401k Plan data: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN plan

CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 401k Plan overview

Plan Name	CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN
Plan identification number	002

CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER has sponsored the creation of one or more 401k plans.

Company Name: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER

Employer identification number (EIN): 133954527

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-01-01
002 2021-01-01
002 2020-01-01
002 2019-01-01
002 2018-01-01
002 2017-01-01 LORRI SENK
002 2016-01-01 LORRI SENK
002 2015-01-01 LORRI SENK
002 2014-01-01 LORRI SENK
002 2013-01-01 LORRI SENK
002 2012-01-01 NICHOLAS DEMISAY
002 2011-01-01 NICHOLAS DEMISAY
002 2010-01-01 NICHOLAS DEMISAY
002 2009-01-01 NICHOLAS DEMISAY
002 2009-01-01 NICHOLAS DEMISAY

Plan Statistics for CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN

401k plan membership statisitcs for CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN

Measure Date Value
2022: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 200
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 159
Number of other retired or separated participants entitled to future benefits 2022-01-01 61
Total of all active and inactive participants 2022-01-01 220
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 220
Number of participants with account balances 2022-01-01 123
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 222
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 152
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 67
Total of all active and inactive participants 2021-01-01 219
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 219
Number of participants with account balances 2021-01-01 125
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 325
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 160
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 62
Total of all active and inactive participants 2020-01-01 222
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 222
Number of participants with account balances 2020-01-01 161
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 316
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 211
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 114
Total of all active and inactive participants 2019-01-01 325
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 325
Number of participants with account balances 2019-01-01 230
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 340
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 192
Number of retired or separated participants receiving benefits 2018-01-01 0
Number of other retired or separated participants entitled to future benefits 2018-01-01 124
Total of all active and inactive participants 2018-01-01 316
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 316
Number of participants with account balances 2018-01-01 240
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 387
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 217
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 123
Total of all active and inactive participants 2017-01-01 340
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 340
Number of participants with account balances 2017-01-01 254
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 380
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 275
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 112
Total of all active and inactive participants 2016-01-01 387
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 387
Number of participants with account balances 2016-01-01 246
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 415
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 271
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 109
Total of all active and inactive participants 2015-01-01 380
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 380
Number of participants with account balances 2015-01-01 240
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 444
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 292
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 123
Total of all active and inactive participants 2014-01-01 415
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 415
Number of participants with account balances 2014-01-01 265
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 395
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 318
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 126
Total of all active and inactive participants 2013-01-01 444
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 444
Number of participants with account balances 2013-01-01 282
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 363
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 278
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 117
Total of all active and inactive participants 2012-01-01 395
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 395
Number of participants with account balances 2012-01-01 269
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 338
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 253
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 110
Total of all active and inactive participants 2011-01-01 363
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 363
Number of participants with account balances 2011-01-01 280
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 380
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 250
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 88
Total of all active and inactive participants 2010-01-01 338
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 338
Number of participants with account balances 2010-01-01 294
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 380
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 281
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 99
Total of all active and inactive participants 2009-01-01 380
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 380
Number of participants with account balances 2009-01-01 302
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2022: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	200
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	159
Number of other retired or separated participants entitled to future benefits	2022-01-01	61
Total of all active and inactive participants	2022-01-01	220
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	220
Number of participants with account balances	2022-01-01	123
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	222
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	152
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	67
Total of all active and inactive participants	2021-01-01	219
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	219
Number of participants with account balances	2021-01-01	125
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	325
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	160
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	62
Total of all active and inactive participants	2020-01-01	222
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	222
Number of participants with account balances	2020-01-01	161
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	316
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	211
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	114
Total of all active and inactive participants	2019-01-01	325
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	325
Number of participants with account balances	2019-01-01	230
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	340
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	192
Number of retired or separated participants receiving benefits	2018-01-01	0
Number of other retired or separated participants entitled to future benefits	2018-01-01	124
Total of all active and inactive participants	2018-01-01	316
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	316
Number of participants with account balances	2018-01-01	240
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	387
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	217
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	123
Total of all active and inactive participants	2017-01-01	340
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	340
Number of participants with account balances	2017-01-01	254
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	380
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	275
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	112
Total of all active and inactive participants	2016-01-01	387
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	387
Number of participants with account balances	2016-01-01	246
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	415
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	271
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	109
Total of all active and inactive participants	2015-01-01	380
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	380
Number of participants with account balances	2015-01-01	240
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	444
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	292
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	123
Total of all active and inactive participants	2014-01-01	415
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	415
Number of participants with account balances	2014-01-01	265
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	395
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	318
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	126
Total of all active and inactive participants	2013-01-01	444
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	444
Number of participants with account balances	2013-01-01	282
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	363
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	278
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	117
Total of all active and inactive participants	2012-01-01	395
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	395
Number of participants with account balances	2012-01-01	269
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	338
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	253
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	110
Total of all active and inactive participants	2011-01-01	363
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	363
Number of participants with account balances	2011-01-01	280
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	380
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	250
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	88
Total of all active and inactive participants	2010-01-01	338
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	338
Number of participants with account balances	2010-01-01	294
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	380
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	281
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	99
Total of all active and inactive participants	2009-01-01	380
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	380
Number of participants with account balances	2009-01-01	302
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN

Measure	Date	Value
2022 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2022 401k financial data
Total income from all sources (including contributions)	2022-12-31	$-1,236,846
Total of all expenses incurred	2022-12-31	$3,868,131
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$3,860,855
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$333,426
Value of total assets at end of year	2022-12-31	$7,479,914
Value of total assets at beginning of year	2022-12-31	$12,584,891
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$7,276
Total interest from all sources	2022-12-31	$4,129
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$77,603
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$77,603
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$220,528
Participant contributions at end of year	2022-12-31	$72,488
Participant contributions at beginning of year	2022-12-31	$100,333
Participant contributions at end of year	2022-12-31	$16,409
Participant contributions at beginning of year	2022-12-31	$15,003
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-5,104,977
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$7,479,914
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$12,584,891
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Investment advisory and management fees	2022-12-31	$7,276
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$4,051,365
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$8,570,458
Interest on participant loans	2022-12-31	$4,129
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$3,226,754
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$3,899,097
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-1,652,004
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$112,898
Employer contributions (assets) at end of year	2022-12-31	$112,898
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$3,860,855
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	RICHARDS, MITCHELL & CROSS PA
Accountancy firm EIN	2022-12-31	464063801
2021 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2021 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2021-12-31	$101,349
Total unrealized appreciation/depreciation of assets	2021-12-31	$101,349
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$1,744,035
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$2,721,370
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$2,710,011
Value of total corrective distributions	2021-12-31	$1,544
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$299,924
Value of total assets at end of year	2021-12-31	$12,584,891
Value of total assets at beginning of year	2021-12-31	$13,562,226
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$9,815
Total interest from all sources	2021-12-31	$3,790
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$299,924
Participant contributions at end of year	2021-12-31	$102,779
Participant contributions at beginning of year	2021-12-31	$101,766
Participant contributions at end of year	2021-12-31	$12,557
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$-977,335
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$12,584,891
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$13,562,226
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$8,570,458
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$8,800,936
Interest on participant loans	2021-12-31	$3,790
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$3,899,097
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$4,659,524
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$1,338,972
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$2,710,011
Contract administrator fees	2021-12-31	$9,815
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	RICHARDS, MITCHELL & CROS
Accountancy firm EIN	2021-12-31	464063801
2020 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2020 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2020-12-31	$112,503
Total unrealized appreciation/depreciation of assets	2020-12-31	$112,503
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$1,965,895
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$1,339,602
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$1,315,614
Expenses. Certain deemed distributions of participant loans	2020-12-31	$9,108
Value of total corrective distributions	2020-12-31	$4,892
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$427,880
Value of total assets at end of year	2020-12-31	$13,562,226
Value of total assets at beginning of year	2020-12-31	$12,935,933
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$9,988
Total interest from all sources	2020-12-31	$5,899
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$500,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$427,819
Participant contributions at end of year	2020-12-31	$101,766
Participant contributions at beginning of year	2020-12-31	$110,861
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$61
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$626,293
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$13,562,226
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$12,935,933
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$8,800,936
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$12,825,072
Interest on participant loans	2020-12-31	$5,899
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$4,659,524
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$1,419,613
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$1,315,614
Contract administrator fees	2020-12-31	$9,988
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	GERALD J. WOOD, CPA, PLLC.
Accountancy firm EIN	2020-12-31	261454694
2019 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$2,244,439
Total income from all sources (including contributions)	2019-12-31	$2,244,439
Total loss/gain on sale of assets	2019-12-31	$0
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$1,818,821
Total of all expenses incurred	2019-12-31	$1,818,821
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$1,802,495
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$1,802,495
Expenses. Certain deemed distributions of participant loans	2019-12-31	$13,002
Expenses. Certain deemed distributions of participant loans	2019-12-31	$13,002
Value of total corrective distributions	2019-12-31	$0
Value of total corrective distributions	2019-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$465,581
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$465,581
Value of total assets at end of year	2019-12-31	$12,935,933
Value of total assets at end of year	2019-12-31	$12,935,933
Value of total assets at beginning of year	2019-12-31	$12,510,315
Value of total assets at beginning of year	2019-12-31	$12,510,315
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$3,324
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$3,324
Total interest from all sources	2019-12-31	$6,897
Total interest from all sources	2019-12-31	$6,897
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$1,771,961
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$1,771,961
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$1,771,961
Total dividends received from registered investment company shares (eg mutual funds)	2019-12-31	$1,771,961
Was this plan covered by a fidelity bond	2019-12-31	Yes
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$500,000
Value of fidelity bond cover	2019-12-31	$500,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$465,581
Contributions received from participants	2019-12-31	$465,581
Participant contributions at end of year	2019-12-31	$110,861
Participant contributions at end of year	2019-12-31	$110,861
Participant contributions at beginning of year	2019-12-31	$167,242
Participant contributions at beginning of year	2019-12-31	$167,242
Participant contributions at end of year	2019-12-31	$0
Participant contributions at end of year	2019-12-31	$0
Participant contributions at beginning of year	2019-12-31	$0
Participant contributions at beginning of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2019-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2019-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$425,618
Value of net income/loss	2019-12-31	$425,618
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$12,935,933
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$12,935,933
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$12,510,315
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$12,510,315
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$12,825,072
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$12,825,072
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$12,343,073
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$12,343,073
Interest on participant loans	2019-12-31	$6,897
Interest on participant loans	2019-12-31	$6,897
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$1,802,495
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$1,802,495
Contract administrator fees	2019-12-31	$3,324
Contract administrator fees	2019-12-31	$3,324
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2019-12-31	No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2019-12-31	No
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm name	2019-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2019-12-31	261454694
Accountancy firm EIN	2019-12-31	261454694
2018 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$407,031
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$2,350,538
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$2,322,513
Expenses. Certain deemed distributions of participant loans	2018-12-31	$20,073
Value of total corrective distributions	2018-12-31	$3,649
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$505,459
Value of total assets at end of year	2018-12-31	$12,510,315
Value of total assets at beginning of year	2018-12-31	$14,453,822
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$4,303
Total interest from all sources	2018-12-31	$9,024
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$955,427
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2018-12-31	$955,427
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$500,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$505,459
Participant contributions at end of year	2018-12-31	$167,242
Participant contributions at beginning of year	2018-12-31	$186,756
Participant contributions at end of year	2018-12-31	$0
Participant contributions at beginning of year	2018-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2018-12-31	$0
Assets. Other investments not covered elsewhere at beginning of year	2018-12-31	$15,670
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$-1,943,507
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$12,510,315
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$14,453,822
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$12,343,073
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$14,251,396
Interest on participant loans	2018-12-31	$9,024
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-1,062,879
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$2,322,513
Contract administrator fees	2018-12-31	$4,303
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2018-12-31	No
Did the plan have assets held for investment	2018-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2018-12-31	261454694
2017 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$2,090,804
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$1,448,614
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$1,432,899
Expenses. Certain deemed distributions of participant loans	2017-12-31	$1,233
Value of total corrective distributions	2017-12-31	$11,957
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$569,503
Value of total assets at end of year	2017-12-31	$14,453,822
Value of total assets at beginning of year	2017-12-31	$13,811,632
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$2,525
Total interest from all sources	2017-12-31	$9,980
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$5,000,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$569,503
Participant contributions at end of year	2017-12-31	$186,756
Participant contributions at beginning of year	2017-12-31	$253,051
Participant contributions at end of year	2017-12-31	$0
Participant contributions at beginning of year	2017-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2017-12-31	$15,670
Assets. Other investments not covered elsewhere at beginning of year	2017-12-31	$17,533
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$642,190
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$14,453,822
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$13,811,632
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in pooled separate accounts at end of year	2017-12-31	$14,251,396
Value of interest in pooled separate accounts at beginning of year	2017-12-31	$13,541,048
Interest on participant loans	2017-12-31	$9,980
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-12-31	$0
Net investment gain/loss from pooled separate accounts	2017-12-31	$1,511,321
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$1,432,899
Contract administrator fees	2017-12-31	$2,525
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2017-12-31	No
Did the plan have assets held for investment	2017-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2017-12-31	261454694
2016 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total income from all sources (including contributions)	2016-12-31	$1,134,738
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$1,523,438
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$1,515,354
Expenses. Certain deemed distributions of participant loans	2016-12-31	$2,451
Value of total corrective distributions	2016-12-31	$2,458
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$585,547
Value of total assets at end of year	2016-12-31	$13,811,632
Value of total assets at beginning of year	2016-12-31	$14,200,332
