Pennsylvania Department of Health
 HICKORY HOUSE NURSING HOME
Building Inspection Results

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HICKORY HOUSE NURSING HOME
Inspection Results For:

There are  42 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.
HICKORY HOUSE NURSING HOME - 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 May 26, 2026, at Hickory House Nursing Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.


 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #083002

Component 01

Original Building

 

Based on a Medicare/Medicaid Recertification Survey completed on May 26, 2026, it was determined that Hickory House Nursing Home was not in compliance with 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 483.90(a).

 

This is a one-story, Type II (000), unprotected noncombustible structure, without a basement, which is fully sprinklered.


 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0291 Based on observation and interview, it was determined the facility failed to maintain emergency lighting fixtures, affecting the entire component. Findings include: 1. Observation on May 26, 2026, at 11:15 AM, revealed the emergency back-up lighting unit, located within the generator, failed to illuminate, when tested. Interview at the time of the exit conference with Administrator and Director of Environmental Services on May 26, 2026, at 1:30 PM, confirmed the lighting fixture did not illuminate.
 Plan of Correction - To be completed: 06/16/2026

This plan of correction constitutes the facility's written allegation of compliance for the deficiency cited. However, submission of the plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by state and federal law.

Service will be requested to replace batteries for the emergency back up lighting. A 90 minute emergency light test will be completed after replacement of battery.

An audit will be completed of emergency lighting to ensure proper functioning both on and off generator use.

An education will be completed by the Nursing Home Administrator/designee with the Maintenance Department on the maintenance of emergency lighting.

An audit will be completed monthly x 12 months on emergency lighting to ensure proper functioning both on and off the generator. Findings will be reviewed during QAPI.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free of debris load, affecting one of five smoke components within the component. Findings include: 1. Observation on May 26, 2026, between 11:30 AM and 11:45 AM, revealed sprinkler heads were subject to load at the following locations: a. 11:30 AM, Main Kitchen, multiple sprinkler heads; b. 11:33 AM, Main Kitchen, walk-in refrigerator, 1 sprinkler head; c. 11:35 AM, Laundry Room, Washer Room, 3 sprinkler heads; d. 11:37 AM, Laundry Room, Dryer Chase area, 2 sprinkler heads; e. 11:45 AM, Laundry Room, Soiled Laundry, 2 sprinkler heads. Interview at the time of the exit conference with Administrator and Director of Environmental Services on May 26, 2026, at 1:30 PM, confirmed sprinkler heads were carrying an accumulated load.
 Plan of Correction - To be completed: 06/16/2026

The sprinkler heads in the main kitchen, walk-in refrigerator, Washer Room in the Laundry Room, Dryer Chase Area in the Laundry Room, and the Soiled Laundry area in the Laundry Room were freed of debris.

An audit will be completed of sprinkler heads throughout the facility to identify additional sprinkler heads that are not free of debris and cleaned as indicated.

An education will be completed by the Nursing Home Administrator/designee with the Maintenance Department on the maintenance of the automatic sprinkler system to keep the sprinkler heads free from debris.

A random audit will be completed by the Maintenance Director/designee monthly x 12 months on sprinkler heads for debris. Findings will be reviewed during QAPI.

NFPA 101 STANDARD HVAC:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0521 Based on document review and interview, it was determined the facility lacked documentation verifying the 4-year fire damper maintenance and exercise was performed, affecting the entire component. Findings include: 1. Review of documentation on May 26, 2026, between 9:30 AM and 10:45 AM, failed to provide documentation of the four-year fire damper exercise and maintenance. Interview at the time of the exit conference with Administrator and Director of Environmental Services on May 26, 2026, at 1:30 PM, lacked documentation of fire damper maintenance and exercise.
 Plan of Correction - To be completed: 06/16/2026

The facility will obtain the 4 year fire damper inspection report and place in the Life Safety Binder.

An audit will be completed of required inspections to ensure inspection reports are received and placed in the Life Safety Binder.

Education will be completed by the Nursing Home Administrator/designee with the Maintenance Department on obtaining inspection reports after the completion of the service and filing in the Life Safety Binder for review.

An audit will be completed monthly x 12 months on inspections completed to ensure reports are obtained and placed in the Life Safety Binder. Findings will be reviewed during QAPI.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0918 Based on document review and interview, it was determined the facility failed to provide annual testing documentation required for the Essential Electrical System, which serves the entire component. Findings include: 1. Review of documentation and interview on May 26, 2026, between 9:30 AM and 10:45 AM, revealed the facility failed to provide annual testing of the generator fuel quality test. Documentation provided on 6/22/2025 analysis showed the fuel sample failed and the facility lacked documentation of a follow-up testing, after treatment. Interview at the time of the exit conference with Administrator and Director of Environmental Services on May 26, 2026, at 1:30 PM, lacked documentation of a fuel sample.
 Plan of Correction - To be completed: 06/16/2026

The generator fuel will be re-tested and any required follow up will be completed as indicated.

An audit will be completed of the last 90 days of inspections to ensure appropriate follow up has been completed as requested.

Education will be completed by the Nursing Home Administrator/designee with the Maintenance Department on reviewing inspection reports for any required follow up.

An audit will be completed monthly x 12 months on inspection reports to ensure all required follow up has been completed. Findings will be reviewed during QAPI.

Initial comments:Name: BUILDING 02 - Component: 02 - Tag: 0000
Facility ID #083002

Component 02

D Wing - New Addition

 

Based on a Medicare/Medicaid Recertification Survey completed on May 26, 2026, it was determined that Hickory House Nursing Home was not in compliance with 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 483.90(a).

 

This is a one-story, Type V (111), protected wood frame structure, without a basement, which is fully sprinklered.

 


 Plan of Correction:


NFPA 101 STANDARD Emergency Lighting:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.
Emergency Lighting
Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0291 Based on observation and interview, it was determined the facility failed to maintain emergency lighting fixtures, affecting the entire component. Findings include: 1. Observation on May 26, 2026, at 11:15 AM, revealed the emergency back-up lighting unit, located within the generator, failed to illuminate, when tested. Interview at the time of the exit conference with Administrator and Director of Environmental Services on May 26, 2026, at 1:30 PM, confirmed the lighting fixture did not illuminate.
 Plan of Correction - To be completed: 06/16/2026

Service will be requested to replace batteries for the emergency back up lighting. A 90 minute emergency light test will be completed after replacement of battery.

An audit will be completed of emergency lighting to ensure proper functioning both on and off generator use.

An education will be completed by the Nursing Home Administrator/designee with the Maintenance Department on the maintenance of emergency lighting.

An audit will be completed monthly x 12 months on emergency lighting to ensure proper functioning both on and off the generator. Findings will be reviewed during QAPI.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system to be free of debris load, affecting one of three smoke components within the component. Findings include: 1. Observation on May 26, 2026, between 12:30 PM and 12:35 PM, revealed sprinkler heads were subject to load, at the following locations: a. 12:30 PM, Therapy Room, Charting Room, 1 sprinkler head; b. 12:35 PM, Therapy Room, Bedroom, 1 sprinkler head. Interview at the time of the exit conference with Administrator and Director of Environmental Services on May 26, 2026, at 1:30 PM, confirmed sprinkler heads were carrying an accumulated load.
 Plan of Correction - To be completed: 06/16/2026

The sprinkler heads in Therapy room, charting room and Therapy room, bedroom were freed of debris.

An audit will be completed of sprinkler heads throughout the facility to identify additional sprinkler heads that are not free of debris and cleaned as indicated.

An education will be completed by the Nursing Home Administrator/designee with the Maintenance Department on the maintenance of the automatic sprinkler system to keep the sprinkler heads free from debris.

A random audit will be completed by the Maintenance Director/designee monthly x 12 months on sprinkler heads for debris. Findings will be reviewed during QAPI.

NFPA 101 STANDARD HVAC:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0521 Based on document review and interview, it was determined the facility lacked documentation verifying the 4-year fire damper maintenance and exercise was performed, affecting the entire component. Findings include: 1. Review of documentation on May 26, 2026, between 9:30 AM and 10:45 AM, failed to provide documentation of the 4-year fire damper exercise and maintenance. Interview at the time of the exit conference with Administrator and Director of Environmental Services on May 26, 2026, at 1:30 PM, lacked documentation of fire damper maintenance and exercise.
 Plan of Correction - To be completed: 06/16/2026

The facility will obtain the 4 year fire damper inspection report and place in the Life Safety Binder.

An audit will be completed of required inspections to ensure inspection reports are received and placed in the Life Safety Binder.

Education will be completed by the Nursing Home Administrator/designee with the Maintenance Department on obtaining inspection reports after the completion of the service and filing in the Life Safety Binder for review.

An audit will be completed monthly x 12 months on inspections completed to ensure reports are obtained and placed in the Life Safety Binder. Findings will be reviewed during QAPI.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
Observations:
Name: BUILDING 02 - Component: 02 - Tag: 0918 Based on document review and interview, it was determined the facility failed to provide annual testing documentation required for the Essential Electrical System, which serves the entire component. Findings include: 1. Review of documentation and interview on May 26, 2026, between 9:30 AM and 10:45 AM, revealed the facility failed to provide annual testing of the generator fuel quality test. Documentation provided on 6/22/2025 analysis showed the fuel sample failed and the facility lacked documentation of a follow-up testing, after treatment. Interview at the time of the exit conference with Administrator and Director of Environmental Services on May 26, 2026, at 1:30 PM, lacked documentation of a fuel sample.
 Plan of Correction - To be completed: 06/16/2026

The generator fuel will be re-tested and any required follow up will be completed as indicated.

An audit will be completed of the last 90 days of inspections to ensure appropriate follow up has been completed as requested.

Education will be completed by the Nursing Home Administrator/designee with the Maintenance Department on reviewing inspection reports for any required follow up.

An audit will be completed monthly x 12 months on inspection reports to ensure all required follow up has been completed. Findings will be reviewed during QAPI.


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