401k Plan data: MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN plan

MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 401k Plan overview

Plan Name	MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN
Plan identification number	001

MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
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

MIDLANDS LIVING CENTER has sponsored the creation of one or more 401k plans.

Company Name: MIDLANDS LIVING CENTER

Employer identification number (EIN): 470924532

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01 JORDAN TJADEN 2023-10-05 JORDAN TJADEN 2023-10-05
001 2021-01-01 JORDAN TJADEN 2022-07-26 JORDAN TJADEN 2022-07-26
001 2020-01-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01	JORDAN TJADEN	2023-10-05	JORDAN TJADEN	2023-10-05
001	2021-01-01	JORDAN TJADEN	2022-07-26	JORDAN TJADEN	2022-07-26
001	2020-01-01

Plan Statistics for MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN

401k plan membership statisitcs for MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN

Measure Date Value
2022: MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 99
Number of retired or separated participants receiving benefits 2022-01-01 1
Number of other retired or separated participants entitled to future benefits 2022-01-01 11
Total of all active and inactive participants 2022-01-01 111
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 111
Number of participants with account balances 2022-01-01 76
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 3
2021: MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 115
Number of retired or separated participants receiving benefits 2021-01-01 1
Number of other retired or separated participants entitled to future benefits 2021-01-01 4
Total of all active and inactive participants 2021-01-01 120
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 120
Number of participants with account balances 2021-01-01 77
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 3

Measure	Date	Value
2022: MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	99
Number of retired or separated participants receiving benefits	2022-01-01	1
Number of other retired or separated participants entitled to future benefits	2022-01-01	11
Total of all active and inactive participants	2022-01-01	111
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	111
Number of participants with account balances	2022-01-01	76
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	3
2021: MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	115
Number of retired or separated participants receiving benefits	2021-01-01	1
Number of other retired or separated participants entitled to future benefits	2021-01-01	4
Total of all active and inactive participants	2021-01-01	120
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	120
Number of participants with account balances	2021-01-01	77
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	3

Financial Data on MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN

Measure	Date	Value
2022 : MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$118,466
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$48,548
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$42,814
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$229,242
Value of total assets at end of year	2022-12-31	$705,193
Value of total assets at beginning of year	2022-12-31	$635,275
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$5,734
Total interest from all sources	2022-12-31	$762
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$100,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$140,684
Participant contributions at end of year	2022-12-31	$20,731
Participant contributions at beginning of year	2022-12-31	$13,609
Participant contributions at end of year	2022-12-31	$1,325
Participant contributions at beginning of year	2022-12-31	$1,621
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$0
Administrative expenses (other) incurred	2022-12-31	$5,734
Total non interest bearing cash at end of year	2022-12-31	$341
Total non interest bearing cash at beginning of year	2022-12-31	$1,478
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$69,918
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$705,193
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$635,275
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in pooled separate accounts at end of year	2022-12-31	$681,572
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$616,659
Interest on participant loans	2022-12-31	$762
Net investment gain/loss from pooled separate accounts	2022-12-31	$-111,538
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$88,558
Employer contributions (assets) at end of year	2022-12-31	$1,224
Employer contributions (assets) at beginning of year	2022-12-31	$1,908
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$42,814
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	FORVIS
Accountancy firm EIN	2022-12-31	440160260
2021 : MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$323,297
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$59,923
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$55,482
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$247,931
Value of total assets at end of year	2021-12-31	$635,275
Value of total assets at beginning of year	2021-12-31	$371,901
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$4,441
Total interest from all sources	2021-12-31	$227
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Administrative expenses professional fees incurred	2021-12-31	$4,441
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$100,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$136,228
Participant contributions at end of year	2021-12-31	$13,609
Participant contributions at beginning of year	2021-12-31	$0
Participant contributions at end of year	2021-12-31	$1,621
Participant contributions at beginning of year	2021-12-31	$3,789
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$13,850
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2021-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2021-12-31	$0
Total non interest bearing cash at end of year	2021-12-31	$1,478
Total non interest bearing cash at beginning of year	2021-12-31	$113
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$263,374
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$635,275
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$371,901
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in pooled separate accounts at end of year	2021-12-31	$616,659
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$363,652
Interest on participant loans	2021-12-31	$227
Net investment gain/loss from pooled separate accounts	2021-12-31	$75,139
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$97,853
Employer contributions (assets) at end of year	2021-12-31	$1,908
Employer contributions (assets) at beginning of year	2021-12-31	$4,347
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$55,482
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	FORVIS
Accountancy firm EIN	2021-12-31	440160260

Form 5500 Responses for MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN

2022: MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: MIDLANDS/ NORTHCREST LIVING CENTERS 401(K) PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

142924

Policy instance

Insurance contract or identification number	142924
Number of Individuals Covered	83
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,080
Total amount of fees paid to insurance company	USD $5,736
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,080
Additional information about fees paid to insurance broker	BROKER COMMISSION
Insurance broker organization code?	7
Amount paid for insurance broker fees	5736

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

142924

Policy instance

Insurance contract or identification number	142924
Number of Individuals Covered	83
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,898
Total amount of fees paid to insurance company	USD $4,441
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,898
Insurance broker organization code?	7
Amount paid for insurance broker fees	4441
Additional information about fees paid to insurance broker	TPA FEES AND COMPENSATION

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Company Name:	MIDLANDS LIVING CENTER
Employer identification number (EIN):	470924532
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities