EIN: 364467489
UEI: NKM9SAXSMLL6
Data as of August 26, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on January 10, 2023. 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 July 10, 2023 (1143 days ago).
What is a management decision? →The Organization does not have adequate internal controls in place to provide reasonable assurance that the input of infection control expenses reported in the HRSA Reporting Portal was reviewed and approved for allowability, accuracy and completeness in compliance with the terms and conditions of the PRF. Cause: The review process of the amounts submitted in the HRSA PRF Reporting Portal was not consistently documented, and therefore, controls are not operating effectively. Questioned Costs: None Context: There was no documented review of the HRSA PRF Reporting Portal submissions for Periods 2 and 3 for the infection control expenses. Repeat Finding: No Recommendation: A formal process should be implemented and placed in service to ensure the review process of the infection control expenses submitted into the HRSA PRF Reporting Portal is documented. Views of Responsible Officials: See Corrective Action Plan.
Show full finding ▾Hide full finding ▴Identifying Number: 2022-001 Information of the Federal Program: Federal Assistance Listing #93.498, Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Criteria or Specific Requirement: Uniform Guidance in 2 CFR 200.303 requires the Organization to establish and maintain internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in accordance with the terms and conditions of the grant. The Post-Payment Notice of Reporting Requirement dated June 11, 2021, requires that nursing home infection control distributions may only be used for infection control expenses, and the infection control expenses be reported in the HRSA PRF Reporting Portal. Condition: The Organization does not have adequate internal controls in place to provide reasonable assurance that the input of infection control expenses reported in the HRSA Reporting Portal was reviewed and approved for allowability, accuracy and completeness in compliance with the terms and conditions of the PRF. Cause: The review process of the amounts submitted in the HRSA PRF Reporting Portal was not consistently documented, and therefore, controls are not operating effectively. Questioned Costs: None Context: There was no documented review of the HRSA PRF Reporting Portal submissions for Periods 2 and 3 for the infection control expenses. Repeat Finding: No Recommendation: A formal process should be implemented and placed in service to ensure the review process of the infection control expenses submitted into the HRSA PRF Reporting Portal is documented. Views of Responsible Officials: See Corrective Action Plan.
Identifying Number: 2022-001 Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management reviews the reported grant expenditures. Management believes this review process to be adequate.
FAC accepted this audit on August 7, 2022 — management decision was due February 7, 2023.
The HRSA report submitted included rent revenue from retirement housing, which is not revenue from patient care. Cause: The CFO reviews and approves the lost revenue calculation. However, the CFO did not catch this error. Questioned Costs: None Repeat Finding: No Context: Population was tested 100%, therefore, was statistically valid. Recommendation: A formal process should be implemented to ensure the review process is conducted by personnel with adequate knowledge of the 2021 OMB Compliance Supplement and with proper due care to ensure the lost revenue calculation is completed. Views of Responsible Officials: Management agrees with finding 2021-001. Lost revenue reported to HRSA was $20,109,606. The corrected lost revenue that excludes rent revenue is $19,384,145. The correct lost revenue amount exceeds the award amount by $17,349,019.
Show full finding ▾Hide full finding ▴Identifying Number:2021-001 Information of the Federal Program:Federal Assistance Listing #93.498, Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Criteria or Specific Requirement:Per the 2021 OMB Compliance Supplement, revenue reported for the lost revenue calculation should include 2019, 2020, and 2021 actual revenue from patient care. Condition: The HRSA report submitted included rent revenue from retirement housing, which is not revenue from patient care. Cause: The CFO reviews and approves the lost revenue calculation. However, the CFO did not catch this error. Questioned Costs: None Repeat Finding: No Context: Population was tested 100%, therefore, was statistically valid. Recommendation: A formal process should be implemented to ensure the review process is conducted by personnel with adequate knowledge of the 2021 OMB Compliance Supplement and with proper due care to ensure the lost revenue calculation is completed. Views of Responsible Officials: Management agrees with finding 2021-001. Lost revenue reported to HRSA was $20,109,606. The corrected lost revenue that excludes rent revenue is $19,384,145. The correct lost revenue amount exceeds the award amount by $17,349,019.
Identifying Number: 2021-001 Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management asserts that the lost revenue calculation is reviewed for accuracy and compliance with the 2021 OMB Compliance Supplement. Management believes this review process to be adequate and notes that excluding the rental revenue had no impact on the lost revenue amounts covered by the provider relief funds. Lost revenue reported to HRSA was $20,109,606. The corrected lost revenue that excludes rent revenue is $19,384,145. The correct lost revenue amount exceeds the award amount by $17,349,019.
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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