Lionstone Care, which has nearly doubled its footprint by adding 25 facilities since 2023, has grown through HUD financing and strategic acquisitions, taking on both distressed properties ripe for turnaround as well as high-performing facilities.
In addition to expanding its footprint, the Cleveland-based provider also added an in-house therapy company.
Ezzie Goldish, Lionstone’s former CFO, sat down with Skilled Nursing News to discuss these developments under his tenure, before recently stepping down to found his own technology company.
On technology deployment in nursing homes, providers would do well to carefully evaluate available technologies, choosing those that fit in with workflows and improve resident care, without becoming overly dependent on a single technology or company, Goldish, currently CEO of Zahavi Technologies, said on SNN’s latest RETHINK podcast.
Tech vendors can fail, stagnate or become obsolete quickly, he said, judging by how fast AI and other technologies are evolving. Goldish also discussed a need for a longer-term perspective from banks, government officials and operators themselves, even as regulatory and compliance pressures encourage short-term thinking.
Goldish touched on new ancillaries for Lionstone as well, a focus on specialty services based on location, and the operator’s interest in strengthening its footprint in Ohio.
Lionstone operates 37 skilled nursing facilities, 19 assisted living properties and six independent living buildings, almost exclusively in Ohio, with some outliers in Kentucky and New Jersey.
Prior to entering the skilled nursing sector, Goldish was a product manager for a business intelligence software company. This conversation has been edited for length and clarity. To listen to the complete episode, click below:
SNN: What are your thoughts on the skilled nursing financing landscape right now?
Goldish: We primarily drive toward HUD ourselves. I know of others who are going the REIT direction but [Lionstone] has not pursued that. We took on 12 facilities in 2023. In 2024, we added six more, and in 2025, we added seven more. Some of those also had ALs included.
We’re pretty active. We’re always looking for interesting deals, particularly in Ohio; we’re focused primarily on Ohio. We know the state well. We like the state. We’re Cleveland-based, we really love and are invested in Ohio. We look at both distressed and very successful facilities. We’ve done a nice job in terms of turning around distressed facilities, and we also really like to step into some of these beautiful facilities where someone may be retiring.
Anything to share in terms of updates to service lines, business lines at Lionstone?
We’ve created our own therapy company, which for now is focused on servicing our Lionstone facilities. It’s been incredible. We have not yet pursued creating any other ancillaries, but it has come up more often, whether it be pharmacy or dialysis or other lines. But nothing currently in the works.
We’re looking at having facilities specialized in certain specific clinical areas. Not necessarily a new company or new line of business per se, but having each facility have an area of focus, which will allow them to provide better clinical care, better results and attract patients who are looking for a certain need.
What keeps you up at night, when thinking about challenges in the sector?
How do we see as much as possible ahead? We want to be proactive, not reactive. Your financials are never going to be as good as you want them to be. From the CFO side, the question is always, okay, well, why not? We’ve built wonderful analytics on our side, and we can really see a lot of these pieces.
We’ve gotten much better at seeing that information in real time, which is very helpful … it tells me what happened yesterday, and I can address it quickly. But how do I get ahead even more? That’s what we’re working toward. It’s constantly building out all the little things that help us get ahead of everything, so that either they never happen or we mitigate it much earlier or most of the time, whatever that may be.
How do you see the skilled nursing sector evolving in the years to come?
I’m a big technology fan, and at the same time I would be wary of the different technological directions. Even if the parts that work really well for AI keep getting better, until someone figures out the pieces that don’t work, it’s going to be a problem. It’ll be interesting to see how things settle.
Skilled nursing is an industry that is ripe for turnover; it was not a technology-focused sector three to five years ago, and now it is getting saturated with technology partners who are building out some really cool things. We are weeding through and figuring out which tech companies are going to continue to grow, and which ones are going to continue to produce and create, and also which ones understand our business logic and the business needs and the process needs.
So operators are weeding though all of these tech companies to find the right fit?
At the end of the day, skilled nursing is a people-oriented business. You have to be able to ensure that you’re fitting those technologies within the care that needs to be provided to residents, and if it doesn’t fit, it doesn’t work…no matter how good the technology might be. It’s going to be interesting to see how these things shake out. Every company is going to pursue different routes, and I think you’ll see a lot of mixed success.
People get very excited and then discover that it stagnated, or it was really exciting, but then something else surpassed it really quickly. Or, it fits a process that isn’t even necessary anymore, solving a problem that won’t exist in two years.
Very true, tech and AI software is evolving rapidly. How do operators protect themselves if the bubble bursts?
Within the technology companies themselves, a lot of them are trying to get valuations, to get funded, and to build based on certain expectations. In two to three years, even if they are doing a great job, they might move too fast or slightly in the wrong direction. Or, they could just collapse.
If you’re an operator and you’re banking on this product to replace a process, and that company then doesn’t succeed for some reason, what are you going to do? If no one else built that product, and you were right, they built the best product for this process, well now they don’t exist. Now what are you going to do?
We’re hyper aware in the space. We’re cautious with who we pursue, why, and how integrated we’re going to get with any specific product. I’d love to bring on products that add value, but I’m very wary of being reliant on any single product.
What do you want others to rethink about the skilled nursing sector?
I think everyone needs a much longer-term approach. It’s very easy to get caught up in the short term, and I think some of that is caused by regulatory issues and compliance concerns. It gets people kind of hyper focused on the current.
We need the government also to take a longer-term view in terms of how it’s approached, how it’s invested in.
Banks should be learning how to invest in long-term approaches, which they don’t really do. They invest in certain aspects, but they don’t invest in long-term as much as you might think. They might invest in a new nursing home, and even that’s limited.
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