401k Plan data: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN plan

CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 401k Plan overview

Plan Name	CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN
Plan identification number	001

CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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.
Partial participant-directed account plan - Participants have the opportunity to direct the investment of a portion of 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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

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

Company Name: CEDAR LAKE NURSING HOME, INC

Employer identification number (EIN): 751667895

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01 MARY C NORWOOD 2023-07-26 MARY C NORWOOD 2023-07-26
001 2021-01-01 MARY C NORWOOD 2022-06-17 MARY C NORWOOD 2022-06-17
001 2020-01-01 MARY C NORWOOD 2021-05-26 MARY C NORWOOD 2021-05-26
001 2019-01-01 MARY NORWOOD 2020-08-18
001 2018-01-01 MARY C NORWOOD 2019-10-14 MARY C NORWOOD 2019-10-14
001 2017-01-01 MARY NORWOOD
001 2016-01-01 MARY C NORWOOD
001 2015-01-01 MARY C NORWOOD MARY C NORWOOD 2016-10-17
001 2014-01-01 MARY NORWOOD
001 2013-01-01 MARY C NORWOOD
001 2012-01-01 MARY C NORWOOD
001 2012-01-01 MARY C NORWOOD 2014-06-10
001 2011-01-01 MARY C NORWOOD 2012-07-18
001 2010-01-01 MARY NORWOOD 2011-09-26 MARY NORWOOD 2011-09-26
001 2009-01-01 MARY NORWOOD

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01	MARY C NORWOOD	2023-07-26	MARY C NORWOOD	2023-07-26
001	2021-01-01	MARY C NORWOOD	2022-06-17	MARY C NORWOOD	2022-06-17
001	2020-01-01	MARY C NORWOOD	2021-05-26	MARY C NORWOOD	2021-05-26
001	2019-01-01	MARY NORWOOD	2020-08-18
001	2018-01-01	MARY C NORWOOD	2019-10-14	MARY C NORWOOD	2019-10-14
001	2017-01-01	MARY NORWOOD
001	2016-01-01	MARY C NORWOOD
001	2015-01-01	MARY C NORWOOD		MARY C NORWOOD	2016-10-17
001	2014-01-01	MARY NORWOOD
001	2013-01-01	MARY C NORWOOD
001	2012-01-01	MARY C NORWOOD
001	2012-01-01	MARY C NORWOOD	2014-06-10
001	2011-01-01	MARY C NORWOOD	2012-07-18
001	2010-01-01	MARY NORWOOD	2011-09-26	MARY NORWOOD	2011-09-26
001	2009-01-01	MARY NORWOOD

Plan Statistics for CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN

401k plan membership statisitcs for CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN

Measure Date Value
2017: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 73
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 15
Total of all active and inactive participants 2017-01-01 88
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 88
Number of participants with account balances 2017-01-01 46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 0
2016: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 96
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 15
Total of all active and inactive participants 2016-01-01 111
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 111
Number of participants with account balances 2016-01-01 46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 116
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 109
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 12
Total of all active and inactive participants 2015-01-01 121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 121
Number of participants with account balances 2015-01-01 49
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 94
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 14
Total of all active and inactive participants 2014-01-01 108
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 108
Number of participants with account balances 2014-01-01 52
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 105
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 2013-01-01 117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 117
Number of participants with account balances 2013-01-01 52
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 106
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 17
Total of all active and inactive participants 2012-01-01 123
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 123
Number of participants with account balances 2012-01-01 63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2009: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 144
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 112
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 9
Total of all active and inactive participants 2009-01-01 121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 121
Number of participants with account balances 2009-01-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2017: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	73
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	15
Total of all active and inactive participants	2017-01-01	88
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	88
Number of participants with account balances	2017-01-01	46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	0
2016: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	96
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	15
Total of all active and inactive participants	2016-01-01	111
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	111
Number of participants with account balances	2016-01-01	46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	116
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	109
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	12
Total of all active and inactive participants	2015-01-01	121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	121
Number of participants with account balances	2015-01-01	49
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	94
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	14
Total of all active and inactive participants	2014-01-01	108
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	108
Number of participants with account balances	2014-01-01	52
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	105
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	117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	117
Number of participants with account balances	2013-01-01	52
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	106
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	17
Total of all active and inactive participants	2012-01-01	123
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	123
Number of participants with account balances	2012-01-01	63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2009: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	144
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	112
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	9
Total of all active and inactive participants	2009-01-01	121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	121
Number of participants with account balances	2009-01-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN

Measure	Date	Value
2017 : CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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	$147,574
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$218,515
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$214,845
Value of total corrective distributions	2017-12-31	$2,670
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$53,059
Value of total assets at end of year	2017-12-31	$640,352
Value of total assets at beginning of year	2017-12-31	$711,293
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$1,000
Total interest from all sources	2017-12-31	$2,655
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	$79,814
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$45,981
Participant contributions at end of year	2017-12-31	$24,667
Participant contributions at beginning of year	2017-12-31	$22,994
Participant contributions at end of year	2017-12-31	$4,938
Participant contributions at beginning of year	2017-12-31	$2,901
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	$-70,941
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$640,352
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$711,293
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	$478,391
Value of interest in pooled separate accounts at beginning of year	2017-12-31	$575,519
Interest on participant loans	2017-12-31	$1,274
Interest earned on other investments	2017-12-31	$1,381
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-12-31	$131,598
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-12-31	$109,424
Net investment gain/loss from pooled separate accounts	2017-12-31	$91,860
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	Yes
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	$7,078
Employer contributions (assets) at end of year	2017-12-31	$758
Employer contributions (assets) at beginning of year	2017-12-31	$455
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$214,845
Contract administrator fees	2017-12-31	$1,000
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	CURTIS BLAKELY & CO., P.C.
Accountancy firm EIN	2017-12-31	751546734
2016 : CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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	$109,915
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$135,805
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$126,620
Expenses. Certain deemed distributions of participant loans	2016-12-31	$8,185
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$59,533
Value of total assets at end of year	2016-12-31	$711,293
Value of total assets at beginning of year	2016-12-31	$737,183
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$1,000
Total interest from all sources	2016-12-31	$2,548
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	$79,814
If this is an individual account plan, was there a blackout period	2016-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$52,274
Participant contributions at end of year	2016-12-31	$22,994
Participant contributions at beginning of year	2016-12-31	$56,673
Participant contributions at end of year	2016-12-31	$2,901
Participant contributions at beginning of year	2016-12-31	$1,921
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	$-25,890
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$711,293
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$737,183
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	$575,519
Value of interest in pooled separate accounts at beginning of year	2016-12-31	$570,829
Interest on participant loans	2016-12-31	$1,305
Income. Interest from loans (other than to participants)	2016-12-31	$0
Interest earned on other investments	2016-12-31	$1,243
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-12-31	$109,424
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-12-31	$107,472
Net investment gain/loss from pooled separate accounts	2016-12-31	$47,834
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	Yes
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	$7,259
Employer contributions (assets) at end of year	2016-12-31	$455
Employer contributions (assets) at beginning of year	2016-12-31	$288
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$126,620
Contract administrator fees	2016-12-31	$1,000
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	CURTIS BLAKELY & CO., P.C.
Accountancy firm EIN	2016-12-31	751546734
2015 : CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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	$44,634
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$87,309
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$85,734
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$50,521
Value of total assets at end of year	2015-12-31	$737,183
Value of total assets at beginning of year	2015-12-31	$779,858
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$1,575
Total interest from all sources	2015-12-31	$2,629
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	$79,814
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	$43,183
Participant contributions at end of year	2015-12-31	$56,673
Participant contributions at beginning of year	2015-12-31	$27,349
Participant contributions at end of year	2015-12-31	$1,921
Participant contributions at beginning of year	2015-12-31	$3,485
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	$-42,675
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$737,183
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$779,858
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	$570,829
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$645,642
Interest on participant loans	2015-12-31	$1,214
Interest earned on other investments	2015-12-31	$1,415
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$107,472
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$102,728
Net investment gain/loss from pooled separate accounts	2015-12-31	$-8,516
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	$7,338
Employer contributions (assets) at end of year	2015-12-31	$288
Employer contributions (assets) at beginning of year	2015-12-31	$654
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$85,734
Contract administrator fees	2015-12-31	$1,575
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	CURTIS BLAKELY & CO., P.C.
Accountancy firm EIN	2015-12-31	751546734
2014 : CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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	$95,988
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$114,265
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$111,059
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$57,313
Value of total assets at end of year	2014-12-31	$779,858
Value of total assets at beginning of year	2014-12-31	$798,135
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$3,206
Total interest from all sources	2014-12-31	$2,606
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$79,814
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$48,304
Participant contributions at end of year	2014-12-31	$27,349
