Mifflin, PA

Locust Grove Retirement Village

2-star overall rating with 3-star inspections with $12,831 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

69 Cottage Road, Mifflin, PA

(717) 436-8921

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

104

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care

Operator or chain grouping

Approved since

1976-05-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

36 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

45%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,777

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

19.15

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

2.78

Baseline 31.25% · Performance 52.31% · Measure score 2.78 · Achievement 2.78 · Improvement 0

Adjusted total nurse staffing

1.05

Baseline 3.64 hours · Performance 3.38 hours · Measure score 1.05 · Achievement 1.05 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.16%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 80 · Observed rate 12.5% · Lower 95% interval 6.91%
Discharge to community	51.15%	50.57% 0.6 pts better	No Different than the National Rate · Eligible stays 69 · Observed rate 43.48% · Lower 95% interval 40.77%
Medicare spending per beneficiary	0.84	1.02 0.2 pts better
Drug regimen review with follow-up	78.26%	95.27% 17 pts worse	Numerator 18 · Denominator 23
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 23
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 23 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	1.85%	8.2% 6.3 pts worse	Numerator 1 · Denominator 54
Staff flu vaccination coverage	45.95%	42% 4 pts better	Numerator 34 · Denominator 74
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.7 About the same	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.0 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.2 0.2 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	86.9% 13.1 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.5%	93.5% 5 pts better	95.5% 3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5%
Percentage of long-stay residents experiencing one or more falls with major injury	3.6%	3.2% 0.4 pts worse	3.3% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.9% · Q3 3.3% · Q4 3.1% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	6.5% 6.5 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	5.5%	6.5% 1 pts better	5.4% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 6.9% · Q3 3.6% · Q4 0.0% · 4Q avg 5.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	33.9%	19.9% 14 pts worse	19.6% 14.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.9% · Q2 35.6% · Q3 33.9% · Q4 31.1% · 4Q avg 33.9%
Percentage of long-stay residents who received an antipsychotic medication	23.0%	18.7% 4.3 pts worse	16.7% 6.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 20.5% · Q3 27.5% · Q4 25.5% · 4Q avg 23.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	31.4%	19.6% 11.8 pts worse	16.3% 15.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 31.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.8%	18.3% 1.5 pts worse	14.9% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 18.2% · Q3 9.6% · Q4 20.7% · 4Q avg 19.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.0%	0.9% 1.1 pts worse	1.0% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.0%	1.7% 0.3 pts worse	1.7% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 4.7% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.2%	26.4% 4.2 pts better	19.8% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 32.5% · Q3 19.5% · Q4 17.4% · 4Q avg 22.2%
Percentage of long-stay residents with pressure ulcers	2.3%	5.3% 3 pts better	5.1% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.0% · Q3 3.2% · Q4 1.4% · 4Q avg 2.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.0%	68.9% 25.1 pts better	81.7% 12.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 92.1% · Q3 95.3% · Q4 95.5% · 4Q avg 94.0%
Percentage of short-stay residents who had an outpatient emergency department visit	4.7%	9.8% 5.1 pts better	12.0% 7.3 pts better	Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.8% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.6%	1.5% 2.1 pts worse	1.6% 2 pts worse	Short Stay · 2024Q4-2025Q3 · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.9%	68.7% 26.2 pts better	79.7% 15.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.8%	23.1% 4.3 pts better	23.9% 5.1 pts better	Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 19.0% · Expected 24.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-27 · Fire 2025-06-27

8 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-05-03 · Fire 2024-05-03

20 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-08-04 · Fire 2023-08-04

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-07-07

E · Potential for more than minimal harm 2025-06-27

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-07-07

F · Potential for more than minimal harm 2024-05-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-29

E · Potential for more than minimal harm 2024-05-03

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-06-29

E · Potential for more than minimal harm 2024-05-03

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-06-29

C · Minimal harm 2024-05-03

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-06-29

C · Minimal harm 2024-05-03

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-06-29

C · Minimal harm 2024-05-03

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-06-29

E · Potential for more than minimal harm 2023-08-04

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-10-02

E · Potential for more than minimal harm 2023-08-04

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-10-02

C · Minimal harm 2023-08-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-02

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-06-27

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-22

E · Potential for more than minimal harm 2025-06-27

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-06-27

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-06-27

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-06-27

F688 · Quality of Life and Care Deficiencies

Health

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 2025-08-22

D · Potential for more than minimal harm 2025-06-27

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-06-27

F742 · Quality of Life and Care Deficiencies

Health

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 2025-08-22

D · Potential for more than minimal harm 2025-06-27

F744 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-08-22

D · Potential for more than minimal harm 2024-10-09

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-11-15

D · Potential for more than minimal harm 2024-06-18

F790 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-07-05

G · Actual harm 2024-05-03

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-03-28

E · Potential for more than minimal harm 2024-05-03

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-06-14

E · Potential for more than minimal harm 2024-05-03

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-06-14

E · Potential for more than minimal harm 2024-05-03

F761 · Pharmacy Service Deficiencies

Health

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 2024-06-14

E · Potential for more than minimal harm 2024-05-03