisitions based on their long-term potential and remain focused on building the clinical and operational foundation necessary to realize that opportunity. Importantly, the continued strength of our existing established operations allows us to make these investments while continuing to deliver substantial earnings growth and increasing our full year adjusted EBITDA guidance. We continue to see a robust pipeline of acquisition opportunities, and we remain actively engaged in evaluating transactions that meet our strategic, operational and financial criteria. The performance of our existing portfolio, together with our cash generation and financial flexibility, positions us to pursue these opportunities while supporting the integration of our recently acquired facilities. With that, Jason, I'll turn the call back to you.

Jason Murray

Great. Thank you, Carey. We're pleased with the progress our teams have made through the first nine months of the year. We remain focused on delivering high-quality care and supporting our local leaders and bring the PAC operating model to more communities across the country. With that, operator, I believe we're ready for questions.

Operator

[Operator Instructions] Our first question is from Ben Hendrix with RBC Capital Markets.

質疑応答

Benjamin Hendrix

Congratulations on the quarter. I just wanted to ask a question maybe for Jason on the expansion into Florida. Obviously, a scaled expansion to a new state. Just wanted to maybe get some color on learnings from the diligence process there, kind of your thoughts on the overall regulatory referral and payer backdrops in that state and kind of those dynamics there and what might be unique about this platform that helps you get comfortable with this level of expansion?

Jason Murray

Yes. Great. And Ben, thanks for the question. So Florida is an interesting state. It's one that we have been studying for several years now. And we've remained excited about the potential of growing in that state for quite some time. And in fact, we've looked at opportunities over those several years where we've been studying the state but nothing really made sense from an economic standpoint or from a facility condition standpoint. And so when this opportunity presented itself, it was exciting because we had seen over the years, the dynamics within the state improve. Years ago, there were significant challenges in Florida in the PLGL front and on the regulatory front as well. We've seen that landscape improve over the last several years. We've seen reimbursement as well improve.

I think what we like about the state is if you look at the state average occupancy, it's relatively high. And we see that as well with skilled mix. Skilled mix occupancy across the state is relatively high. So when we look at this particular opportunity, and we underwrite it and compare it to what we typically run in our ramping and mature cohorts, there's ample opportunity for us to expand and add value to what they're doing in those facilities. So those are just a few considerations, right, that we looked at. Florida is also a desirable state to live where we pride ourselves in our ability to attract talented leaders. And we've been very fortunate to find people who are highly interested in living in the state of Florida. And so with all of those things coming together, we're excited about this opportunity. We feel like we have a solid foundation to grow our platform there.

Benjamin Hendrix

Great. And just switching gears quickly. With the election results last night, we know that typically from a regulatory perspective, Republican administrations have been modestly more favorable to the skilled nursing industry, at least that's our read. With kind of the Congress shifting Democrat, any expectation or concern about more punitive policies kind of resurfacing like minimum staffing or otherwise?

Jason Murray

Yes. And it's a good question and certainly one that we've been talking about even prior to the elections, just kind of reading the tea leaves and seeing the things potentially might change in Congress. And we've been working alongside our friends at American Healthcare Association, who we've been lobbying in these areas. I think the initial reaction for us is that we're pretty measured with what we is what we're seeing there. Typically, what happens when you see Republicans in control of Congress, there is an increase. And like you said, maybe there's some challenges and pressures on rate, but there's usually relief on the regulatory front.

With Democrats, it's the opposite of that. We'll continue to fight, and we have done so successfully over the last several years, some of the challenges around the minimum staffing. And we feel like we're in a decent place there from an industry to push back on those requirements. And listen, we work in a very highly regulated industry. And so working in that environment is what I would call kind of normal operating for us. So while it doesn't feel good to have additional scrutiny around the regulatory environment, that is what we do. And we feel like we do this very well as a company, and we've built the infrastructure to help support our local teams to adapt to any type of change that may be coming that way. And so we feel like we're positioned well there.

