Locust Grove Retirement Village
Mifflin, Juniata County, Pennsylvania · CCN 395350 · For-profit (Corporation) · part of Avardis Health (38 facilities, chain average 2 stars)
CMS rates Locust Grove Retirement Village 3 of 5 overall as of August 2026. 104 certified beds, 66 residents a day on average. 39 citations on record from the current inspection cycles, 1 involving actual harm; 1 fine totalling $12,831.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★☆☆ 3 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★★☆ 4 of 5 |
| Quality measures | ★★★★☆ 4 of 5 |
| Quality: long-stay / short-stay | 5 / 4 of 5 |
Staffing
| Total nurse staffing | 3.90637 hours per resident per day |
|---|---|
| Registered nurses | 0.60223 hours per resident per day |
| Weekend total | 3.24492 hours per resident per day |
| Nursing staff turnover | 34.3% (registered nurses 25%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-06-27 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-08-22 |
| 2025-06-27 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-08-22 |
| 2025-06-27 | Develop 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 Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-22 |
| 2025-06-27 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-22 |
| 2025-06-27 | 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-22 |
| 2025-06-27 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-22 |
| 2025-06-27 | 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. Quality of Life and Care Deficiencies · tag F0742 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-22 |
| 2025-06-27 complaint survey |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-22 |
| 2024-10-09 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-15 |
| 2024-06-18 complaint survey |
Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · tag F0790 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-05 |
| 2024-05-03 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Past Non-Compliance 2024-03-28 |
| 2024-05-03 complaint survey |
Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | 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. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | 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. Resident Rights Deficiencies · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 complaint survey |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · tag F0726 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2024-05-03 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-06-14 |
| 2023-08-04 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Nursing and Physician Services Deficiencies · tag F0729 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-08-04 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-05-03 | Fine | $12,831 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Mifflin Parentco LLC Organization | 5% or greater direct ownership interest | 100% | 2025-05-01 |
| Juniata Holdco LLC Organization | 5% or greater indirect ownership interest | — | 2025-05-01 |
| Paop Holdco LLC Organization | 5% or greater indirect ownership interest | — | 2025-05-01 |
| Mifflin Re Owner, LLC Organization | 5% or greater security interest | — | 2025-05-01 |
| Mifflin Re Owner, LLC Organization | adp of the snf | — | 2025-05-01 |
| Snf Mgr LLC Organization | adp of the snf | — | 2025-04-11 |
| Snf Mgr LLC Organization | operational/managerial control | — | 2025-05-01 |
| Clark, Alyssa Individual | adp of the snf | — | 2025-05-01 |
| Criag, Michele Individual | adp of the snf | — | 2025-05-01 |
| Hoback, Tiffany Individual | adp of the snf | — | 2025-05-01 |
| Jones, Tequilla Individual | adp of the snf | — | 2025-05-01 |
| Roscoe, Brandon Individual | adp of the snf | — | 2025-05-01 |
| Simpson, Louann Individual | adp of the snf | — | 2025-05-01 |
| Clark, Alyssa Individual | managing control - governing body | — | 2025-05-01 |
| Hoback, Tiffany Individual | managing control - governing body | — | 2025-05-01 |
| Clark, Alyssa Individual | operational/managerial control | — | 2025-05-01 |
| Criag, Michele Individual | operational/managerial control | — | 2025-05-01 |
| Hoback, Tiffany Individual | operational/managerial control | — | 2025-05-01 |
| Jones, Tequilla Individual | operational/managerial control | — | 2025-05-01 |
| Roscoe, Brandon Individual | operational/managerial control | — | 2025-05-01 |
| Simpson, Louann Individual | operational/managerial control | — | 2025-05-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Locust Grove Retirement Village.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Juniata County.