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$3,175
Total interest from all sources	2016-12-31	$8,770
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$5,000,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$580,826
Participant contributions at end of year	2016-12-31	$253,051
Participant contributions at beginning of year	2016-12-31	$219,245
Participant contributions at end of year	2016-12-31	$0
Participant contributions at beginning of year	2016-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2016-12-31	$17,533
Assets. Other investments not covered elsewhere at beginning of year	2016-12-31	$17,533
Income. Received or receivable in cash from other sources (including rollovers)	2016-12-31	$4,721
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$-388,700
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$13,811,632
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$14,200,332
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in pooled separate accounts at end of year	2016-12-31	$13,541,048
Value of interest in pooled separate accounts at beginning of year	2016-12-31	$13,963,554
Interest on participant loans	2016-12-31	$8,770
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-12-31	$0
Net investment gain/loss from pooled separate accounts	2016-12-31	$540,421
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$1,515,354
Contract administrator fees	2016-12-31	$3,175
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2016-12-31	No
Did the plan have assets held for investment	2016-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2016-12-31	261454694
2015 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$541,753
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$1,149,564
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$1,135,791
Value of total corrective distributions	2015-12-31	$12,353
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$486,226
Value of total assets at end of year	2015-12-31	$14,200,332
Value of total assets at beginning of year	2015-12-31	$14,808,143
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$1,420
Total interest from all sources	2015-12-31	$9,554
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$5,000,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$486,226
Participant contributions at end of year	2015-12-31	$219,245
Participant contributions at beginning of year	2015-12-31	$305,563
Participant contributions at end of year	2015-12-31	$0
Participant contributions at beginning of year	2015-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2015-12-31	$17,533
Assets. Other investments not covered elsewhere at beginning of year	2015-12-31	$89,835
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-607,811
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$14,200,332
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$14,808,143
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in pooled separate accounts at end of year	2015-12-31	$13,963,554
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$14,412,745
Interest on participant loans	2015-12-31	$9,554
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$0
Net investment gain/loss from pooled separate accounts	2015-12-31	$45,973
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$1,135,791
Contract administrator fees	2015-12-31	$1,420
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2015-12-31	No
Did the plan have assets held for investment	2015-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2015-12-31	261454694
2014 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total income from all sources (including contributions)	2014-12-31	$1,394,141
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$5,130,899
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$5,112,650
Value of total corrective distributions	2014-12-31	$16,682
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$494,159
Value of total assets at end of year	2014-12-31	$14,808,143
Value of total assets at beginning of year	2014-12-31	$18,544,901
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$1,567
Total interest from all sources	2014-12-31	$296,388
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$5,000,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$494,159
Participant contributions at end of year	2014-12-31	$305,563
Participant contributions at beginning of year	2014-12-31	$338,360
Participant contributions at end of year	2014-12-31	$0
Participant contributions at beginning of year	2014-12-31	$38,740
Assets. Other investments not covered elsewhere at end of year	2014-12-31	$89,835
Assets. Other investments not covered elsewhere at beginning of year	2014-12-31	$58,666
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$-3,736,758
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$14,808,143
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$18,544,901
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in pooled separate accounts at end of year	2014-12-31	$14,412,745
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$9,048,169
Interest on participant loans	2014-12-31	$19,418
Interest earned on other investments	2014-12-31	$276,970
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$9,060,966
Net investment gain/loss from pooled separate accounts	2014-12-31	$603,594
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$5,112,650
Contract administrator fees	2014-12-31	$1,567
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2014-12-31	No
Did the plan have assets held for investment	2014-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2014-12-31	261454694
2013 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total income from all sources (including contributions)	2013-12-31	$2,631,014
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$1,190,817
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$1,174,278
Value of total corrective distributions	2013-12-31	$15,515
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$524,666
Value of total assets at end of year	2013-12-31	$18,544,901
Value of total assets at beginning of year	2013-12-31	$17,104,704
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$1,024
Total interest from all sources	2013-12-31	$302,826
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$500,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$513,593
Participant contributions at end of year	2013-12-31	$338,360
Participant contributions at beginning of year	2013-12-31	$480,740
Participant contributions at end of year	2013-12-31	$38,740
Participant contributions at beginning of year	2013-12-31	$39,127
Assets. Other investments not covered elsewhere at end of year	2013-12-31	$58,666
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$11,073
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$1,440,197
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$18,544,901
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$17,104,704
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest in pooled separate accounts at end of year	2013-12-31	$9,048,169
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$7,525,675
Interest on participant loans	2013-12-31	$18,865
Interest earned on other investments	2013-12-31	$283,961
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$9,060,966
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$9,059,162
Expenses. Payments to insurance carriers foe the provision of benefits	2013-12-31	$2,800
Net investment gain/loss from pooled separate accounts	2013-12-31	$1,803,522
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$1,171,478
Contract administrator fees	2013-12-31	$1,024
Did the plan have assets held for investment	2013-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	GERALD J. WOOD, CPA., PLLC
Accountancy firm EIN	2013-12-31	261454694
2012 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2012 401k financial data
Total income from all sources (including contributions)	2012-12-31	$1,523,936
Total of all expenses incurred	2012-12-31	$1,675,422
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$1,666,051
Value of total corrective distributions	2012-12-31	$8,160
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$547,903
Value of total assets at end of year	2012-12-31	$17,104,704
Value of total assets at beginning of year	2012-12-31	$17,256,190
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$1,211
Total interest from all sources	2012-12-31	$257,044
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$500,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$547,903
Participant contributions at end of year	2012-12-31	$480,740
Participant contributions at beginning of year	2012-12-31	$591,492
Participant contributions at end of year	2012-12-31	$39,127
Participant contributions at beginning of year	2012-12-31	$52,957
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$-151,486
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$17,104,704
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$17,256,190
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in pooled separate accounts at end of year	2012-12-31	$7,525,675
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$6,899,160
Interest on participant loans	2012-12-31	$24,458
Interest earned on other investments	2012-12-31	$232,586
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$9,059,162
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$9,712,581
Net investment gain/loss from pooled separate accounts	2012-12-31	$718,989
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$1,666,051
Contract administrator fees	2012-12-31	$1,211
Did the plan have assets held for investment	2012-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2012-12-31	261454694
2011 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2011 401k financial data
Total income from all sources (including contributions)	2011-12-31	$641,923
Total of all expenses incurred	2011-12-31	$1,085,220
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$1,071,140
Value of total corrective distributions	2011-12-31	$12,349
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$628,254
Value of total assets at end of year	2011-12-31	$17,256,190
Value of total assets at beginning of year	2011-12-31	$17,699,487
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$1,731
Total interest from all sources	2011-12-31	$259,024
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$500,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$599,676
Participant contributions at end of year	2011-12-31	$591,492
Participant contributions at beginning of year	2011-12-31	$433,091
Participant contributions at end of year	2011-12-31	$52,957
Participant contributions at beginning of year	2011-12-31	$57,047
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$28,578
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$-443,297
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$17,256,190
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$17,699,487
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in pooled separate accounts at end of year	2011-12-31	$6,899,160
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$7,871,269
Interest on participant loans	2011-12-31	$24,025
Interest earned on other investments	2011-12-31	$234,999
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$9,712,581
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$9,338,080
Net investment gain/loss from pooled separate accounts	2011-12-31	$-245,355
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$0
Employer contributions (assets) at end of year	2011-12-31	$0
Employer contributions (assets) at beginning of year	2011-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$1,071,140
Contract administrator fees	2011-12-31	$1,731
Did the plan have assets held for investment	2011-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2011-12-31	261454694
2010 : CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2010 401k financial data
Total income from all sources (including contributions)	2010-12-31	$1,726,994
Total of all expenses incurred	2010-12-31	$1,111,927
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$1,097,113
Value of total corrective distributions	2010-12-31	$13,297
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$670,726
Value of total assets at end of year	2010-12-31	$17,699,487
Value of total assets at beginning of year	2010-12-31	$17,084,420
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$1,517
Total interest from all sources	2010-12-31	$259,279
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$500,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$670,726
Participant contributions at end of year	2010-12-31	$433,091
Participant contributions at beginning of year	2010-12-31	$405,291
Participant contributions at end of year	2010-12-31	$57,047
Participant contributions at beginning of year	2010-12-31	$61,712
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$615,067
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$17,699,487
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$17,084,420
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in pooled separate accounts at end of year	2010-12-31	$7,871,269
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$7,092,417
Interest on participant loans	2010-12-31	$25,777
Interest earned on other investments	2010-12-31	$233,502
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$9,338,080
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$9,316,598
Net investment gain/loss from pooled separate accounts	2010-12-31	$796,989
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$0
Employer contributions (assets) at end of year	2010-12-31	$0
Employer contributions (assets) at beginning of year	2010-12-31	$208,402
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$1,097,113
Contract administrator fees	2010-12-31	$1,517
Did the plan have assets held for investment	2010-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	GERALD J. WOOD, CPA, PLLC
Accountancy firm EIN	2010-12-31	261454694