Participant contributions at beginning of year	2014-12-31	$21,735
Participant contributions at end of year	2014-12-31	$3,485
Participant contributions at beginning of year	2014-12-31	$2,087
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	$-18,277
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$779,858
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$798,135
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	$645,642
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$671,768
Interest on participant loans	2014-12-31	$1,310
Interest earned on other investments	2014-12-31	$1,296
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$102,728
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$102,166
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$-1,869
Net investment gain/loss from pooled separate accounts	2014-12-31	$37,938
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	$9,009
Employer contributions (assets) at end of year	2014-12-31	$654
Employer contributions (assets) at beginning of year	2014-12-31	$379
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$111,059
Contract administrator fees	2014-12-31	$3,206
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	CURTIS BLAKELY & CO., P.C.
Accountancy firm EIN	2014-12-31	751546734
2013 : CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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	$218,135
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$32,465
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$30,765
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$63,163
Value of total assets at end of year	2013-12-31	$796,265
Value of total assets at beginning of year	2013-12-31	$610,595
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$1,700
Total interest from all sources	2013-12-31	$3,219
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	$50,000
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	$52,886
Participant contributions at end of year	2013-12-31	$21,735
Participant contributions at beginning of year	2013-12-31	$20,464
Participant contributions at end of year	2013-12-31	$2,087
Participant contributions at beginning of year	2013-12-31	$4,323
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	$185,670
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$796,265
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$610,595
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	$671,767
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$496,945
Interest on participant loans	2013-12-31	$1,730
Interest earned on other investments	2013-12-31	$1,489
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$100,297
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$93,186
Net investment gain/loss from pooled separate accounts	2013-12-31	$151,753
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	$10,277
Employer contributions (assets) at end of year	2013-12-31	$379
Employer contributions (assets) at beginning of year	2013-12-31	$667
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$30,765
Contract administrator fees	2013-12-31	$1,700
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	CURTIS BLAKELY & CO PC
Accountancy firm EIN	2013-12-31	751546734
2012 : CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 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	$135,748
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$5,902
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$4,527
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$68,139
Value of total assets at end of year	2012-12-31	$616,522
Value of total assets at beginning of year	2012-12-31	$486,676
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$1,375
Total interest from all sources	2012-12-31	$1,488
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	$50,000
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	$56,398
Participant contributions at end of year	2012-12-31	$21,401
Participant contributions at beginning of year	2012-12-31	$22,383
Participant contributions at end of year	2012-12-31	$4,167
Other income not declared elsewhere	2012-12-31	$1,569
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	$129,846
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$616,522
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$486,676
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	$496,945
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$386,030
Interest on participant loans	2012-12-31	$1,488
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$93,186
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$78,263
Net investment gain/loss from pooled separate accounts	2012-12-31	$64,552
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	$11,741
Employer contributions (assets) at end of year	2012-12-31	$823
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$4,527
Contract administrator fees	2012-12-31	$1,375
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

Form 5500 Responses for CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN

2017: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
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: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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
2009: CEDAR LAKE NURSING HOME, INC 401(K) PROFIT SHARING 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

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

13212

Policy instance

Insurance contract or identification number	13212
Number of Individuals Covered	46
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $0
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?	Yes
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

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

13212

Policy instance

Insurance contract or identification number	13212
Number of Individuals Covered	49
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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?	Yes
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

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

13212

Policy instance

Insurance contract or identification number	13212
Number of Individuals Covered	52
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
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

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

13212

Policy instance

Insurance contract or identification number	13212
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 $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

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

13212

Policy instance

Insurance contract or identification number	13212
Number of Individuals Covered	63
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,312
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

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Company Name:	CEDAR LAKE NURSING HOME, INC
Employer identification number (EIN):	751667895
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities