Inspection Reports for
The Preserve at Cedarwood
925 S. LINCOLN AVE,, TYRONE, PA, 16686
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Notice — Apr 6, 2026
Date: Apr 6, 2026
Visit Reason
The document is a response to a request for a waiver of 55 Pa. Code § 2600.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications in a personal care home.
Findings
The waiver is granted with conditions including successful completion of medication administration training, in-person training by licensed health care professionals, annual training hours, and facility policies for monitoring and documentation of medication administration.
Inspection Report — Feb 25, 2026
Renewal
Date: Feb 25, 2026
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation at THE PRESERVE AT CEDARWOOD.
Findings
The facility was found to have multiple deficiencies including failure to report incidents timely, unsecured handrails, use of prohibited portable space heaters, incomplete medical evaluations, and unsecured medications. The submitted plan of correction was determined to be fully implemented as of the follow-up.
Citations (6)
2600.16c The home failed to report a missing/stolen gold necklace and a mechanical failure causing no heat to the Department within 24 hours as required.
2600.93a The outside ramp handrail was loose and held together by a metal wire, not securely fastened to the ground.
2600.127a Portable space heaters were found in use in the Activity Director's office and resident rooms, which is prohibited.
2600.141a Resident #2's initial medical evaluation did not contain the Medical Professional License number on the form.
2600.141b.1 Resident #3's annual medical evaluation did not identify whether the resident's needs can be safely met at the Personal Care Home.
2600.183b Prescription medications and syringes were found unlocked and accessible on Resident #4's nightstand.
Report Facts
Residents Served: 43
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 6
Staff Total Daily: 59
Staff Waking: 44
Residents Age 60 or Older: 43
Residents with Mobility Need: 16
Inspection Report — May 30, 2025
Complaint Investigation
Date: May 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 37
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 — May 8, 2025
Complaint Investigation
Date: May 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 05/08/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 37
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 5
Residents with Mobility Need: 15
Residents Age 60 or Older: 37
Inspection Report — Mar 12, 2025
Complaint Investigation
Date: Mar 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 56
Waking Staff: 42
Resident Support Staff: 0
Residents Served: 40
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 — Dec 10, 2024
Renewal
Date: 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.
Citations (4)
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
Residents Served: 37
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 — Sep 4, 2024
Date: 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
Memory Care Residents Served: 11
Hospice Current Residents: 10
Total Daily Staff: 57
Waking Staff: 43
Inspection Report — Sep 4, 2024
Re-Inspection
Date: Sep 4, 2024
Visit Reason
The inspection was conducted as a licensing inspection for the newly licensed facility, with a re-inspection planned within 3 months to ensure compliance.
Findings
The facility was found to be in substantial compliance with applicable regulations, and no regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 41
Secure Dementia Care Unit Residents Served: 11
Hospice Current Residents: 10
Total Daily Staff: 57
Waking Staff: 43
Inspection Report — May 22, 2024
Follow-Up
Date: 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.
Citations (6)
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
Residents Served: 38
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 — Oct 11, 2023
Follow-Up
Date: 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.
Complaint Details
The inspection was complaint-related, with the reason stated as Complaint, Incident. Substantiation status is not explicitly stated.
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.
Citations (3)
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
Residents Served: 39
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 — Apr 6, 2023
Renewal
Date: 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.
Complaint Details
The inspection included a complaint investigation component, but the report does not specify substantiation status.
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.
Citations (5)
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
Residents Served: 33
Secured Dementia Care Unit Residents Served: 10
Hospice Current Residents: 7
Staff Total Daily: 47
Staff Waking: 35
Inspection Report — Aug 12, 2021
Renewal
Date: 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.
Citations (9)
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
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 — Aug 1, 2021
Renewal
Date: 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding renewal license |
Inspection Report — Jul 9, 2019
Renewal
Date: Jul 9, 2019
Visit Reason
The inspection was an annual licensing inspection conducted on July 9, 2019, for renewal of the facility's license.
Findings
Violations of 55 Pa.Code Ch. 2600 related to personal care homes were found, including issues with hot water temperature, fire safety inspection, and medication administration. Plans of correction were submitted and partially implemented as of July 26, 2019.
Citations (3)
89b - Hot water temperature exceeded 120°F at bathroom sinks in rooms 102 and 112 and the activity room sink, measuring 127°F, 130°F, and 131°F respectively.
132b - The most recent fire safety inspection and fire drill conducted by a fire safety expert occurred on 6/22/18, not within the required annual timeframe.
