Inspection Reports for The Preserve at Cedarwood
925 S. LINCOLN AVE,, TYRONE, PA, 16686
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
69% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 37
Capacity: 54
Deficiencies: 0
May 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 54
Residents Served: 37
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 6
Resident Support Staff Hours: 0
Total Daily Staff Hours: 55
Waking Staff Hours: 41
Residents Age 60 or Older: 37
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 37
Capacity: 54
Deficiencies: 0
May 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 05/08/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 54
Residents Served: 37
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 5
Residents with Mobility Need: 15
Residents Age 60 or Older: 37
Inspection Report
Complaint Investigation
Census: 40
Capacity: 54
Deficiencies: 0
Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 56
Waking Staff: 42
Resident Support Staff: 0
Residents Served: 40
License Capacity: 54
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 7
Residents Age 60 or Older: 40
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 16
Residents with Physical Disability: 1
Residents Receiving Supplemental Security Income: 0
Inspection Report
Renewal
Census: 37
Capacity: 54
Deficiencies: 4
Dec 10, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for THE PRESERVE AT CEDARWOOD on 12/10/2024 and 12/11/2024.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Several deficiencies were identified including staff qualification issues, broken window repair, incomplete preadmission screening documentation, and incomplete resident support plans, all of which had corrective plans accepted and implemented by 01/22/2025.
Deficiencies (4)
| Description |
|---|
| Staff Member A does not have a high school diploma from the United States, a GED, or active registry status on the Pennsylvania nurse aide registry. |
| The outside windowpane of resident room #110 was observed having a hole and spidering glass around the hole. |
| Resident #1’s preadmission screening form does not include a determination that the needs of the resident can be met by the services provided by the home. |
| The resident assessment support plan (RASP) for resident #2 does not indicate the resident has a need for an enabler bar, but an enabler bar was observed in resident #2's room attached to the bed. |
Report Facts
License Capacity: 54
Residents Served: 37
Secured Dementia Care Unit Capacity: 12
Residents Served in Dementia Unit: 11
Hospice Residents: 9
Residents 60 Years or Older: 37
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 14
Residents with Physical Disability: 1
Total Daily Staff: 51
Waking Staff: 38
Inspection Report
Census: 41
Capacity: 41
Deficiencies: 0
Sep 4, 2024
Visit Reason
The inspection was conducted due to a change in legal entity for the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 41
License Capacity: 41
Memory Care Capacity: 12
Memory Care Residents Served: 11
Hospice Current Residents: 10
Total Daily Staff: 57
Waking Staff: 43
Inspection Report
Follow-Up
Census: 38
Capacity: 54
Deficiencies: 6
May 22, 2024
Visit Reason
The inspection was a full, unannounced follow-up visit conducted on 05/22/2024 to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. Several deficiencies were identified and addressed, including issues with quarterly financial accounts, resident refunds after death, annual staff training, locking poisonous materials, preadmission screening, and posting of key-locking device instructions.
Deficiencies (6)
| Description |
|---|
| Residents #1, #2, #3 and #4 had not received a quarterly account of financial transactions. |
| Refund issued to the family of Resident #5 after death was not in accordance with the Elder Care Payment Restitution Act. |
| Staff person A did not receive required annual training in fire safety, emergency preparedness, and falls/accident prevention during 2023. |
| A spray bottle labeled 'Peroxide Multi Cleaner & Disinfectant' was unlocked and accessible to residents in the memory support unit bathroom cabinet. |
| Resident #6's cognitive preadmission screening was incomplete, missing physician acknowledgement that the resident's needs can be met in the home. |
| Directions for operating the home's locking mechanism were not conspicuously posted near the external courtyard gate in the Secure Dementia Care Unit. |
Report Facts
License Capacity: 54
Residents Served: 38
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 9
Hospice Current Residents: 6
Total Daily Staff: 48
Waking Staff: 36
Residents with Mobility Need: 10
Inspection Report
Follow-Up
Census: 39
Capacity: 54
Deficiencies: 3
Oct 11, 2023
Visit Reason
The inspection was conducted as a follow-up review of a previously submitted plan of correction for the facility, triggered by a complaint and incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the follow-up inspection dates 10/11/2023 and 10/12/2023. Continued compliance must be maintained.
Complaint Details
The inspection was complaint-related, with the reason stated as Complaint, Incident. Substantiation status is not explicitly stated.
Deficiencies (3)
| Description |
|---|
| A staff member made an inappropriate statement to a resident, violating the requirement that residents be treated with dignity and respect. |
| The medication administration record for a resident did not indicate the diagnosis or purpose of a prescribed medication. |
| A resident's assessment did not include impairment details and how the home will meet this need as required. |
Report Facts
License Capacity: 54
Residents Served: 39
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 11
Current Hospice Residents: 4
Residents with Mobility Need: 14
Residents Age 60 or Older: 39
Residents Diagnosed with Mental Illness: 2
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 33
Capacity: 54
Deficiencies: 5
Apr 6, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance and verify the submitted plan of correction.
Findings
The inspection found multiple deficiencies including missing required staff training hours, sanitary issues with a strong urine odor in the secured dementia care unit, missing thermometers in refrigerators/freezers, and lack of documentation for resident no objection statements for admission to the secured dementia care unit. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The inspection included a complaint investigation component, but the report does not specify substantiation status.
Deficiencies (5)
| Description |
|---|
| Direct Care Staff Person A did not receive 12 hours of annual training for Training Year 2022. |
| Strong urine odor detected throughout the secured dementia care unit due to untimely carpet cleaning. |
| No thermometer in the Midea refrigerator/freezer and Frigidaire refrigerator/freezer in the activity room; items not labeled. |
| No documentation that residents and their designated persons have not objected to admission to the secured dementia care unit for two residents. |
| Direct Care Staff Person A did not receive required 6 hours of annual dementia training for 2022. |
Report Facts
License Capacity: 54
Residents Served: 33
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 7
Staff Total Daily: 47
Staff Waking: 35
Inspection Report
Renewal
Census: 17
Capacity: 54
Deficiencies: 9
Aug 12, 2021
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing requirements.
Findings
Multiple deficiencies were identified including cleanliness issues in kitchen and shower areas, hot water temperatures exceeding 120°F, missing medication documentation, lack of resident signatures on support plans, and missing manufacturer statements for locking systems. All deficiencies had plans of correction implemented and were verified as completed.
Deficiencies (9)
| Description |
|---|
| Shelves of stainless steel prep tables in the main kitchen covered with food debris and dried-on spilled liquid; dirty floors in secured unit shower and toilet rooms; food debris in memory care kitchen freezer; brown liquid spills on kitchen surfaces. |
| Hot water temperatures in resident areas measured above 120°F (124.5°F, 126.1°F, 128.8°F). |
| Windowsill had two nail heads sticking up creating risk of injury. |
| Last record of dryer duct cleaning was dated 2019. |
| PRN medication for Resident #1 not listed in MAR; medication for Resident #2 expired but still in medication cart. |
| Resident #3 refused scheduled medication dose but refusal was not documented in MAR. |
| Residents #1 and #3 participated in support plan development but did not sign nor was inability to sign documented. |
| No manufacturer statement verifying electronic or magnetic locking system will shut down and doors will open immediately upon fire alarm, power failure, or override. |
| Code to operate electronic/magnetic locking device keypad not posted or not visible at secured unit emergency exit and main door. |
Report Facts
License Capacity: 54
Residents Served: 17
Hot Water Temperature: 124.5
Hot Water Temperature: 126.1
Hot Water Temperature: 128.8
Staffing: 25
Waking Staff: 19
Inspection Report
Renewal
Capacity: 54
Deficiencies: 0
Aug 1, 2021
Visit Reason
The document is a renewal license issued in response to the May 13, 2021 renewal application to operate Epworth Manor Senior Living, a Personal Care Home. The Department advises that an annual inspection will be conducted within the next twelve months.
Findings
The Department has issued a regular license for the facility to operate as a Personal Care Home with a maximum capacity of 54 residents, including a Secure Dementia Care Unit with a capacity of 12. No findings of noncompliance are stated in this document.
Report Facts
Maximum capacity: 54
Secure Dementia Care Unit capacity: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding renewal license |
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