And I think the silver lining with the potential of increase in the regulatory scrutiny across our sector is rates. The Democrats have traditionally been very good at making sure the entitlement programs are funded from Medicaid to Medicare in the different states where we operate. And so we look forward to seeing that trend hopefully continue, and we feel like that as a sector, we will benefit from that.

Operator

Our next question is from A.J. Rice with UBS.

Albert Rice

Maybe I'll just ask about the labor environment. I know we're in a sort of a full employment economy and the skew on staffing in the skilled nursing facilities is a little different than acute care, a little more oriented toward hourly workers as well as registered nurses. What are you seeing? Are there any challenges, pressures? I know you're moving into some markets as well like Florida that have pretty full employment. You're saying at the administrator level, you're able to find people, but I'm wondering more about the staffing of the facility and what you're seeing there.

Joshua Jergensen

Yes. Thanks for the question, A.J. This is Josh. We feel really good about the labor environment. Probably the best. I know you've heard us say this on this call before, as we go quarter-to-quarter and get further away from the challenges that existed during the COVID time, the strength of the labor environment continues to get better. We're attracting more and better talent to skilled nursing. There's also been some help that we've seen.

Most recently, some of you may have seen that there was a program that was released to try and not just get nurses to become nurses, but get nurses to enter in and work in skilled nursing. There's a reimbursement mechanism for people that they can seek if they commit to three years of working in nursing homes. So they actually get tuition reimbursement for that. So we see the trends as an actual tailwind right now. And as we enter some of these states, Jason mentioned a number of the things that we were most interested as we looked at Texas and we looked at Florida and a couple of these states we got into, these are great labor environments. We already see very low usage of agency.

And I would say we're ahead of schedule of eliminating premium labor. And what that says to me and to our local operators is that there is an influx of people willing and wanting to enter into the space. and work in these nursing homes. I think we also try and position ourselves very well as we go in and we commit to investment in the facilities, both investments in the physical plant, investment in benefits and other things that are attractive to candidates looking for employment. That sort of reputation is helpful as we try and become not only the provider of choice in each of the communities that we enter into, but the employer of choice. And we're already seeing really positive trends and probably ahead of schedule in both the Aduro and the Florida acquisitions.

Carey Hendrickson

Yes. And A.J., one thing I'll note is that we've seen our agency staffing costs come down this year. They've been trending down as the year has gone along, and that's a telltale indicator of the environment for caregiving and that kind of thing at our facility levels.

Albert Rice

Interesting. Just to go back to the deal activity and the pacing out there you're seeing. I know there was a time when we thought properties a year was sort of going to be the average. You're doing substantially more than that. Is there a new sort of bogey? And how do you think about new states? You're doing a lot in the new state arena versus continuing to build out existing states. Is the risk profile, the opportunity profile materially different on one versus the other?

Joshua Jergensen

Yes. Thanks for the question. This is Josh again. I think that as we look and underwrite deals, one thing we've become as we've become more professionalized in that process. We continue to be disciplined as we look at opportunities as it relates to new states, maybe just kicking off that one first. One thing that we're confident in is our operating model. We believe that travels into communities incredibly well. It's very well received when we allow the people that are closest to the patients and to the employees to be the ones making decisions to building teams. And so it doesn't intimidate us going into these new states, even with large portfolio type acquisitions like in the case of Florida and Aduro, many of that growth represented new states.

We do a lot of diligence. It's important that everyone understands that as we go into these states, we're contacting the health care association. We're learning and underwriting the rates. We're understanding that as we look at growth in these new areas that they underwrite to our expectations, things that we've talked about consistently over time, and each of these deals have.

As we look at kind of identifying growth opportunities to hit the first part of your question, sometimes it's hard to anticipate when this growth will come. We've always been opportunistic, and we've always been disciplined in our acquisitions, and we'll continue to do that as we look at these deals. The environment certainly has changed. We've seen deals naturally, and we're seeing a huge influx of deals that are coming up. Some of those don't fit the profile. Some of them don't underwrite the way that we want them to. And as tempting it is to grow for growth's sake, we're not going to do that. People can count on us to be disciplined and ensure that the commitments that we've made to how these deals underwrite remain to be things that we can commit to and execute on.

Operator

Our next question is from Benjamin Rossi with J.P Morgan.

Benjamin Rossi

I guess as a starter, a numbers question for next year. So I know you haven't provided formal guidance for 2027, but I figured I'm just trying to see how you're thinking about directional trends. So year-to-date, you've received about $21 million in Medicaid supplemental payments from California. You're expecting another $5 million from Ohio next quarter. When we think about baseline earnings for 2026 and you're approaching next year, is it fair to take out those Medicaid items and then maybe apply a 6% same-store growth and layer in some embedded earnings from your recent transactions as those ramp? Or how would you frame the jumping off point and moving pieces to consider for next year?

Carey Hendrickson

Ben, thanks for that question. Yes, it's a little too early for me to comment too much on 2027. I will say when you talk about these supplemental payments, the California payments that we received this year for WQIP, we've got one more payment related to the 2025 year that we do expect to receive. It's probably going to be in the first quarter of 2027. So I think we'll have some WQIP payments in 2027. I don't know what that amount is going to be. That's why it's not included and we won't include in our guidance unless we've actually received it by the time we provide guidance.

But yes, I think from a normalization standpoint, you could take that out of 2026. when you think about what's going to happen in 2027. The Ohio funds that we received the $5 million, that is a onetime payment, if you will, but those quality payments have been incorporated into the rate in Ohio. So I think you'll see the Ohio rates up in 2027 versus where they were in 2026. So I think both of those are good indicators for 2027. And look, we continue to have very strong performance quarter-to-quarter this year. We don't see any reason why that's not going to continue. We're confident in our ability to turn these acquisitions from where they are into meaningful improvements. So we expect to see some of that in 2027. It's lining up, I think, to be a good year without giving too much commentary on '27.

Benjamin Rossi

Understood. I guess flipping topics, just thinking about your broader real estate strategy. You mentioned adding 6 properties during 3Q. How are you balancing the continued opportunistic real estate purchases against your capital needs to fund the remaining closings and your ongoing M&A pipeline? And then can you just remind us where you want your overall owned versus rented to sit over time across your facilities?

Carey Hendrickson

Yes, I appreciate that, Ben. And it's all about allocation of capital, right? And what we're trying to do is allocate our capital to the highest and best use. And when we look at the real estate opportunities that we have, some of them are very attractive. And so we're glad that we were able to add six new facilities from an ownership standpoint in the third quarter. And it doesn't detract from our ability to acquire new facilities.

Look at the cash generation we've had. We had $583 million of cash we generated in the first 9 months of 2026. Our EBITDA continues to grow, and we have lots of cash available to us. So we're really just looking at is this a really good use of our capital or not. And when these opportunities come along, we'll take advantage of them. But we're going to do it opportunistically. We have some good new built-in opportunities in some of the acquisitions we've made recently that there could be some real estate opportunities as we go forward related to those acquisitions. So we'll just continue to look at it opportunistically and consider the highest and best use of capital as we go along.

Operator

Our next question is from David MacDonald with Truist Securities. Congratulations.

David MacDonald

Guys, just wanted to come back for a quick minute to the core trends. So if we look at the outperformance in 3Q and the guide implies certainly continued strong trends into 4Q, and it's all been during a period of pretty robust M&A. So Jason, I just wanted to confirm, I think you said during the prepared remarks that kind of all the deals in this quarter and also the ones that you've closed 4Q to date are consistent with how we think about your kind of typical underperforming deal that you guys bring on? And then is there any couple of areas that you would highlight that have been disproportionate drivers kind of humming along from a core trend standpoint?