182c - Medication administration was observed with Staff Person A giving medications to Residents 1, 2, 3, and 4, but the resident ingestion was not observed for Resident 1.
Report Facts
Residents Served: 42
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 5
Residents Age 60 or Older: 42
Residents with Mobility Need: 14
Total Daily Staff: 56
Waking Staff: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patti Stockley | Administrator | Named in relation to signature on plans of correction and administrator role |
| Shawnee Miller | Medication Train the Trainer | Provided re-education to Staff Person A on medication administration |
Notice — May 16, 2019
Date: May 16, 2019
Visit Reason
This document serves as a renewal notice for the license to operate Epworth Manor Senior Living as a Personal Care Home, confirming the renewal application received on May 16, 2019.
Findings
No inspection findings are reported in this document. It confirms the issuance of a renewal license without changes to expiration dates or conditions.
Report Facts
Inspection Report — Jul 17, 2018
Renewal
Date: Jul 17, 2018
Visit Reason
The inspection was a renewal licensing inspection conducted by the Department's Bureau of Human Services Licensing on July 17, 2018, to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The inspection found multiple violations related to staff training, menu posting, and medication administration documentation. Plans of correction were submitted and partially or fully implemented to address these deficiencies.
Citations (4)
Regulation 55 Pa.Code §2600.65(f): Staff member A did not have medication self-administration training during training year 2017.
Regulation 55 Pa.Code §2600.65(g): Staff members A and B did not have training in falls and accident prevention during training year 2017.
Regulation 55 Pa.Code §2600.162(c): The menu for 7/22/18 - 7/29/18 was not posted one week in advance as required.
Regulation 55 Pa.Code §2600.187(b): Resident #1 was administered medication but the administration was not documented in the Medication Administration Record.
Report Facts
Number of Residents Served: 31
Total Daily Staff: 40
Walking Staff: 30
Number of Residents Served in Secured Dementia Care Unit: 7
Number of Residents Age 60 or Older: 31
Number of Residents with Mobility Need: 9
Number of Hospice Residents in Past Year: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patti Stockley | Administrator | Named as legal entity representative and administrator signing plans of correction related to multiple findings. |
Inspection Report — Apr 13, 2018
Renewal
Date: Apr 13, 2018
Visit Reason
The document is a renewal application and license issuance for Epworth Healthcare and Rehabilitation Center to operate as a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the issuance of a regular license based on the renewal application.
Report Facts
Inspection Report — Sep 19, 2017
Renewal
Date: Sep 19, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Department of Human Services on September 19, 2017, for Epworth Healthcare and Rehabilitation Center.
Findings
A violation of 55 Pa.Code Ch. 2600 related to medication administration and blood glucose reading documentation was found. The facility submitted a plan of correction to address the improper use and documentation of glucometer readings.
Citations (1)
55 Pa.Code §2600.185(a) requires the home to develop and implement procedures for safe storage, access, security, distribution, and use of medications and medical equipment by trained staff. The facility failed to properly use and document blood glucose readings for Resident #1 on multiple dates.
Report Facts
Number of Residents Served: 25
Total Daily Staff: 34
Walking Staff: 26
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 16
Number of Residents 65 Years or Older: 25
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Need: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Maierhofer | Administrator | Named as Administrator and signed plan of correction related to medication administration violation. |
| Kellee Cargile | Department representative conducting inspection on 09/19/2017. | |
| Gloria Emrick | Department representative conducting inspection on 09/19/2017. |
Inspection Report — Apr 26, 2017
Renewal
Date: Apr 26, 2017
Visit Reason
The document is a renewal application and license issued for Epworth Healthcare and Rehabilitation Center to operate as a Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the facility's authorization to operate and outlining the requirement for a future inspection.
Report Facts
Inspection Report — Feb 1, 2017
Complaint Investigation
Date: Feb 1, 2017
Visit Reason
The inspection was conducted as a complaint and incident investigation at Epworth Healthcare and Rehabilitation Center.
Complaint Details
The inspection was triggered by a complaint and incident. Specific substantiation status is not stated.
Findings
Two violations of 55 Pa.Code Chapter 2600 were found: blocked exit doors in the activity room and lack of posted directions for electronic locks in the secure dementia care unit. Plans of correction were submitted and approved.
Citations (2)
55 Pa.Code §2600.121(a) - Exit doors in the activity room were blocked by tables and wicker furniture on both sides, obstructing egress routes.
