401k Plan data: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. plan

EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 401k Plan overview

Plan Name	EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC.
Plan identification number	001

EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 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.
Prototype plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion or notification letter; and under which a seperate funding medium (for example, a seperate trust or custodial account) is established for the use of each adopting employer.

401k Sponsoring company profile

HOLBROOK NURSING HOME, INC. has sponsored the creation of one or more 401k plans.

Company Name: HOLBROOK NURSING HOME, INC.

Employer identification number (EIN): 550571877

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2018-01-01
001 2018-01-01
001 2017-01-01 BONNIE HITT
001 2016-01-01 BONNIE HITT
001 2015-01-01 BONNIE HITT
001 2014-01-01 HOLLY HITT
001 2014-01-01
001 2013-01-01
001 2012-01-01 HOLLY L HITT HOLLY L HITT 2013-10-10
001 2011-01-01 HOLLY L HITT HOLLY L HITT 2012-10-15

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
001	2018-01-01
001	2018-01-01
001	2017-01-01	BONNIE HITT
001	2016-01-01	BONNIE HITT
001	2015-01-01	BONNIE HITT
001	2014-01-01	HOLLY HITT
001	2014-01-01
001	2013-01-01
001	2012-01-01	HOLLY L HITT	HOLLY L HITT	2013-10-10
001	2011-01-01	HOLLY L HITT	HOLLY L HITT	2012-10-15

Plan Statistics for EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC.

401k plan membership statisitcs for EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC.

Measure Date Value
2018: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2018 401k membership
Total participants, beginning-of-year 2018-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 97
Number of other retired or separated participants entitled to future benefits 2018-01-01 27
Total of all active and inactive participants 2018-01-01 124
Total participants 2018-01-01 124
Number of participants with account balances 2018-01-01 118
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2017 401k membership
Total participants, beginning-of-year 2017-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 85
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 36
Total of all active and inactive participants 2017-01-01 121
Total participants 2017-01-01 121
Number of participants with account balances 2017-01-01 114
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2016 401k membership
Total participants, beginning-of-year 2016-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 108
Number of other retired or separated participants entitled to future benefits 2016-01-01 15
Total of all active and inactive participants 2016-01-01 123
Total participants 2016-01-01 123
Number of participants with account balances 2016-01-01 123
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 5
2015: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2015 401k membership
Total participants, beginning-of-year 2015-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 103
Number of other retired or separated participants entitled to future benefits 2015-01-01 9
Total of all active and inactive participants 2015-01-01 112
Total participants 2015-01-01 112
Number of participants with account balances 2015-01-01 107
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 13
2014: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2014 401k membership
Total participants, beginning-of-year 2014-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 100
Total of all active and inactive participants 2014-01-01 100
Total participants 2014-01-01 100
Number of other retired or separated participants entitled to future benefits 2014-01-01 29
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Number of participants with account balances 2014-01-01 108
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2013 401k membership
Total participants, beginning-of-year 2013-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 95
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 12
Total of all active and inactive participants 2013-01-01 107
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 107
Number of participants with account balances 2013-01-01 107
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 10
2012: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2012 401k membership
Total participants, beginning-of-year 2012-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 92
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 13
Total of all active and inactive participants 2012-01-01 105
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 105
Number of participants with account balances 2012-01-01 105
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 15
2011: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2011 401k membership
Total participants, beginning-of-year 2011-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 101
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 6
Total of all active and inactive participants 2011-01-01 107
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 107
Number of participants with account balances 2011-01-01 107
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 6

