Locust Grove Retirement Village

69 Cottage Road · Mifflin, PA · 17058 · 7174368921

104 certified beds For profit - Corporation Chain: Avardis Health

  • Inspection results have improved across recent cycles.

The composite number cleared 71 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.

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Red flags

1 abuse-related citation at the actual-harm level

Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.

Score breakdown

Inspection record 30% of score 53
Serious harm & abuse 20% 84
Staffing 20% 72
Federal penalties 15% 75
Trend 10% 84
Context 5% 75

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 4 of 5 Inspections: 3 of 5 Staffing: 4 of 5 Quality measures: 5 of 5

Total nurse hours / resident-day3.963.48 min · 4.1 strong
RN hours / resident-day0.550.55–0.75
Weekend hours / resident-day3.25≈ weekday level
Nursing turnover / year39%median 45%
Fines (3-yr window)1 · $12,831

Inspection citations (39 in the current record)

  • Potential for harm · D June 27, 2025

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected August 22, 2025 · Resident Assessment and Care Planning

  • Potential for harm · E June 27, 2025

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected August 22, 2025 · Quality of Life and Care

  • Potential for harm · D June 27, 2025

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Corrected August 22, 2025 · Quality of Life and Care

  • Potential for harm · D June 27, 2025

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

    Corrected August 22, 2025 · Quality of Life and Care

  • Potential for harm · D June 27, 2025

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected August 22, 2025 · Quality of Life and Care

  • Potential for harm · E June 27, 2025

    Provide safe, appropriate pain management for a resident who requires such services.

    Corrected August 22, 2025 · Quality of Life and Care

  • Potential for harm · D June 27, 2025

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

    Corrected August 22, 2025 · Quality of Life and Care

  • Potential for harm · D June 27, 2025 · found via complaint

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    Corrected August 22, 2025 · Quality of Life and Care

  • Potential for harm · D October 9, 2024 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected November 15, 2024 · Quality of Life and Care

  • Potential for harm · D June 18, 2024 · found via complaint

    Provide routine and 24-hour emergency dental care for each resident.

    Corrected July 5, 2024 · Quality of Life and Care

  • Actual harm · G May 3, 2024 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected March 28, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D May 3, 2024

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

    Corrected June 14, 2024 · Resident Rights

  • Potential for harm · D May 3, 2024

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Corrected June 14, 2024 · Resident Rights

  • Potential for harm · D May 3, 2024

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Corrected June 14, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D May 3, 2024

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Corrected June 14, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D May 3, 2024

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected June 14, 2024 · Quality of Life and Care

  • Potential for harm · D May 3, 2024

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Corrected June 14, 2024 · Quality of Life and Care

  • Potential for harm · D May 3, 2024

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

    Corrected June 14, 2024 · Quality of Life and Care

  • Potential for harm · D May 3, 2024

    Provide enough food/fluids to maintain a resident's health.

    Corrected June 14, 2024 · Quality of Life and Care

  • Potential for harm · D May 3, 2024

    Provide care or services that was trauma informed and/or culturally competent.

    Corrected June 14, 2024 · Quality of Life and Care

  • Potential for harm · D May 3, 2024

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

    Corrected June 14, 2024 · Quality of Life and Care

  • Potential for harm · D May 3, 2024

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

    Corrected June 14, 2024 · Pharmacy Service

  • Potential for harm · D May 3, 2024

    Ensure medication error rates are not 5 percent or greater.

    Corrected June 14, 2024 · Pharmacy Service

  • Potential for harm · E May 3, 2024

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Corrected June 14, 2024 · Pharmacy Service

  • Potential for harm · E May 3, 2024

    Provide and implement an infection prevention and control program.

    Corrected June 14, 2024 · Infection Control

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
May 3, 2024Fine$12,831

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 395350 · certified since May 12, 1976. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.