LOCUST GROVE RETIREMENT VILLAGE

CCN 395350 · 69 COTTAGE ROAD OPCO LLC · For profit - Corporation · AVARDIS HEALTH chain · 104 certified beds · Juniata · PA


LOCUST GROVE RETIREMENT VILLAGE is a 104-bed nursing home in MIFFLIN, Pennsylvania. CMS has certified it for Medicare and Medicaid since 1976-05-12. It averages 66.3 residents a day.

What harm was found in the violations cited at LOCUST GROVE RETIREMENT VILLAGE?

CMS lists 39 health-inspection deficiencies for LOCUST GROVE RETIREMENT VILLAGE, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2025-06-27.

Survey dateTagDeficiencySeverity
2025-06-27F0684, F0697Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide safe, appropriate pain management for a resident who requires such services.E
2025-06-27F0656, F0686, F0688, F0689, F0742, F0744Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / 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. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.D
2024-10-09F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D
2024-06-18F0790Provide routine and 24-hour emergency dental care for each resident.D
2024-05-03F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.G
2024-05-03F0677, F0725, F0761, F0880Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / 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. / Provide and implement an infection prevention and control program.E
2024-05-03F0578, F0584, F0607, F0655, F0684, F0686, F0688, F0692, F0699, F0726, F0744, F0758, F0759Honor 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. / 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. / Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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. / Provide enough food/fluids to maintain a resident's health. / Provide care or services that was trauma informed and/or culturally competent. / 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. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. / 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. / Ensure medication error rates are not 5 percent or greater.D
2023-08-04F0697, F0730, F0812Provide safe, appropriate pain management for a resident who requires such services. / Observe each nurse aide's job performance and give regular training. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E
2023-08-04F0600, F0607, F0641, F0684, F0686, F0729, F0791, F0842Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Ensure each resident receives an accurate assessment. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. / Provide or obtain dental services for each resident. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D

Why was LOCUST GROVE RETIREMENT VILLAGE fined?

DateTypeAmount
2024-05-03Fine$12,831

How is LOCUST GROVE RETIREMENT VILLAGE staffed?

MeasureThis facilityPA average
Total nurse staffing hours per resident per day3.906373.88823
Total nursing staff turnover (%)34.344.5
Average number of residents per day66.3104.6

Who owns LOCUST GROVE RETIREMENT VILLAGE, and what chain is it in?

LOCUST GROVE RETIREMENT VILLAGE is registered with CMS as For profit - Corporation, operates under the legal business name 69 COTTAGE ROAD OPCO LLC and belongs to the AVARDIS HEALTH chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTMIFFLIN PARENTCO LLCsince 05/01/2025
5% OR GREATER INDIRECT OWNERSHIP INTERESTJUNIATA HOLDCO LLC, PAOP HOLDCO LLCsince 05/01/2025
5% OR GREATER SECURITY INTERESTMIFFLIN RE OWNER, LLCsince 05/01/2025
MANAGING CONTROL - GOVERNING BODYCLARK, ALYSSA, HOBACK, TIFFANYsince 05/01/2025
OPERATIONAL/MANAGERIAL CONTROLSNF MGR LLC, CLARK, ALYSSA, CRIAG, MICHELE, HOBACK, TIFFANY, JONES, TEQUILLA, ROSCOE, BRANDON, SIMPSON, LOUANNsince 05/01/2025
ADP OF THE SNFMIFFLIN RE OWNER, LLC, SNF MGR LLC, CLARK, ALYSSA, CRIAG, MICHELE, HOBACK, TIFFANY, JONES, TEQUILLA, ROSCOE, BRANDON, SIMPSON, LOUANNsince 04/11/2025

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