55 Pa.Code §2600.233(c) - The secure dementia care unit did not have posted directions for operating electronic locks, and the release button was not visible from the main doors.
Report Facts
Number of Residents Served: 31
Number of Residents Served in Secured Dementia Care Unit: 6
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Malerhofer | Administrator | Named as legal entity representative and administrator in the report and plan of correction |
| Douglas Hoover | Department representative on-site during inspection |
Inspection Report — Nov 4, 2016
Complaint Investigation
Date: Nov 4, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving resident interactions.
Complaint Details
The complaint investigation was substantiated based on observation of inappropriate touching by Resident #1 toward Resident #2. Resident #1 was placed on one-to-one supervision and medication changes were made. Hospice and primary care providers were notified and involved in care adjustments.
Findings
A violation of 55 Pa.Code §2600.42(b) was found where Resident #1 was observed inappropriately touching Resident #2. Resident #1 has a known history of inappropriate sexual behaviors. The facility implemented a plan of correction including one-to-one supervision and medication adjustments.
Citations (1)
55 Pa.Code §2600.42(b) - A resident was found to have been neglected and subjected to inappropriate physical contact by another resident with a known history of inappropriate sexual behaviors.
Report Facts
Number of Residents Served: 25
Total Daily Staff: 38
Waking Staff: 29
Number of Residents Served in Secured Dementia Care Unit: 10
Number of Current Hospice Residents: 5
Number of Residents 60 Years or Older: 36
Number of Residents with Mental Illness: 1
Number of Residents with Mobility Needs: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Maierhafer | Administrator | Named as legal entity representative and signer of plan of correction |
| Brett Swanger | Human Services Licensing Supervisor | Signed cover letter for inspection report |
Inspection Report — Sep 27, 2016
Annual Inspection
Date: Sep 27, 2016
Visit Reason
The inspection was an annual licensing inspection conducted on September 27, 2016, including renewal and incident triggers.
Findings
Multiple violations were found related to hot water temperature, medication administration records, resident assessments, support plans, medical evaluations, cognitive preadmission screening, secure dementia care unit security, and incident reporting. Plans of correction were submitted and partially or fully implemented as of October 13, 2016.
Citations (8)
Regulation 55 Pa.Code 2600.89(b) - Hot water temperature in resident-accessible areas exceeded 120°F, with measurements up to 127°F in multiple rooms.
Regulation 55 Pa.Code 2600.187(e) - Medication Administration Records for Residents #1 and #3 lacked diagnoses or purposes for prescribed medications.
Regulation 55 Pa.Code 2600.225(c) - Resident #2's assessment and support plan lacked documentation identifying sexually acting out behaviors requiring heightened supervision.
Regulation 55 Pa.Code 2600.227(d) - Resident #2's support plan did not document identifying or contact information for hospice provider after admission to hospice services.
Regulation 55 Pa.Code 2600.231(b) - Medical evaluations for Resident #2 did not document diagnosis of dementia or Alzheimer's disease required for secure dementia care unit admission.
Regulation 55 Pa.Code 2600.231(c) - Cognitive preadmission screening for Resident #3 was completed outside the required 72-hour timeframe prior to admission to secure dementia care unit.
Regulation 55 Pa.Code 2600.233(c) - Directions for operation of locking mechanisms in the secure dementia care unit were not conspicuously posted near exits.
Regulation 55 Pa.Code 2600.252 - Resident #3's record lacked a copy of the incident report and information regarding an alleged sexual assault incident involving Resident #2.
Report Facts
Number of Residents Served: 36
Hot water temperature: 127
Hot water temperature: 126
Total Daily Staff: 50
Walking Staff: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Maierhofer | Administrator | Named in relation to multiple findings and plans of correction. |
| Michael Showers | Department representative conducting the inspection. | |
| Cybil Bomberger | Department representative conducting the inspection. |
Notice — May 24, 2016
Date: May 24, 2016
Visit Reason
The document serves as a renewal notice and license issuance for the operation of a Personal Care Home, confirming the facility's capacity and compliance with state regulations.
Findings
The Department of Human Services has approved the renewal application and issued a license for the facility to operate with a maximum capacity of 54 residents, including a secure dementia care unit with a capacity of 12.
Report Facts
Notice — June 1, 2020
Date: June 1, 2020
Visit Reason
The document serves as a license renewal approval for Epworth Manor Senior Living and notifies that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license following the renewal application.
Report Facts
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