Form 5500 Responses for CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN

2022: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER 401(K) PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

780740-01

Policy instance

Insurance contract or identification number	780740-01
Number of Individuals Covered	97
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR 61428-01

Policy instance

Insurance contract or identification number	MR 61428-01
Number of Individuals Covered	137
Insurance policy start date	2022-01-01
Insurance policy end date	2022-10-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR6142801

Policy instance

Insurance contract or identification number	MR6142801
Number of Individuals Covered	125
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $10,469
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,469
Insurance broker organization code?	4

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR6142801

Policy instance

Insurance contract or identification number	MR6142801
Number of Individuals Covered	161
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,762
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Commission paid to Insurance Broker	USD $510
Insurance broker organization code?	4

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR61428-01

Policy instance

Insurance contract or identification number	MR61428-01
Number of Individuals Covered	230
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $12,504
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Commission paid to Insurance Broker	USD $12,504
Insurance broker organization code?	4

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR61428-01

Policy instance

Insurance contract or identification number	MR61428-01
Number of Individuals Covered	240
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $15,375
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,375
Insurance broker organization code?	4

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR61428-01

Policy instance

Insurance contract or identification number	MR61428-01
Number of Individuals Covered	254
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $16,331
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,331
Insurance broker organization code?	4
Insurance broker name	WELLS FARGO ADVISORS, INC. AGENCY

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR61428-1

Policy instance

Insurance contract or identification number	MR61428-1
Number of Individuals Covered	240
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $9,271
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,271
Insurance broker organization code?	4
Insurance broker name	WELLSFARGOADVISORS, INS.AGENCY, LLC

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

MR61428-1

Policy instance

Insurance contract or identification number	MR61428-1
Number of Individuals Covered	265
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $89,437
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $89,437
Insurance broker organization code?	4
Insurance broker name	WELLSFARGOADVISORS, INS AGENCY, LLC

AXA EQUITABLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62944 )

Policy contract number

13-3954527

Policy instance

Insurance contract or identification number	13-3954527
Number of Individuals Covered	0
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $23,658
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	HOWARD ROSS, CFP, CHFC, CLU

AXA EQUITABLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62944 )

Policy contract number

13-3954527

Policy instance

Insurance contract or identification number	13-3954527
Number of Individuals Covered	282
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker name	HOWARD ROSS, CFP, CHFC. CLU

AXA EQUITABLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62944 )

Policy contract number

91652893

Policy instance

Insurance contract or identification number	91652893
Number of Individuals Covered	269
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $34,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	33634
Insurance broker organization code?	3
Insurance broker name	HOWARD ROSS, CFP, CHFC, CLU

AXA EQUITABLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62944 )

Policy contract number

91652893

Policy instance

Insurance contract or identification number	91652893
Number of Individuals Covered	280
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $34,395
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AXA EQUITABLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62944 )

Policy contract number

91652893

Policy instance

Insurance contract or identification number	91652893
Number of Individuals Covered	294
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $33,352
Total amount of fees paid to insurance company	USD $0
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CLOVE LAKES HEALTH CARE AND REHABILITATION CENTER
Employer identification number (EIN):	133954527
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities