Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Crest Nursing Centre Inc during CMS and state inspections, most recent first.
Failure to follow physician orders for medication and wound care: one resident’s physician-approved hospice order for lorazepam was not transcribed as ordered, and another resident with a right foot wound received Calcium Alginate instead of the ordered Calcium Alginate AG during a dressing change. An RN acknowledged both errors, and the DON/DNS confirmed the medication order had not been entered until the surveyor raised the issue.
A resident with pulmonary HTN had an order for Diltiazem ER 180 mg daily with instructions to hold if SBP was below 110. MAR review showed the medication was given multiple times when SBP was under the ordered limit, and a CMT and the DON acknowledged the doses should have been held.
The facility was found deficient in food safety standards, with dietary staff not wearing required hair/beard restraints and significant cleanliness issues in the kitchen. Observations included unclean equipment, such as a greasy convection oven and a dusty floor fan, and improperly maintained cutting boards. The Food Service Director could not provide evidence of compliance or corrective actions.
The facility failed to follow physician orders for two residents. One resident with congestive heart failure refused furosemide multiple times without the physician being notified, contrary to facility policy. Another resident with aspiration precautions was observed using a straw, despite an order against it. Staff were unaware of the orders, leading to non-compliance with professional standards.
A facility failed to provide adequate pharmaceutical services for a resident with congestive heart failure and chronic kidney disease. The resident refused prescribed furosemide doses multiple times in August, but these refusals were not identified by the pharmacist during a medication review. This oversight was confirmed by the DON, highlighting a deficiency in ensuring proper medication administration.
Two residents with orders for a pureed diet were served scrambled eggs that were not pureed, contrary to the facility's diet manual. Staff interviews revealed a misunderstanding of the diet guidelines, as scrambled eggs were incorrectly considered pureed. The registered dietitian admitted that an addendum to the manual should have been created to include scrambled eggs for pureed diets, but no such documentation was available.
The facility failed to maintain Enhanced Barrier Precautions for a resident with ESBL, as a nursing assistant did not wear a gown during a high-contact activity. Additionally, infection control was compromised during wound care for another resident, as a nurse used uncleaned scissors and reused a wound measurement strip. The Director of Nursing acknowledged these lapses in protocol.
A resident with severe cognitive impairment was found with unattended medications on their bedside table, contrary to the facility's policy requiring medications to be locked or attended by authorized personnel. Both an LPN and the DON acknowledged the error, highlighting a failure in medication storage procedures.
A resident did not receive a scheduled dose of Lyrica due to the facility's failure to properly store and account for the medication. Discrepancies in the narcotic count procedure were identified, with one LPN unaware of missing medication and another realizing the issue later. The DON suggested the medication might have been discarded accidentally, but could not provide evidence of proper storage.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when a physician-approved hospice recommendation for lorazepam was not transcribed as ordered. Resident ID #11 was re-admitted with a diagnosis including anxiety disorder and was receiving hospice services with a plan to administer medications as ordered for comfort. A hospice care coordination note recommended continuing lorazepam 0.5 mg by mouth at bedtime and every one hour as needed, and a progress note documented physician approval of that recommendation. However, the record did not show that the order for lorazepam 0.5 mg every one hour as needed was entered as ordered. An RN acknowledged that the order had not been transcribed, and the DNS confirmed that the facility did not place the order in the chart until it was brought to staff attention by the surveyor. The facility also failed to provide the ordered wound treatment for another resident with a right foot wound. Resident ID #159 was re-admitted with an ulceration of the right mid foot, and a physician ordered the wound to be cleansed with normal saline and covered with Calcium Alginate AG daily. During observation of the dressing change, the RN cleansed the wound with normal saline but applied Calcium Alginate instead of Calcium Alginate AG. The RN acknowledged the dressing applied was not the one ordered, and the DNS was unable to provide evidence that the resident had received the appropriate wound care treatment as ordered.
Unnecessary Drug Regimen: Antihypertensive Given Despite Hold Parameters
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met for Resident ID #93, who was readmitted in July 2024 with a diagnosis including pulmonary hypertension. A physician's order dated 4/30/2025 directed Diltiazem HCL extended release 180 mg daily and to hold the medication if the systolic blood pressure was less than 110. Review of the August and September 2025 MARs showed the Diltiazem was administered on multiple occasions when the resident's SBP was below the ordered parameter, including readings of 108, 106, and 105. During interview, a Certified Medication Technician acknowledged signing off the medication as administered on 8/25/2025 and 9/4/2025 when the SBP was less than 110, and the DNS acknowledged the medication should have been held on the dates when the resident's SBP was below the ordered threshold.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food safety as observed during a survey. Multiple dietary staff members, including cooks and aides, were found not wearing required hair and beard restraints while preparing and serving food. This was observed in the main kitchen and during meal service in the dining room. Additionally, a dietary aide in the dish room was also not wearing a beard/hair restraint. These observations indicate a lack of compliance with the Rhode Island Food Code 2018 Edition, which mandates that food employees wear hair and beard restraints to prevent hair from contacting exposed food. Further deficiencies were noted in the cleanliness and maintenance of kitchen equipment and surfaces. The main kitchen had a convection oven with significant grease and grime buildup, a utility cart with a black substance and brown stains, and a floor fan with dust accumulation. The kitchenette refrigerator had a sticky purple substance and brown spills, while the freezer had a heavy accumulation of ice. Additionally, five cutting boards were found with significant scoring and scratches, making them difficult to clean and sanitize effectively. The Food Service Director was unable to provide evidence that these issues had been addressed or that the dietary staff were compliant with hair/beard restraint requirements.