Carey Hendrickson

Yes. Thanks, Dave, for that question. Yes, as you mentioned, I did note in my remarks that this does include the investments that we're going to make related to Florida and Texas and the Aduro facilities as well, investments we're making in the fourth quarter for those facilities. But the good news is our existing operations are humming along so well, as you mentioned, that we can absorb that and still continue to grow our EBITDA and our earnings. So it's a good position to be in.

When you think about what it is, it's really just, honestly, David, it's our occupancy is continuing to increase at our mature facilities. When you look at our -- and they're going to -- I mean, yes, we're getting continued strong growth from the ramping in the new facilities, yes. But the mature facilities can also continue to grow. They're at 93% occupancy and near 30% skilled mix, but that's not the goal. We have some of our communities that are facilities that are at 100% occupancy and 100% skilled mix, and that's the ultimate goal.

So they can continue to grow as well. And we're continuing to see movement in that mature facility group, which has really helped us this year. The 6.4% organic growth for our same-store facilities is a really solid number. And I think we can continue to grow at that kind of level as we go forward, especially given some of the -- we have, I think, right around 78 or so of the facilities are in that same store are in the ramping cohort, and they'll continue to grow at a really good pace. And then the mature, as I said, we'll continue to see good performance there. So it really does come down to me to that occupancy and the skilled mix trends that we're seeing, and they're continuing to be very positive. I'll say our operating team is an impressive group, and they are doing a great job.

David MacDonald

Okay. And then just one more quick follow-up. I'm just curious, any nuance in terms of changes that you would call out relative to the M&A pipeline just in terms of the size of the typical deal that you guys are looking at, how long it's taking to close, et cetera. And then one other quick one, Carey, just on the cash flow. The cash conversion has been fantastic. Anything that you would kind of call out or flag there?

Jason Murray

Yes. This is Josh. I'll take that first one, Dave. As we look at the acquisition pipeline, we're seeing as many deals as we've ever seen historically. And again, that causes us to have to continue to be very disciplined in the way that we underwrite these deals as we look for specific sort of assets, and those are generally moderately performing or underperforming distressed facilities. That's always historically been where we feel not only we can execute on our mission as a company to try and make improvements to the space that are much needed. But the expertise that we have as we've been able to see facilities go from new ramping and mature, those are the opportunities that we're looking for.

As we've announced certain deals, what we've seen also happen as we enter, and this has happened recently as we look at Florida, that all of a sudden, we become an option that maybe people weren't thinking about because we weren't in the state of Florida and see an influx of deals there or influx of deals in Texas as we now have a really strong footprint there. And so not only are we seeing people who recognize our ability to do larger portfolio-type acquisitions, but I believe that as we continue to grow, the tuck-in opportunities continue to exist as we establish ourselves as a key player in each of these individual communities.

Carey Hendrickson

On the cash flow conversion, Dave, yes, it's strong operating performance, obviously, that we've had. But we've also had improvements in our collections this year. Our DSO has gone down by 2 or 3 days, and that adds to this cash flow generation for us in 2026. So those are the things I'd point out there.

Operator

Our last question is from Raj Kumar with Stephens Inc.

Raj Kumar

Maybe kind of focusing on the mature facility bucket. I know there's a lot of embedded opportunity across the transitioning and newly acquired. But as you kind of think about this kind of mid-single-digit type of top line growth those facilities are kind of exhibiting, it would be helpful to maybe frame the kind of dispersion of performance across maybe the upper quartile and the lower quartile facilities within that mature bucket as you kind of think about how much more tail there is for improvement within those mature facilities? Any kind of color around that would be helpful.

Jason Murray

Yes. Thanks for the question, Raj. This is Josh again. We try not to break up those cohorts anymore. But certainly, as we look at a facility that goes into the very beginning stage of maturity at 36 months, we would expect that performance to be a little bit lower than what we would expect to say, some of our facilities that we had early on in the acquisition or in the portfolio of ten-plus years, stable leadership, both at the administrator position, director of nursing positions.

