401k Plan data: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN plan

BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 401k Plan overview

Plan Name	BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN
Plan identification number	001

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

401k Sponsoring company profile

SOUTH HILLS, LLC DBA BOULEVARD HEALTH CTR has sponsored the creation of one or more 401k plans.

Company Name: SOUTH HILLS, LLC DBA BOULEVARD HEALTH CTR

Employer identification number (EIN): 260343272

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2016-01-01 DOUG MACHOWICZ
001 2016-01-01
001 2015-01-01 KIM JOHNSON KIM JOHNSON 2016-10-13
001 2014-01-01 DOUGLAS E MACHOWICZ
001 2013-01-01 DOUGLAS E MACHOWICZ
001 2012-01-01 KEITH POMEROY
001 2011-01-01 KEITH POMEROY
001 2010-01-01 KEITH POMEROY 2011-09-19

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2016-01-01	DOUG MACHOWICZ
001	2016-01-01
001	2015-01-01	KIM JOHNSON		KIM JOHNSON	2016-10-13
001	2014-01-01	DOUGLAS E MACHOWICZ
001	2013-01-01	DOUGLAS E MACHOWICZ
001	2012-01-01	KEITH POMEROY
001	2011-01-01	KEITH POMEROY
001	2010-01-01	KEITH POMEROY	2011-09-19

Plan Statistics for BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN

401k plan membership statisitcs for BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN

Measure Date Value
2016: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 236
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
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 0
Total of all active and inactive participants 2016-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 0
Number of participants with account balances 2016-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 254
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 203
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 33
Total of all active and inactive participants 2015-01-01 236
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 236
Number of participants with account balances 2015-01-01 63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 230
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 221
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 24
Total of all active and inactive participants 2014-01-01 245
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 245
Number of participants with account balances 2014-01-01 58
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 179
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 207
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 11
Total of all active and inactive participants 2013-01-01 218
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 218
Number of participants with account balances 2013-01-01 46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 191
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 170
Number of retired or separated participants receiving benefits 2012-01-01 1
Number of other retired or separated participants entitled to future benefits 2012-01-01 8
Total of all active and inactive participants 2012-01-01 179
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 179
Number of participants with account balances 2012-01-01 36
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 195
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 176
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 7
Total of all active and inactive participants 2011-01-01 183
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 183
Number of participants with account balances 2011-01-01 35
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0

Measure	Date	Value
2016: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	236
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
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	0
Total of all active and inactive participants	2016-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	0
Number of participants with account balances	2016-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	254
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	203
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	33
Total of all active and inactive participants	2015-01-01	236
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	236
Number of participants with account balances	2015-01-01	63
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	230
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	221
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	24
Total of all active and inactive participants	2014-01-01	245
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	245
Number of participants with account balances	2014-01-01	58
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	179
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	207
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	11
Total of all active and inactive participants	2013-01-01	218
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	218
Number of participants with account balances	2013-01-01	46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	191
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	170
Number of retired or separated participants receiving benefits	2012-01-01	1
Number of other retired or separated participants entitled to future benefits	2012-01-01	8
Total of all active and inactive participants	2012-01-01	179
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	179
Number of participants with account balances	2012-01-01	36
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	195
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	176
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	7
Total of all active and inactive participants	2011-01-01	183
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	183
Number of participants with account balances	2011-01-01	35
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0

Financial Data on BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN

Measure	Date	Value
2016 : BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total transfer of assets from this plan	2016-12-31	$571,155
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	$156,272
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$47,468
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$46,415
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$105,271
Value of total assets at end of year	2016-12-31	$0
Value of total assets at beginning of year	2016-12-31	$462,351
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$1,053
Total interest from all sources	2016-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Transfers to/from the plan	2016-12-31	$0
Total plan liabilities at end of year	2016-12-31	$0
Total plan liabilities at beginning of year	2016-12-31	$0
Total income from all sources	2016-12-31	$618,623
Expenses. Total of all expenses incurred	2016-12-31	$47,468
Benefits paid (including direct rollovers)	2016-12-31	$46,415
Total plan assets at end of year	2016-12-31	$571,155
Total plan assets at beginning of year	2016-12-31	$0
Value of fidelity bond covering the plan	2016-12-31	$20,000
Total contributions received or receivable from participants	2016-12-31	$105,271
Expenses. Other expenses not covered elsewhere	2016-12-31	$0
Contributions received from other sources (not participants or employers)	2016-12-31	$0
Other income received	2016-12-31	$513,352
Net income (gross income less expenses)	2016-12-31	$571,155
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$571,155
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$0
Assets. Value of participant loans	2016-12-31	$7,806
Total contributions received or receivable from employer(s)	2016-12-31	$0
Value of certain deemed distributions of participant loans	2016-12-31	$0
Value of corrective distributions	2016-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$1,053
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2016-12-31	$0
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$20,000
If this is an individual account plan, was there a blackout period	2016-12-31	Yes
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2016-12-31	$0
Minimum employer required contribution for this plan year	2016-12-31	$0
Amount contributed by the employer to the plan for this plan year	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	$105,271
Participant contributions at beginning of year	2016-12-31	$11,522
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2016-12-31	$46,415
Administrative expenses (other) incurred	2016-12-31	$1,053
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	$108,804
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$0
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$462,351
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 registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$450,829
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$51,001
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
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2016-12-31	Yes
Did the plan have assets held for investment	2016-12-31	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	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	Yes
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	PLANTE & MORAN PLLC
Accountancy firm EIN	2016-12-31	381357951
2015 : BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total transfer of assets to this plan	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	$102,276
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$35,945
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$35,620
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$112,947
Value of total assets at end of year	2015-12-31	$462,351
Value of total assets at beginning of year	2015-12-31	$396,020
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$325
Total interest from all sources	2015-12-31	$491
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$19,307
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2015-12-31	$19,307
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$40,000
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	$112,947
Participant contributions at end of year	2015-12-31	$11,522
Participant contributions at beginning of year	2015-12-31	$7,696
Assets. Other investments not covered elsewhere at end of year	2015-12-31	$0
Administrative expenses (other) incurred	2015-12-31	$325
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	$66,331
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$462,351
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$396,020
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 registered invesment companies (eg mutual funds) at end of year	2015-12-31	$450,829
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$388,324
Interest on participant loans	2015-12-31	$491
Value of interest in common/collective trusts at end of year	2015-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2015-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-30,469
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	Yes
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$35,620
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	PLANTE MORAN
Accountancy firm EIN	2015-12-31	381357951
2014 : BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total transfer of assets to this plan	2014-12-31	$0
Total transfer of assets from this plan	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	$12,726
Total income from all sources (including contributions)	2014-12-31	$140,322
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$39,995
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$25,674
Value of total corrective distributions	2014-12-31	$13,598
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$123,047
Value of total assets at end of year	2014-12-31	$396,020
Value of total assets at beginning of year	2014-12-31	$308,419
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$723
Total interest from all sources	2014-12-31	$304
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$18,006
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	$18,006
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$30,000
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	$123,047
Participant contributions at end of year	2014-12-31	$7,696
Participant contributions at beginning of year	2014-12-31	$678
Participant contributions at beginning of year	2014-12-31	$7,352
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2014-12-31	$12,726
Administrative expenses (other) incurred	2014-12-31	$723
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	$100,327
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$396,020
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$295,693
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	$388,324
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$300,389
Interest on participant loans	2014-12-31	$304
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$-1,035
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	Yes
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$25,674
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	PLANTE MORAN
Accountancy firm EIN	2014-12-31	381357951
2013 : BOULEVARD HEALTH CENTER 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	$12,726
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	$128,626
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$21,806
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$19,949
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$82,795
Value of total assets at end of year	2013-12-31	$308,419
Value of total assets at beginning of year	2013-12-31	$188,873
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$1,857
Total interest from all sources	2013-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$10,634
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	$10,634
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$19,000
If this is an individual account plan, was there a blackout period	2013-12-31	Yes
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	$82,795
Participant contributions at end of year	2013-12-31	$678
Participant contributions at end of year	2013-12-31	$7,352
Participant contributions at beginning of year	2013-12-31	$8,802
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2013-12-31	$12,726
Administrative expenses (other) incurred	2013-12-31	$1,857
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	$106,820
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$295,693
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$188,873
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	$300,389
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$180,071
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2013-12-31	$35,197
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$19,949
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2013-12-31	Yes
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	PLANTE MORAN
Accountancy firm EIN	2013-12-31	381357951
2012 : BOULEVARD HEALTH CENTER 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	$97,562
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$28,688
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$24,915
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$80,712
Value of total assets at end of year	2012-12-31	$188,873
Value of total assets at beginning of year	2012-12-31	$119,999
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$3,773
Total interest from all sources	2012-12-31	$0
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
Administrative expenses professional fees incurred	2012-12-31	$3,773
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$80,000
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	$80,712
Participant contributions at end of year	2012-12-31	$8,802
Participant contributions at beginning of year	2012-12-31	$2,077
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	$68,874
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$188,873
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$119,999
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	$180,071
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$117,922
Net investment gain/loss from pooled separate accounts	2012-12-31	$16,850
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	Yes
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$24,915
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	PLANTE & MORAN PLLC
Accountancy firm EIN	2012-12-31	381357951
2011 : BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 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	$64,693
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$12,656
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$8,374
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$69,955
Value of total assets at end of year	2011-12-31	$119,999
Value of total assets at beginning of year	2011-12-31	$67,962
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$4,282
Total interest from all sources	2011-12-31	$0
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	$80,000
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	$69,955
Participant contributions at end of year	2011-12-31	$2,077
Participant contributions at beginning of year	2011-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$52,037
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$119,999
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$67,962
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in pooled separate accounts at end of year	2011-12-31	$117,922
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$67,962
Net investment gain/loss from pooled separate accounts	2011-12-31	$-5,262
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$8,374
Contract administrator fees	2011-12-31	$4,282
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	PLANTE & MORAN PLLC
Accountancy firm EIN	2011-12-31	381357951

Form 5500 Responses for BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN

2016: BOULEVARD HEALTH CENTER 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	Yes
2016-01-01	This submission is the final filing	Yes
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 – Trust	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: BOULEVARD HEALTH CENTER 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 – Trust	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: BOULEVARD HEALTH CENTER 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 – Trust	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: BOULEVARD HEALTH CENTER 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	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: BOULEVARD HEALTH CENTER 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	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: BOULEVARD HEALTH CENTER 401(K) PROFIT SHARING PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	Yes
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

269-0403

Policy instance

Insurance contract or identification number	269-0403
Number of Individuals Covered	36
Insurance policy start date	2013-01-01
Insurance policy end date	2013-05-31
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

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

269-80403

Policy instance

Insurance contract or identification number	269-80403
Number of Individuals Covered	36
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $615
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
Commission paid to Insurance Broker	USD $615
Insurance broker organization code?	4
Insurance broker name	THE BURWICK GROUP

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

269-80403

Policy instance

Insurance contract or identification number	269-80403
Number of Individuals Covered	35
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $571
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

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Company Name:	SOUTH HILLS, LLC DBA BOULEVARD HEALTH CTR
Employer identification number (EIN):	260343272
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities