EIN: 250969478
UEI: GSA_MIGRATION
Single Audit filed under EIN: 251527666
202932676, 237040715, 250965419, 250986051, 251349943, 251738347, 251883384 · unlinked EINs have no separate FAC filing
Audited by: CLIFTONLARSONALLEN
Oversight agency: 14 [Department of Housing and Urban Development]
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Data as of September 7, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on May 15, 2022. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by November 15, 2022 (1393 days ago).
What is a management decision? →St. John was charged a management fee by SeniorLife, its parent but did not have an approved management contract meeting the requirements of the regulatory agreement. Questioned costs: None. Context: St. John did not have an approved management agreement. Cause: St. John?s existing management agreement was with Lutheran Affiliated Services (LAS) from 1992 and had not been updated to reflect the current management fee charged by the successor to LAS, SeniorLife. Effect: The management agreement was not approved by HUD and did not contain the provisions required by the regulatory agreement. Recommendation: St. John should enter into an approved management agreement with SeniorLife. Views of Responsible Officials and Planned Corrective Actions: St. John updated internal agreements to reflect the change from Lutheran Affiliated Services to Lutheran SeniorLife, but neglected to complete the process with HUD. St John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating without this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions. During Fiscal Year 2021, St John entered into a refinancing plan with a lender in order to facilitate a repositioning of the facility and to enable facility improvements that were identified. The closing on the refinancing of the existing HUD loan took place on July 8, 2021
Show full finding ▾Hide full finding ▴2021-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities CFDA Number: 14.129 Award Period: Year Ended June 30, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: Failure to Maintain Approved Management Agreements Condition: St. John was charged a management fee by SeniorLife, its parent but did not have an approved management contract meeting the requirements of the regulatory agreement. Questioned costs: None. Context: St. John did not have an approved management agreement. Cause: St. John?s existing management agreement was with Lutheran Affiliated Services (LAS) from 1992 and had not been updated to reflect the current management fee charged by the successor to LAS, SeniorLife. Effect: The management agreement was not approved by HUD and did not contain the provisions required by the regulatory agreement. Recommendation: St. John should enter into an approved management agreement with SeniorLife. Views of Responsible Officials and Planned Corrective Actions: St. John updated internal agreements to reflect the change from Lutheran Affiliated Services to Lutheran SeniorLife, but neglected to complete the process with HUD. St John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating without this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions. During Fiscal Year 2021, St John entered into a refinancing plan with a lender in order to facilitate a repositioning of the facility and to enable facility improvements that were identified. The closing on the refinancing of the existing HUD loan took place on July 8, 2021
Views of Responsible Officials and Planned Corrective Actions: St. John updated internal agreements to reflect the change from Lutheran Affiliated Services to Lutheran SeniorLife, but neglected to complete the process with HUD. St John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating without this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions. During Fiscal Year 2021, St John entered into a refinancing plan with a lender in order to facilitate a repositioning of the facility and to enable facility improvements that were identified. The closing on the refinancing of the existing HUD loan took place on July 8, 2021.
2020-001
St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Questioned costs: None. Context: Results of REAC inspection 613308. Cause: St. John has not corrected all deficiencies identified during the REAC inspection. Effect: Noncompliance with HUD requirements. Recommendation: St. John should work to address all REAC inspection findings. Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of Covid-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other vendors has been limited for a number of periods during the pandemic during FY21. Management completed an assessment of the facility?s use and has begun a repositioning plan to bring new living options into the building. In order to complete the needed improvements to the building, St. John has completed a refinancing of its existing HUD debt and negotiated a construction loan to fund the improvements. The closing on the refinancing of the existing HUD loan and the construction loan took place on July 8, 2021.
Show full finding ▾Hide full finding ▴2021-002 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities CFDA Number: 14.129 Award Period: Year Ended June 30, 2021 Type of Finding: ? Material Weakness in Internal Control over Compliance ? Material Noncompliance (Modified Opinion) Criteria or specific requirement: REAC Inspection Results Condition: St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Questioned costs: None. Context: Results of REAC inspection 613308. Cause: St. John has not corrected all deficiencies identified during the REAC inspection. Effect: Noncompliance with HUD requirements. Recommendation: St. John should work to address all REAC inspection findings. Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of Covid-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other vendors has been limited for a number of periods during the pandemic during FY21. Management completed an assessment of the facility?s use and has begun a repositioning plan to bring new living options into the building. In order to complete the needed improvements to the building, St. John has completed a refinancing of its existing HUD debt and negotiated a construction loan to fund the improvements. The closing on the refinancing of the existing HUD loan and the construction loan took place on July 8, 2021.
Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of Covid-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other vendors has been limited for a number of periods during the pandemic during FY21. Management completed an assessment of the facility?s use and has begun a repositioning plan to bring new living options into the building. In order to complete the needed improvements to the building, St. John has completed a refinancing of its existing HUD debt and negotiated a construction loan to fund the improvements. The closing on the refinancing of the existing HUD loan and the construction loan took place on July 8, 2021.
2020-002
Two instances of expenses incurred prior to March 1, 2020 were included in the Non-Public Nursing Facility Act 24 Cost Reporting Form. Questioned costs: $38,962. Context: 60 expenses sampled from the Non-Public Nursing Facility Act 24 Cost Reporting Form. Cause: Expenses were included based on payment date rather than incurred date. Effect: Overstatement of reported expenses in the Non-Public Nursing Facility Act 24 Cost Reporting Form. Recommendation: St. John should review all expenses being reported to ensure they relate to the proper reporting period.. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the inclusion of two expenses on the ACT24 cost report that were outside the reporting period. These were pulled in error based on the payment date of the expense versus the incurred date. There were sufficient expenses reported to cover the use of funds with the exclusion of these two items. For any future reporting, management will implement further detailed review of reported expenses to ensure that all expenses are reported in the proper period by incurred date versus payment date.
Show full finding ▾Hide full finding ▴2021-003 Federal agency: U.S. Department of the Treasury Federal program title: Coronavirus Relief Fund CFDA Number: 21.019 Pass-through Agency: Pennsylvania Department of Human Services Award Period: Year Ended June 30, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: Pennsylvania Department of Human Services required cost reporting related to the Public Health Emergency (PHE). COVID-19 PHE expenses included in the report should began or for increases after March 1, 2020. Condition: Two instances of expenses incurred prior to March 1, 2020 were included in the Non-Public Nursing Facility Act 24 Cost Reporting Form. Questioned costs: $38,962. Context: 60 expenses sampled from the Non-Public Nursing Facility Act 24 Cost Reporting Form. Cause: Expenses were included based on payment date rather than incurred date. Effect: Overstatement of reported expenses in the Non-Public Nursing Facility Act 24 Cost Reporting Form. Recommendation: St. John should review all expenses being reported to ensure they relate to the proper reporting period.. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the inclusion of two expenses on the ACT24 cost report that were outside the reporting period. These were pulled in error based on the payment date of the expense versus the incurred date. There were sufficient expenses reported to cover the use of funds with the exclusion of these two items. For any future reporting, management will implement further detailed review of reported expenses to ensure that all expenses are reported in the proper period by incurred date versus payment date.
Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the inclusion of two expenses on the ACT24 cost report that were outside the reporting period. These were pulled in error based on the payment date of the expense versus the incurred date. There were sufficient expenses reported to cover the use of funds with the exclusion of these two items. For any future reporting, management will implement further detailed review of reported expenses to ensure that all expenses are reported in the proper period by incurred date versus payment date.
FAC accepted this audit on March 14, 2021 — management decision was due September 14, 2021.
St. John was charged a management fee by SeniorLife, its parent but did not have an approved management contract meeting the requirements of the regulatory agreement. Questioned costs: None. Context: St. John did not have an approved management agreement. Cause: St. John?s existing management agreement was with Lutheran Affiliated Services (LAS) from 1992 and had not been updated to reflect the current management fee charged by the successor to LAS, SeniorLife. Effect: The management agreement was not approved by HUD and did not contain the provisions required by the regulatory agreement. Recommendation: St. John should enter into an approved management agreement with SeniorLife. Views of Responsible Officials and Planned Corrective Actions: St. John updated internal agreements to reflect the change from Lutheran Affiliated Services to Lutheran SeniorLife, but neglected to complete the process with HUD. St. John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating with this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Housing and Urban Development Federal program title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities CFDA Number: 14.129 Award Period: Year Ended June 30, 2020 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: Failure to Maintain Approved Management Agreements Condition: St. John was charged a management fee by SeniorLife, its parent but did not have an approved management contract meeting the requirements of the regulatory agreement. Questioned costs: None. Context: St. John did not have an approved management agreement. Cause: St. John?s existing management agreement was with Lutheran Affiliated Services (LAS) from 1992 and had not been updated to reflect the current management fee charged by the successor to LAS, SeniorLife. Effect: The management agreement was not approved by HUD and did not contain the provisions required by the regulatory agreement. Recommendation: St. John should enter into an approved management agreement with SeniorLife. Views of Responsible Officials and Planned Corrective Actions: St. John updated internal agreements to reflect the change from Lutheran Affiliated Services to Lutheran SeniorLife, but neglected to complete the process with HUD. St. John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating with this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions.
Views of Responsible Officials and Planned Corrective Actions: St. John updated internal agreements to reflect the change from Lutheran Affiliated Services to Lutheran SeniorLife, but neglected to complete the process with HUD. St. John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating with this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions.
2019-001
St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Questioned costs: None. Context: Results of REAC inspection 613308. Cause: St. John has not corrected all deficiencies identified during the REAC inspection. Effect: Noncompliance with HUD requirements. Recommendation: St. John should work to address all REAC inspection findings. Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of COVID-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other Vendors has been limited to emergencies only during the pandemic. Once COVID-19 restrictions are lifted, St. John will prioritize needs at the facility and will address the inspection findings as soon as possible.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Housing and Urban Development Federal program title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities CFDA Number: 14.129 Award Period: Year Ended June 30, 2020 Type of Finding: ? Material Weakness in Internal Control over Compliance ? Material Noncompliance (Modified Opinion) Criteria or specific requirement: REAC Inspection Results Condition: St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Questioned costs: None. Context: Results of REAC inspection 613308. Cause: St. John has not corrected all deficiencies identified during the REAC inspection. Effect: Noncompliance with HUD requirements. Recommendation: St. John should work to address all REAC inspection findings. Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of COVID-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other Vendors has been limited to emergencies only during the pandemic. Once COVID-19 restrictions are lifted, St. John will prioritize needs at the facility and will address the inspection findings as soon as possible.
Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of COVID-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other Vendors has been limited to emergencies only during the pandemic. Once COVID-19 restrictions are lifted, St. John will prioritize needs at the facility and will address the inspection findings as soon as possible.
2019-002
FAC accepted this audit on February 20, 2020 — management decision was due August 20, 2020.
St. John was charged a management fee by SeniorLife, its parent but did not have an approved management contract meeting the requirements of the regulatory agreement. Questioned costs: None. Context: St. John did not have an approved management agreement. Cause: St. John?s existing management agreement was with Lutheran Affiliated Services (LAS) from 1992 and had not been updated to reflect the current management fee charged by the successor to LAS, SeniorLife. Effect: The management agreement was not approved by HUD and did not contain the provisions required by the regulatory agreement. Recommendation: St. John should enter into an approved management agreement with SeniorLife. Views of Responsible Officials and Planned Corrective Actions: St. John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating with this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions.
Show full finding ▾Hide full finding ▴2019-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities CFDA Number: 14.129 Award Period: Year Ended June 30, 2019 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: Failure to Maintain Approved Management Agreements Condition: St. John was charged a management fee by SeniorLife, its parent but did not have an approved management contract meeting the requirements of the regulatory agreement. Questioned costs: None. Context: St. John did not have an approved management agreement. Cause: St. John?s existing management agreement was with Lutheran Affiliated Services (LAS) from 1992 and had not been updated to reflect the current management fee charged by the successor to LAS, SeniorLife. Effect: The management agreement was not approved by HUD and did not contain the provisions required by the regulatory agreement. Recommendation: St. John should enter into an approved management agreement with SeniorLife. Views of Responsible Officials and Planned Corrective Actions: St. John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating with this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions.
Views of Responsible Officials and Planned Corrective Actions: St. John will submit the paperwork to obtain a certified HUD approved management agreement. While the organization was operating with this agreement in place, management fees charged were only to reimburse costs incurred in performing these management functions.
St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Questioned costs: None. Context: Results of REAC inspection 613308. Cause: St. John has not corrected all deficiencies identified during the REAC inspection. Effect: Noncompliance with HUD requirements. Recommendation: St. John should work to address all REAC inspection findings. Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. St. John is prioritizing needs at the facility and will address the inspection findings as soon as feasible.
Show full finding ▾Hide full finding ▴2019-002 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities CFDA Number: 14.129 Award Period: Year Ended June 30, 2019 Type of Finding: ? Material Weakness in Internal Control over Compliance ? Material Noncompliance (Modified Opinion) Criteria or specific requirement: REAC Inspection Results Condition: St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Questioned costs: None. Context: Results of REAC inspection 613308. Cause: St. John has not corrected all deficiencies identified during the REAC inspection. Effect: Noncompliance with HUD requirements. Recommendation: St. John should work to address all REAC inspection findings. Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. St. John is prioritizing needs at the facility and will address the inspection findings as soon as feasible.
Views of Responsible Officials and Planned Corrective Actions: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. St. John is prioritizing needs at the facility and will address the inspection findings as soon as feasible.
FAC accepted this audit on December 19, 2018 — management decision was due June 19, 2019.
FAC accepted this audit on December 9, 2017 — management decision was due June 9, 2018.
FAC accepted this audit on December 20, 2016 — management decision was due June 20, 2017.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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