Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Little Flower Manor during CMS and state inspections, most recent first.
The facility did not ensure the State LTC Ombudsman was notified of facility-initiated transfers and discharges. Although the facility policy required monthly submission of discharge and transfer lists to the LTC Ombudsman, records showed notifications were sent only to the county ombudsman program for multiple months, and the NHA confirmed the facility was not notifying the State Ombudsman as required.
The facility failed to maintain fire resistance in common wall separations as certain fire-rated doors did not positively bottom latch. Observations revealed that the double doors at Tony's Café and a level fire door in the basement, both separating different components, failed to latch properly. This was confirmed during an exit interview with the Facility Administrator and Director of Maintenance.
The facility was found to be non-compliant with NFPA 70, National Electric Code, as non-GFCI outlets were installed within 6 feet of a sink in the Soiled Linen Room and Chapel Prep Room on the first floor. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility was found deficient in providing two remote exits for the basement, as required. The boiler room opened into stair towers on either side, failing to offer the necessary remote egress paths. This was confirmed during an interview with the Facility Administrator and Director of Maintenance.
The facility was found to have a smoke compartment in the C Wing that exceeded the maximum allowable area of 22,500 square feet, as per NFPA 101 standards. This deficiency was confirmed during an observation and document review, affecting one of four smoke compartments.
A facility failed to create a comprehensive care plan for a resident with multiple diagnoses, including rhabdomyolysis and prostate cancer. The resident frequently refused treatments such as ADLs, medication, and therapies, but the care plan did not address these refusals. A nurse confirmed the absence of a relevant care plan, violating facility policies.
A resident with anxiety, hypertension, and acute respiratory failure continued to receive Loratadine 10 mg daily for seasonal allergic rhinitis, despite a pharmacist's recommendation to limit its use to the allergy season. The physician agreed to this recommendation, but the standing order for Loratadine remained without a stop date, as confirmed by the DON.
The facility did not meet the required LPN staffing levels during the night shift on four occasions. With a census of 92 residents, the facility needed 2.30 LPNs but provided fewer: 2.06, 2.14, 2.23, and 1.45 LPNs on different nights. No additional higher-level staff were available to cover the shortfall.
Failure to Notify State Ombudsman of Facility-Initiated Transfers and Discharges
Penalty
Summary
The facility did not ensure that the State Long-Term Care Ombudsman was notified of facility-initiated transfers and discharges for six of six months reviewed, covering June 2025 through November 2025. Review of the facility policy titled "Admission, Discharge, and Transfer," reviewed in October 2025, indicated that a list of discharges and transfers would be sent to the Long-Term Care Ombudsman monthly. However, facility-provided discharge and transfer notifications showed that notifications were sent to the county ombudsman program instead, with 20 discharges in June 2025, 22 in July 2025, 28 in August 2025, 26 in September 2025, 32 in October 2025, and 35 in November 2025. During interview, the Nursing Home Administrator stated that the facility was not providing notification of facility-initiated transfers and discharges to the State Ombudsman as required and was only notifying the County Ombudsman program.
Failure to Maintain Fire Resistance in Common Wall Separations
Penalty
Summary
The facility failed to maintain fire resistance in common wall fire separations within one of its components. During an observation on January 27, 2025, between 9:05 a.m. and 9:45 a.m., it was noted that certain fire-rated doors did not positively bottom latch when tested. Specifically, at 9:05 a.m., the double doors on the first floor at Tony's Café, which separate Component 1 from Component 2, failed to latch. Additionally, at 9:45 a.m., the level fire door in the basement, also separating Component 1 from Component 2, did not latch properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Director of Maintenance.
Plan Of Correction
The doors and door hardware will be adjusted so the door will positively latch into the frame. We will continue to inspect for these conditions on our monthly environmental rounds for compliance. The Director of Maintenance will be responsible for maintaining compliance of this inspection.
Non-GFCI Outlets Installed Near Sinks
Penalty
Summary
The facility failed to comply with NFPA 70, National Electric Code, specifically Section 210.8(B) 5, which requires ground-fault circuit interrupter (GFCI) protection for outlets installed within 6 feet of a sink. During observations conducted on January 27, 2025, between 9:10 a.m. and 9:25 a.m., it was noted that non-GFCI outlets were installed within 6 feet of a sink in two locations: the Soiled Linen Room on the first floor, C-Wing Green Hall, and the Chapel Prep Room on the first floor. This deficiency was confirmed during an exit interview with the Facility Administrator and the Maintenance Director.
Plan Of Correction
The outlets were replaced with GFCI protected outlets. The Director of Maintenance will be responsible for maintaining compliance with this issue.
Deficiency in Remote Exits for Basement
Penalty
Summary
The facility failed to ensure compliance with the requirement of having not less than two approved exits, remote from each other, for each story and smoke compartment. During an observation and document review conducted on January 27, 2025, at 8:30 a.m., it was found that the basement of the facility lacked two remote exits. This deficiency was due to the boiler room opening into the stair towers on either side, which did not provide the necessary remote egress paths. The issue was confirmed during an exit interview with the Facility Administrator and Director of Maintenance at 10:30 a.m. on the same day.