The reputation that ultimately gets built is so important in these local communities. I mean these skilled nursing facilities kind of become the backbone of post-acute care in the community and the longer that you have been in those communities and shown that you can be relied upon to provide excellent quality outcomes, excellent customer service. You're known not only by the hospitals, the referral sources, the payers, but you actually begin to be noticed by individual family members and members of the community, both people who are working there, who have needed or received care. And so we would expect in each of those individual cohorts, continued maturity throughout the cohort. Carey referenced, I know you were asking mostly about mature.

But in our new facilities, the ones that we just took on, the Aduro and the Florida facilities that are in their first couple of months and in Florida, their very first month, we would expect that along the path towards ramping for us, which hits after 18 months, there's going to be significant improvement, and we're already beginning to see that. And so Carey references this, and we're not just saying it out there to throw it out of 100% occupancy and 100% skilled. There are serious tailwinds that exist from a demographic perspective across the country.

And as we continue to stay disciplined in what matters most, providing excellent care, getting excellent outcomes, we believe that, that reputation will continue to be aided by those tailwinds. And as facilities progress, both through new ramping and even our mature cohorts, we believe we'll establish ourselves as the premier employer provider and continue to see those metrics improve all the way up to the possibility of 100% occupied and 100% skilled.

Raj Kumar

Got it. And maybe just as a follow-up, kind of thinking about quality and how you guys kind of highlight that. And I think maybe in the context of payers and how they reimburse certain skilled nursing providers. And I guess curious on whether there's a direct linkage between kind of your quality ratings in terms of per diem rate or those are still kind of early day conversations? And then whether or not you guys saw any significant impacts from the Star ratings methodology change that happened a couple of months ago around some of the cut points and if that meaningfully kind of might have changed kind of how payers reimbursed based on quality?

Jason Murray

Yes, we love talking about this. It is our product. It is what matters most. There is no reason that we lead in any of our comments in any of the discussions if you were to hear our operating teams talk, it centers around care. I get weekly updates from our operators that are in these new areas in Florida and Texas, and they start by talking about survey results, quality measures, focusing on building a foundation because we've instilled that very early on that, that is what matters most because anyone who's worked in the space understands that as you improve that, that virtuous cycle as people begin to trust you, referral sources, you mentioned payers.

Payers care is more about quality right now than they ever have before. They want to see providers who they can rely upon to take a higher acuity patient and not just admit them, but actually deliver on excellent outcomes so they can discharge to a lower level of care where there's lower expense associated with them. And so we certainly lead with that as we meet with these providers and doors continue to open from a payer perspective. The other thing that we're seeing more and more is that the state programs from Medicaid reimbursement perspective want to incentivize quality.

As Carey mentioned the Ohio, there was lump sum payment. Now that's built into the rate. There's a huge portion of the rate in both Texas and in Florida and a number of other states. Tennessee, I mentioned Ohio, that are correlated with care. The better you perform from a care perspective and generally, the more willing you are to take on higher acuity and then do it well, the reimbursement follows that mechanism. We love that. When we see that happen to us, that means there's greater opportunity to do what we feel we excel at best. And so as we talk about QMs, we'll continue to talk about that. You'll hear us talk about them.

The goalposts do change, as you mentioned, Raj. The cut points, they're moving them consistently. In the October refresh that just happened, they're not reported here, we actually saw an increase in quality measures because our teams are incredibly focused on it. That's a culture of who we are. It is what we do, and we'll continue to focus on that and believe the results, both clinically and financially will follow that.

Operator

We have reached the end of our question-and-answer session. I would like to turn the conference back over to Jason for closing remarks.

Jason Murray

Yes. Thank you, operator, and thank you all again for joining us today. We appreciate your time. We hope you have a great rest of your day.

Operator

Thank you. This will conclude today's conference. You may disconnect at this time, and thank you for your participation.