Measure	Date	Value
2018: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2018 401k membership
Total participants, beginning-of-year	2018-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	97
Number of other retired or separated participants entitled to future benefits	2018-01-01	27
Total of all active and inactive participants	2018-01-01	124
Total participants	2018-01-01	124
Number of participants with account balances	2018-01-01	118
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2017 401k membership
Total participants, beginning-of-year	2017-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	85
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	36
Total of all active and inactive participants	2017-01-01	121
Total participants	2017-01-01	121
Number of participants with account balances	2017-01-01	114
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2016 401k membership
Total participants, beginning-of-year	2016-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	108
Number of other retired or separated participants entitled to future benefits	2016-01-01	15
Total of all active and inactive participants	2016-01-01	123
Total participants	2016-01-01	123
Number of participants with account balances	2016-01-01	123
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	5
2015: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2015 401k membership
Total participants, beginning-of-year	2015-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	103
Number of other retired or separated participants entitled to future benefits	2015-01-01	9
Total of all active and inactive participants	2015-01-01	112
Total participants	2015-01-01	112
Number of participants with account balances	2015-01-01	107
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	13
2014: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2014 401k membership
Total participants, beginning-of-year	2014-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	100
Total of all active and inactive participants	2014-01-01	100
Total participants	2014-01-01	100
Number of other retired or separated participants entitled to future benefits	2014-01-01	29
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Number of participants with account balances	2014-01-01	108
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2013 401k membership
Total participants, beginning-of-year	2013-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	95
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	12
Total of all active and inactive participants	2013-01-01	107
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	107
Number of participants with account balances	2013-01-01	107
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	10
2012: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2012 401k membership
Total participants, beginning-of-year	2012-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	92
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	13
Total of all active and inactive participants	2012-01-01	105
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	105
Number of participants with account balances	2012-01-01	105
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	15
2011: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2011 401k membership
Total participants, beginning-of-year	2011-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	101
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	6
Total of all active and inactive participants	2011-01-01	107
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	107
Number of participants with account balances	2011-01-01	107
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	6

Financial Data on EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC.

Measure	Date	Value
2018 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2018 401k financial data
Total income from all sources (including contributions)	2018-12-31	$120,491
Total of all expenses incurred	2018-12-31	$46,901
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$41,057
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$208,123
Value of total assets at end of year	2018-12-31	$1,525,431
Value of total assets at beginning of year	2018-12-31	$1,451,841
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$5,844
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$3,000,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$109,379
Participant contributions at end of year	2018-12-31	$50,152
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	$73,590
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$1,525,431
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$1,451,841
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
Investment advisory and management fees	2018-12-31	$5,844
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$1,475,279
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$1,451,841
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-87,632
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
Contributions received in cash from employer	2018-12-31	$98,744
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$41,057
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	No
Opinion of an independent qualified public accountant for this plan	2018-12-31	Qualified
Accountancy firm name	2018-12-31	ARNETT CARBIS TOOTHMAN LLP
Accountancy firm EIN	2018-12-31	550486667
2017 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2017 401k financial data
Total income from all sources (including contributions)	2017-12-31	$375,076
Total of all expenses incurred	2017-12-31	$330,724
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$324,744
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$206,228
Value of total assets at end of year	2017-12-31	$1,451,841
Value of total assets at beginning of year	2017-12-31	$1,407,489
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$5,980
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	$3,000,000
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	$109,380
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	$44,352
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$1,451,841
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$1,407,489
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
Investment advisory and management fees	2017-12-31	$5,980
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$1,451,841
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$1,407,489
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$168,848
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
Contributions received in cash from employer	2017-12-31	$96,848
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$324,744
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	No
Opinion of an independent qualified public accountant for this plan	2017-12-31	Qualified
Accountancy firm name	2017-12-31	ARNETT CARBIS TOOTHMAN LLP
Accountancy firm EIN	2017-12-31	550486667
2016 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2016 401k financial data
Total income from all sources (including contributions)	2016-12-31	$289,945
Total of all expenses incurred	2016-12-31	$213,648
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$209,256
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$220,140
Value of total assets at end of year	2016-12-31	$1,407,489
Value of total assets at beginning of year	2016-12-31	$1,331,192
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$4,392
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	$3,000,000
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	$119,099
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	$76,297
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$1,407,489
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$1,331,192
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
Investment advisory and management fees	2016-12-31	$4,392
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$1,407,489
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$1,331,192
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$69,805
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
Contributions received in cash from employer	2016-12-31	$101,041
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$209,256
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	No
Opinion of an independent qualified public accountant for this plan	2016-12-31	Qualified
Accountancy firm name	2016-12-31	ARNETT CARBIS TOOTHMAN LLP
Accountancy firm EIN	2016-12-31	550486667
2015 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2015 401k financial data
Total income from all sources (including contributions)	2015-12-31	$212,576
Total of all expenses incurred	2015-12-31	$155,980
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$153,663
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$232,146
Value of total assets at end of year	2015-12-31	$1,331,192
Value of total assets at beginning of year	2015-12-31	$1,274,596
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$2,317
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	No
If this is an individual account plan, was there a blackout period	2015-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$116,856
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	$56,596
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$1,331,192
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$1,274,596
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
Investment advisory and management fees	2015-12-31	$2,317
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$1,331,192
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$845,701
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$428,895
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-19,570
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
Contributions received in cash from employer	2015-12-31	$115,290
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$153,663
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	No
Opinion of an independent qualified public accountant for this plan	2015-12-31	Qualified
Accountancy firm name	2015-12-31	ARNETT CARBIS TOOTHMAN LLP
Accountancy firm EIN	2015-12-31	550486667
2014 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2014 401k financial data
Unrealized appreciation/depreciation of other (non real estate) assets	2014-12-31	$-328,431
Total unrealized appreciation/depreciation of assets	2014-12-31	$-328,431
Total income from all sources (including contributions)	2014-12-31	$-115,320
Total of all expenses incurred	2014-12-31	$19,319
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$18,979
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$184,446
Value of total assets at end of year	2014-12-31	$1,274,596
Value of total assets at beginning of year	2014-12-31	$1,409,235
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$340
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$28,665
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2014-12-31	$28,665
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	$98,054
Administrative expenses (other) incurred	2014-12-31	$340
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	$-134,639
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$1,274,596
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$1,409,235
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 registered invesment companies (eg mutual funds) at end of year	2014-12-31	$845,701
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$667,797
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$428,895
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$741,438
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
Contributions received in cash from employer	2014-12-31	$86,392
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$18,979
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	No
Opinion of an independent qualified public accountant for this plan	2014-12-31	Qualified
Accountancy firm name	2014-12-31	TETRICK & BARTLETT
Accountancy firm EIN	2014-12-31	550357807
2013 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 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	$267,612
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$241,742
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$235,142
Expenses. Certain deemed distributions of participant loans	2013-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$176,606
Value of total assets at end of year	2013-12-31	$1,409,235
Value of total assets at beginning of year	2013-12-31	$1,350,605
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$6,600
Total interest from all sources	2013-12-31	$8,079
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
Total dividends received from registered investment company shares (eg mutual funds)	2013-12-31	$0
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$79,626
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$17,135
Other income not declared elsewhere	2013-12-31	$2,706
Administrative expenses (other) incurred	2013-12-31	$6,600
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	$25,870
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$1,409,235
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$1,350,605
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 registered invesment companies (eg mutual funds) at end of year	2013-12-31	$667,797
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-12-31	$616,722
Interest on participant loans	2013-12-31	$0
Interest earned on other investments	2013-12-31	$8,079
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$741,438
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$733,883
Expenses. Payments to insurance carriers foe the provision of benefits	2013-12-31	$0
Net investment gain/loss from pooled separate accounts	2013-12-31	$80,221
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
Contributions received in cash from employer	2013-12-31	$79,845
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$235,142
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	ARNETT FOSTER TOOTHMAN PLLC
Accountancy firm EIN	2013-12-31	550486667
2012 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$282,125
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$241,373
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$232,289
Expenses. Certain deemed distributions of participant loans	2012-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$194,377
Value of total assets at end of year	2012-12-31	$1,350,605
Value of total assets at beginning of year	2012-12-31	$1,309,853
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$9,084
Total interest from all sources	2012-12-31	$12,144
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$98,568
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$0
Other income not declared elsewhere	2012-12-31	$3,305
Administrative expenses (other) incurred	2012-12-31	$9,084
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	$40,752
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$1,350,605
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$1,309,853
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 registered invesment companies (eg mutual funds) at end of year	2012-12-31	$616,722
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$574,162
Interest on participant loans	2012-12-31	$0
Interest earned on other investments	2012-12-31	$12,144
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$733,883
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$735,691
Expenses. Payments to insurance carriers foe the provision of benefits	2012-12-31	$0
Net investment gain/loss from pooled separate accounts	2012-12-31	$72,299
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
Contributions received in cash from employer	2012-12-31	$95,809
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$232,289
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	ARNETT FOSTER TOOTHMAN PLLC
Accountancy firm EIN	2012-12-31	550486667
2011 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total income from all sources (including contributions)	2011-12-31	$157,530
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$189,999
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$182,629
Expenses. Certain deemed distributions of participant loans	2011-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$145,542
Value of total assets at end of year	2011-12-31	$1,309,852
Value of total assets at beginning of year	2011-12-31	$1,342,321
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$7,370
Total interest from all sources	2011-12-31	$14,351
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$73,927
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$0
Administrative expenses (other) incurred	2011-12-31	$7,370
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	$-32,469
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$1,309,852
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$1,342,321
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 registered invesment companies (eg mutual funds) at end of year	2011-12-31	$574,162
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$616,752
Interest on participant loans	2011-12-31	$0
Interest earned on other investments	2011-12-31	$14,351
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$735,690
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$725,569
Expenses. Payments to insurance carriers foe the provision of benefits	2011-12-31	$0
Net investment gain/loss from pooled separate accounts	2011-12-31	$-2,363
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	Yes
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	$71,615
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$182,629
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	ARNETT FOSTER TOOTHMAN PLLC
Accountancy firm EIN	2011-12-31	550486667
2010 : EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2010 401k financial data
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total income from all sources (including contributions)	2010-12-31	$245,244
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$99,069
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$92,798
Expenses. Certain deemed distributions of participant loans	2010-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$145,371
Value of total assets at end of year	2010-12-31	$1,342,321
Value of total assets at beginning of year	2010-12-31	$1,196,146
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$6,271
Total interest from all sources	2010-12-31	$19,284
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
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
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$72,587
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$0
Other income not declared elsewhere	2010-12-31	$5,645
Administrative expenses (other) incurred	2010-12-31	$6,271
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	$146,175
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$1,342,321
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$1,196,146
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 registered invesment companies (eg mutual funds) at end of year	2010-12-31	$616,752
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$499,359
Value of interest in pooled separate accounts at end of year	2010-12-31	$616,752
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$499,359
Interest on participant loans	2010-12-31	$0
Interest earned on other investments	2010-12-31	$19,284
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$725,569
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$696,787
Expenses. Payments to insurance carriers foe the provision of benefits	2010-12-31	$0
Net investment gain/loss from pooled separate accounts	2010-12-31	$74,944
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	$72,784
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$92,798
Contract administrator fees	2010-12-31	$4,820
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	ARNETT & FOSTER, P.L.L.C.
Accountancy firm EIN	2010-12-31	550486667

Form 5500 Responses for EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC.

2018: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
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: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
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: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	First time form 5500 has been submitted	Yes
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 benefit arrangement – Insurance	Yes
2012: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 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 benefit arrangement – Insurance	Yes
2011: EMPLOYEE BENEFIT PLAN OF HOLBROOK NURSING HOME, INC. 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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

GA834979

Policy instance

Insurance contract or identification number	GA834979
Number of Individuals Covered	105
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31

MUTUAL OF AMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88668 )

Policy contract number

055288-D

Policy instance

Insurance contract or identification number	055288-D
Number of Individuals Covered	107
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $707
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	1
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 $0
Amount paid for insurance broker fees	707
Additional information about fees paid to insurance broker	PORTION OF INCENTIVE COMP. PROGRAM
Insurance broker organization code?	3

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Company Name:	HOLBROOK NURSING HOME, INC.
Employer identification number (EIN):	550571877
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities