Pennsylvania Department of Health
LITTLE FLOWER MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 38 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


LITTLE FLOWER MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on March 28, 2024, at Little Flower Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: (A, B, AND C WINGS AND THE CHAPEL) - Component: 01 - Tag: 0000

Facility ID #121902
Component 01
A, B, C Wings and Chapel

Based on a Medicare/Medicaid Recertification Survey completed on March 28, 2024, it was determined that Little Flower Manor - A, B, C Wings and the Chapel had deficiencies that have the potential for minimal harm as related to the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.70(a).

This is a one-story, Type V (000), unprotected wood frame structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Number of Exits - Story and Compartment:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Number of Exits - Story and Compartment
Not less than two exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

Observations:
Name: (A, B, AND C WINGS AND THE CHAPEL) - Component: 01 - Tag: 0241

Based on observation, document review and interview, it was determined the facility failed to provide not less than two approved exits, remote from each other, on each floor, affecting one of four smoke compartments within the component.

Findings include:

1. Observation and review of documentation on March 28, 2024, at 10:00 AM, revealed the basement lacked two remote exits, due to the Boiler Room opening into the stairtowers on either side.

Interview with the Director of Maintenance on March 28, 2024, at 10:00 AM, confirmed the lack of two remote exits.

Plan of Correction - To be completed: 04/12/2024

The facility requests that a new FSES be performed by The Department of Life Safety for the deficiency that the building has one compartment with less than 2 approved exits, remote from each other.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Compar:

Subdivision of Building Spaces - Smoke Compartments
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Observations:
Name: (A, B, AND C WINGS AND THE CHAPEL) - Component: 01 - Tag: 0371

Based on observation, document review, and interview, it was determined the facility failed to provide smoke compartments not exceeding 22,500 square feet, affecting one of four smoke compartments within this component.

Findings include:

1. Observation and review of documentation on March 28, 2024, at 10:30 AM, revealed the C Wing smoke zone exceeded 22,500 square feet in area.

Interview with the Director of Maintenance on March 28, 2024, at 10:30 AM, confirmed the smoke compartment exceeded the maximum allowance.

Plan of Correction - To be completed: 04/12/2024

The facility requests that a new FSES be performed by the Department of Life Safety for the deficiency that the smoke compartment exceeds 22,500 square feet.

Initial comments:Name: (ST JOSEPH'S HALL) - Component: 02 - Tag: 0000

Facility ID #121902
Component 02
St. Joseph's Hall

Based on a Medicare/Medicaid Recertification Survey completed on March 28, 2024, it was determined that Little Flower Manor - St. Joseph's Hall, was not in compliance with the following requirements of the Life Safety Code for an existing nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Installation:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: (ST JOSEPH'S HALL) - Component: 02 - Tag: 0351

Based on observation and interview, it was determined the facility failed to install sprinkler heads of consistent thermal sensitivity, affecting one of two smoke compartments within the component.

Findings include:

1. Observation on March 28, 2024, at 11:55 AM, revealed three quick response sprinkler heads and six standard response sprinkler heads protecting the St. Joseph's Hall Business Hall from the same level ceiling plane.

Interview with the Director of Maintenance on March 28, 2024, at 11:55 AM, confirmed the inconsistent thermal sensitivity of the sprinkler heads protecting the area.

Plan of Correction - To be completed: 04/12/2024

On Friday, April 5, 2024, Johnson Controls installed 6 quick response sprinkler heads in the area identified in St. Joseph's Hall business office. The installation of these 6 quick response sprinkler heads now provides consistent thermal sensitivity in that ceiling plane.

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