Failure to Follow Physician Orders for Medication and Aspiration Precautions
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident ID #95, who was readmitted with acute on chronic congestive heart failure and chronic kidney disease, there was a physician's order for furosemide 40 mg twice a day. However, the medication was refused multiple times throughout August and September 2024, and there was no evidence that the physician was notified of these refusals, as required by the facility's policy. Interviews with staff revealed that the medication aide was aware of the refusals but only communicated them informally to the nurse, who was unaware of the extent of the refusals and did not notify the physician. For Resident ID #242, who was readmitted with pneumonitis due to inhalation of food and dementia, there was a physician's order for aspiration precautions, specifically stating no use of straws. Despite this, the resident was observed using a straw on multiple occasions. Nursing assistants and an LPN acknowledged providing the resident with a straw and were unaware of the order prohibiting its use. The Director of Nursing Services confirmed that the resident should not have been using a straw due to the recent diagnosis of aspiration pneumonia.
Failure to Address Medication Refusals in Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident with acute on chronic congestive heart failure and chronic kidney disease. The resident was prescribed furosemide, a diuretic medication, to be taken twice daily. However, the medication was consistently refused by the resident on multiple occasions throughout August 2024, including both AM and PM doses on several days. Despite these refusals, there was no evidence that the pharmacist identified these issues during a medication regimen review conducted on August 27, 2024. During an interview with the Director of Nursing Services on September 19, 2024, it was confirmed that the medication refusals were not identified in the pharmacist's review. This oversight indicates a failure in the facility's procedures to ensure the administration of medications as prescribed, which is crucial for managing the resident's medical conditions. The lack of identification and follow-up on the medication refusals represents a deficiency in the facility's pharmaceutical services.
Failure to Provide Properly Pureed Diets
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of residents on a pureed diet, as observed during a survey. Two residents, both with physician's orders for a pureed diet, were served scrambled eggs that were not pureed, contrary to the guidelines outlined in the facility's Diet and Nutrition Care Manual. The manual specifies that all foods for a Level 4 Pureed Diet should be pureed, eliminating the need for chewing. Despite this, scrambled eggs were served to residents with pureed diet orders, which does not align with the manual's requirements. Interviews with facility staff revealed a misunderstanding or misapplication of the diet manual. A registered nurse and the food service director both indicated that scrambled eggs were considered pureed, despite the lack of an official addendum to the manual supporting this practice. The registered dietitian acknowledged that the manual is used to create menus and guide mechanically altered diets, but admitted that an addendum should have been created to include scrambled eggs for pureed diets, though no such documentation was available. This oversight led to the improper serving of non-pureed scrambled eggs to residents requiring a pureed diet.
Infection Control Deficiencies in EBP and Wound Care
Penalty
Summary
The facility failed to maintain Enhanced Barrier Precautions (EBP) for a resident with Extended-Spectrum Beta-Lactamase (ESBL) in the urine. Despite a physician's order for EBP, a nursing assistant was observed transferring the resident without wearing a gown, which is required during high-contact activities to prevent the spread of multidrug-resistant organisms. The nursing assistant acknowledged the failure to adhere to the EBP protocol, and the Assistant Director of Nursing and Infection Preventionist confirmed the expectation for staff to wear gowns during such activities. Additionally, the facility did not maintain proper infection prevention and control during wound care for another resident. A registered nurse was observed using uncleaned scissors to cut a soiled dressing and then using the same scissors to cut a new dressing, which was then placed back into its packaging for potential reuse. The nurse also used a paper wound measurement strip directly on the wound and placed it back on the treatment cart for multi-resident use. The Director of Nursing Services acknowledged that the scissors should have been cleaned, the dressing should have been designated for single-resident use, and the measurement strip should have been discarded after use.
Unattended Medications at Resident's Bedside
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with currently accepted professional principles, as observed by surveyors. During a surveyor observation, medications were found unattended on the bedside table of a resident, identified as Resident ID #57, who was asleep at the time. The facility's policy on medication storage requires that medication supplies remain locked when not in use or attended by authorized personnel. However, this policy was not followed, as the medications were left unattended. Resident ID #57, who was admitted to the facility in March 2023, has diagnoses including vascular dementia and recurrent depressive disorder. A Minimum Data Set (MDS) assessment indicated severe cognitive impairment with a Brief Interview for Mental Status score of 4 out of 15. During interviews, both a Licensed Practical Nurse and the Director of Nursing Services acknowledged that medications should not have been left unattended at the resident's bedside, indicating a lapse in adherence to the facility's medication administration procedures.
Failure to Properly Store and Account for Controlled Medication
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with currently accepted professional principles, as evidenced by an incident involving a missing controlled medication. A resident, who was admitted with conditions including rheumatoid arthritis and osteoporosis, was unable to receive a scheduled dose of Lyrica, a controlled medication, because the facility could not locate the 16 pills that were documented as available. The narcotic book indicated that the pills were removed from the count, but there was no evidence provided that the medication was stored properly. During interviews, discrepancies in the narcotic count procedure were revealed. One LPN stated that she completed the narcotic count with the oncoming nurse, but was not notified of any missing medication. The oncoming LPN reported that the resident's medication was not counted during the shift change, and she only realized the medication was missing later. The Director of Nursing Services suggested that the medication might have been accidentally discarded, but could not provide evidence of proper storage practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cranston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morgan Health Center | 1.6 mi | ★★★★★ | 3 | 1 |
| Briarcliffe Manor | 3.2 mi | ★★★★★ | 0 | 0 |
| Elmwood Nursing And Rehabilitation Center | 3.3 mi | ★★★★★ | 14 | 0 |
| Adviniacare Providence Dodge Rehab Center, Llc | 3.6 mi | ★★★★★ | 4 | 0 |
| Scandinavian Home Inc | 4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.