Nursing HomeInspections

Locust Grove Retirement Village

Nursing home in Mifflin, PA

Medicare & Medicaid certified3★ overall (CMS)

Call (717) 436-8921Send a messageMap ↗

Public-record details

Address
69 Cottage Road, Mifflin, PA 17058
Phone
(717) 436-8921
Listed under
For-profit
Medicare CCN
395350
Overall star rating
3 of 5 ★★★☆☆
Health inspection rating
3 of 5
Staffing rating
4 of 5
Quality measures rating
4 of 5
Certified beds
104
Average residents per day
66
Ownership
For-profit, corporation
Legal business name
69 Cottage Road Opco LLC
Chain
Avardis Health (38 facilities)
Certified for
Medicare and Medicaid
First approved by Medicare/Medicaid
May 12, 1976
Changed ownership in last 12 months
No
Continuing care retirement community
No
Located inside a hospital
No
Resident or family council
Resident council
Sprinklers in all required areas
Yes

CMS certification number 395350. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: Jun 27, 2025. CMS lists 39 health citations for this facility across its last three standard inspection cycles and complaint inspections (Aug 4, 2023 to Jun 27, 2025): 7 from complaint inspections, 1 at the “actual harm” level or higher.

InspectionCitationSeverity
Jun 27, 2025Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning		D
Potential for more than minimal harm, isolated
Jun 27, 2025Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jun 27, 2025Provide 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.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jun 27, 2025Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jun 27, 2025Provide 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…
Quality of Life and Care		D
Potential for more than minimal harm, isolated
Jun 27, 2025Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care · complaint inspection		D
Potential for more than minimal harm, isolated
Jun 27, 2025Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care		E
Potential for more than minimal harm, pattern
Jun 27, 2025Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care		E
Potential for more than minimal harm, pattern
Oct 9, 2024Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care · complaint inspection		D
Potential for more than minimal harm, isolated
Jun 18, 2024Provide routine and 24-hour emergency dental care for each resident.
Quality of Life and Care · complaint inspection		D
Potential for more than minimal harm, isolated
May 3, 2024Honor 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…
Resident Rights		D
Potential for more than minimal harm, isolated
May 3, 2024Honor 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.
Resident Rights		D
Potential for more than minimal harm, isolated

Showing the 12 most recent of 39. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records 1 fine totalling $12,831 in the last three years.

May 3, 2024Fine: $12,831

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day
3.91 hours
Registered nurse (RN) time per resident per day
0.60 hours
Nurse aide time per resident per day
2.15 hours
Total nurse staffing on weekends
3.24 hours
Nursing staff turnover (yearly)
34%
RN turnover (yearly)
25%
Administrators who left in the past year
1

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.