Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LOCUST GROVE RETIREMENT VILLAGE
MIFFLIN, PA · 104 certified beds · Last Life Safety survey June 27, 2025
CMS Certification Number 395350 · first certified May 1976
Ownership
Operated by AVARDIS HEALTH · For profit - Corporation
- New ownershipOwnership changed June 1, 2025 (change of ownership)from LOCUST GROVE FACILITY OPERATIONS, LLC
Position within PA
11 citations — more than 51% of the 656 certified nursing homes in PA. Compared within PA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to June 2026), and past the point by which nine in ten PA facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in PA are typically surveyed 10–12 months after the last one (median 11), measured over 1,113 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 11 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in PA, and nationally. Surveyors differ markedly between states, so the PA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in PA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 4, 2023 | 3 |
| May 3, 2024 | 6 |
| June 27, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2025-06-27 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-05-03 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-05-03 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-08-04 |
| K-0100 | Meet other general requirements. | 1 | 2024-05-03 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2024-05-03 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2024-05-03 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2025-06-27 |
What the citations cover
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Construction Deficiencies 1
- Emergency Preparedness Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Construction Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 27, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 7, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 7, 2025) |
May 3, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 29, 2024) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (June 29, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 29, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 29, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 29, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (June 29, 2024) |
August 4, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 2, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 2, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 2, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.