Cycle 1
Health 2025-12-11 · Fire 2025-12-11
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Darby, PA
Little Flower Manor
5-star overall rating with 5-star inspections with 1 recent health deficiencies
1201 Springfield Road, Darby, PA
(610) 534-6000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
127
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
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
0.83
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
334
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
72.82
Composite VBP score used to determine payment impact.
Payment multiplier
1.0237
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 20.28% · Performance 15.55% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.87
Baseline 7.69% · Performance 6.08% · Measure score 5.87 · Achievement 5.87 · Improvement 5.46
Total nurse turnover
8.18
Performance 30.23% · Measure score 8.18 · Achievement 8.18 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.08
Baseline 4.33 hours · Performance 4.52 hours · Measure score 5.08 · Achievement 5.08 · Improvement 0.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 198 · Observed rate 10.61% · Lower 95% interval 8.31% |
| Discharge to community | 62.78% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 190 · Observed rate 64.21% · Lower 95% interval 56.93% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 80% |
95.27%
15.3 pts worse
|
Numerator 88 · Denominator 110 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 110 |
| Discharge self-care score | 61.39% |
53.69%
7.7 pts better
|
Numerator 62 · Denominator 101 |
| Discharge mobility score | 32.67% |
50.94%
18.3 pts worse
|
Numerator 33 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 110 · Adjusted rate 2.13% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 3.81% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 13.38% |
8.2%
5.2 pts better
|
Numerator 21 · Denominator 157 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 190 · Denominator 190 |
| Discharge function score | 38.61% |
56.45%
17.8 pts worse
|
Numerator 39 · Denominator 101 |
| Transfer of health information to provider | 98.28% |
95.95%
2.3 pts better
|
Numerator 57 · Denominator 58 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 31.75% |
25.2%
6.6 pts better
|
Numerator 20 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · 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 | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.2%
1.6 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.6% · Q3 4.4% · Q4 4.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.4% |
6.5%
1.9 pts worse
|
11.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 11.9% · Q3 7.7% · Q4 7.2% · 4Q avg 8.4% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.5%
0.7 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 7.9% · Q3 6.2% · Q4 4.5% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
19.9%
1.9 pts worse
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 24.6% · Q3 18.8% · Q4 15.7% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
18.7%
8.9 pts better
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 12.2% · Q3 9.8% · Q4 10.5% · 4Q avg 9.8% · 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 | 12.6% |
19.6%
7 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q4 9.1% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
18.3%
1.2 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 23.1% · Q3 11.3% · Q4 20.6% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.7%
0.1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 4.4% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
26.4%
4.5 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 13.5% · Q3 22.1% · Q4 24.9% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.3%
1.9 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.6% · Q3 4.4% · Q4 6.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
68.9%
25 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 94.0% · Q3 91.8% · Q4 94.3% · 4Q avg 93.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.9% |
9.8%
6.9 pts better
|
12.0%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.9% · Observed 2.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 3.8% · Q4 2.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
68.7%
26.3 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.2% |
23.1%
10.9 pts better
|
23.9%
11.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 10.3% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-09 · Fire 2025-01-09
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2024-03-12 · Fire 2024-03-12
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-12
Inspection history
Recent health citations
C · Minimal harm
2025-12-11
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-17
D · Potential for more than minimal harm
2025-01-09
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 2025-02-01
D · Potential for more than minimal harm
2025-01-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-01
F · Potential for more than minimal harm
2024-03-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-04
D · Potential for more than minimal harm
2024-03-12
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 2024-04-04
Penalties and ownership
What sits behind the stars
Ownership
Buchanan, Brianna
Operational/Managerial Control · Individual
Fox, Donald
Corporate Director · Individual
Friel, Donald
Operational/Managerial Control · Individual
Friel, Donald
Corporate Officer · Individual
Graham, Rosanne
Corporate Director · Individual
Marvel, Ellen
Corporate Director · Individual
Mullen, Mark
Corporate Director · Individual
Port, Rosemary
Operational/Managerial Control · Individual
Port, Rosemary
Corporate Officer · Individual
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#3
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