Smoke Compartment Size Exceeds Maximum Allowance
Penalty
Summary
The facility failed to comply with the NFPA 101 requirements for smoke compartments, as evidenced by the C Wing smoke zone exceeding the maximum allowable area of 22,500 square feet. This deficiency was identified during an observation and document review conducted on January 27, 2025, at 8:30 a.m. The issue was confirmed during an exit interview with the Facility Administrator and Director of Maintenance later that morning. The deficiency affects one of the four smoke compartments within the facility, indicating a failure to ensure proper subdivision of building spaces for smoke control.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident, identified as Resident R70, who was admitted with diagnoses including rhabdomyolysis, hypertension, and malignant neoplasm of the prostate. Despite the facility's policy requiring a comprehensive care plan with measurable objectives and time frames, Resident R70's care plan did not address the resident's repeated refusals of various treatments, such as activities of daily living, medication, physical therapy, and occupational therapy, which occurred several times weekly from October 1, 2024, to January 8, 2024. A review of the clinical records and an interview with a licensed nurse confirmed the absence of a care plan addressing these refusals. This deficiency was identified during a survey, as the facility did not meet the requirements outlined in 28 Pa. Code: 211.12 (d) (1) (5) Nursing services and 28 Pa. Code 211.10 (c) Resident care policies.
Plan Of Correction
The Care Plan for Resident R70 was immediately updated on 01/09/2025 to reflect Resident R70's refusals of medications, PT, OT, and Activities of Daily Living. Following the completion of the survey, the care plans for all the current residents were reviewed. Any resident that was refusing medications, treatments, therapies, ADLs, etc., had their care plans updated to reflect these refusals. Upon admission to the facility, refusals of care will be monitored by the Interdisciplinary Team (which would include our nursing, therapy, social service, activities, and dietary team members). The care plans for these residents will reflect any refusals of medications, treatments, therapies, ADLs, etc. The RNAC will be responsible for monitoring the completion of these care plans and review them prior to each resident assessment and care conference.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically for a resident diagnosed with anxiety, hypertension, and acute respiratory failure. The resident was receiving Loratadine 10 mg daily for seasonal allergic rhinitis, as noted in the monthly pharmacy review dated October 29, 2024. The pharmacist recommended that the administration of Loratadine should be limited to the allergy season to avoid adverse events from long-term use and suggested a reevaluation of its necessity, possibly considering a trial discontinuation or PRN (as needed) period. Despite the physician agreeing to the pharmacist's recommendation on October 31, 2024, the resident's clinical record showed that the standing order for Loratadine, which began on February 13, 2024, continued without a stop date. This oversight was confirmed during an interview with the Director of Nursing on January 8, 2024, indicating that the medication should have been discontinued as per the pharmacy's recommendation and the physician's response.
Plan Of Correction
On January 9, 2025, Loratadine was discontinued from the profile of Resident R30 as recommended by the Consultant Pharmacist. Going forward, all Pharmacy Consultant reports will now require a review by our Resident Care Coordinators after being scanned into the EMR system to ensure that all recommendations were addressed by the physician and that all orders were followed accordingly. The Director of QI will review the Pharmacy Consultant reports monthly for 6 months to ensure accuracy and then quarterly for 3 months. The Pharmacy Consultant will also inform the Director of Nursing each month that all recommendations from the previous month were addressed appropriately.
LPN Staffing Deficiency During Night Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one LPN per 40 residents during the night shift on four specific dates. The facility census data indicated that on each of these dates, the census was 92, necessitating 2.30 LPNs for adequate coverage. However, the nursing time schedules revealed that the facility provided fewer LPNs than required: 2.06 LPNs on 11/23/2024, 2.14 LPNs on 11/24/2024, 2.23 LPNs on 11/28/2024, and 1.45 LPNs on 11/29/2024. There were no additional higher-level staff available to compensate for this deficiency, leading to non-compliance with the staffing regulation.
Plan Of Correction
Our Staffing Coordinator in conjunction with our Director of Nursing will monitor our daily census and prepare for any increase in census throughout the day. They will continue to use the staffing tool provided by DOH to ensure compliance with all PPDs and staffing ratios. This tool will be monitored by the Director of Nursing on a daily basis.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Darby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Francis Center For Rehabilitation & Healthcare | 0.4 mi | ★★★★★ | 0 | 0 |
| Providence Rehab And Hlthcare Ctratmercyfitzgerald | 0.8 mi | ★★★★★ | 8 | 0 |
| Edenbrook Of Yeadon | 1.3 mi | ★★★★★ | 1 | 0 |
| Holy Family Home | 2.8 mi | ★★★★★ | 8 | 0 |
| Care Pavilion Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 51 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.