Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
126% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 25, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication management, and treatment protocols at Cedar Crest Nursing Centre Inc during the annual survey.
Findings
The facility failed to ensure proper transcription and administration of physician orders for medications and wound care for multiple residents. Specifically, lorazepam orders were not transcribed as ordered, incorrect wound dressing was applied, and an antihypertensive medication was administered despite parameters to hold it.
Deficiencies (2)
F 0658: The facility failed to ensure residents received treatment and care according to professional standards. Resident #11's lorazepam order for 0.5 mg every hour as needed was not transcribed as ordered. Resident #159 received incorrect wound dressing; Calcium Alginate was applied instead of Calcium Alginate AG as ordered.
F 0757: The facility failed to ensure a resident's drug regimen was free from unnecessary drugs. Resident #93 received Diltiazem despite systolic blood pressure readings below the ordered hold parameter of 110.
Report Facts
Residents reviewed: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication administration dates with SBP below 110: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN), Staff A | Acknowledged failure to transcribe lorazepam order and incorrect wound dressing application | |
| Director of Nursing Services (DNS) | Acknowledged failure to transcribe lorazepam order and failure to provide appropriate wound care | |
| Certified Medication Technician, Staff B | Acknowledged signing off Diltiazem administration despite low systolic blood pressure |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
The inspection was conducted due to a complaint or allegation regarding improper medication storage practices at the facility.
Complaint Details
The complaint was substantiated based on surveyor observation and staff interviews confirming medication was left unattended at the resident's bedside.
Findings
The facility failed to store drugs and biologicals according to accepted professional principles, specifically leaving medications unattended at a resident's bedside. Observation and staff interviews confirmed that medications were left unattended for Resident ID #57, which is against facility policy.
Deficiencies (1)
F 0761: The facility failed to store drugs and biologicals in locked compartments and left medications unattended at the bedside of Resident ID #57. Licensed Practical Nurse acknowledged the medications should not have been left unattended.
Report Facts
Tablets left unattended: 4
Brief Interview for Mental Status score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Acknowledged medications were left unattended on the resident's bedside table | |
| Director of Nursing Services | Indicated expectation that medications not be left unattended and staff remain with resident during medication administration |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 20, 2024
Visit Reason
Routine inspection to assess compliance with professional standards of care, pharmaceutical services, medication storage, food preparation, infection control, and food safety in a nursing facility.
Findings
The facility failed to ensure proper medication administration and physician notification for medication refusals, failed to follow aspiration precaution orders, improperly stored medications, served non-pureed food to residents on pureed diets, failed to maintain food safety standards in kitchens, and did not fully comply with infection prevention protocols including Enhanced Barrier Precautions and wound care procedures.
Deficiencies (6)
F0658: The facility failed to ensure residents received treatment according to physician's orders, including failure to notify the physician of multiple refusals of furosemide and failure to follow aspiration precaution orders prohibiting straw use for Resident ID #242.
F0755: The facility failed to provide pharmaceutical services ensuring medication refusals were identified during pharmacist review for Resident ID #95.
F0761: The facility failed to store drugs and biologicals properly, leaving medications unattended on a resident's bedside table.
F0805: The facility failed to provide food prepared in a form designed to meet individual needs, serving scrambled eggs not pureed to residents on pureed diets.
F0812: The facility failed to ensure food safety standards, including staff not wearing hair/beard restraints, dirty kitchen equipment, and poorly maintained cutting boards.
F0880: The facility failed to maintain Enhanced Barrier Precautions for a resident with ESBL infection and failed to follow proper wound care procedures, including reuse of wound supplies and failure to clean instruments.
Report Facts
Medication refusal dates: 30
Brief Interview for Mental Status score: 8
Brief Interview for Mental Status score: 4
Physician order dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Acknowledged resident frequently refused medication and documented refusals on paper. |
| Staff B | Registered Nurse | Unaware of medication refusals and observed failing to clean wound care scissors and reuse supplies. |
| Staff C | Nursing Assistant | Acknowledged providing straw to resident despite order prohibiting it. |
| Staff D | Nursing Assistant | Acknowledged providing straw to resident despite order prohibiting it. |
| Staff E | Licensed Practical Nurse | Acknowledged resident had a straw despite no-straw order. |
| Staff F | Licensed Practical Nurse | Acknowledged medications were left unattended on bedside table. |
| Staff G | Registered Nurse | Indicated facility considers scrambled eggs as pureed food. |
| Staff H | Nursing Assistant | Reported residents consumed 100% of breakfast meals including scrambled eggs. |
| Staff I | Registered Dietitian | Acknowledged facility serves scrambled eggs for pureed diets and lack of addendum to diet manual. |
| Staff J | Nursing Assistant | Observed transferring resident without wearing gown as required by Enhanced Barrier Precautions. |
| Staff K | Dietary Cook | Observed not wearing hair/beard restraint during food preparation. |
| Staff L | Dietary Aide | Observed not wearing hair/beard restraint. |
| Staff M | Dietary Aide | Observed not wearing hair/beard restraint and serving food without restraint. |
| Staff N | Dietary Staff | Observed not wearing hair/beard restraint and serving food without restraint. |
| Staff O | Dietary Aide | Observed not wearing hair/beard restraint in dish room. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 5, 2024
Visit Reason
The inspection was conducted following a complaint related to the facility's failure to properly store and account for controlled medications, specifically a missing dose of Lyrica for a resident.
Complaint Details
The complaint investigation found that Resident ID #1 did not receive a scheduled dose of Lyrica due to missing pills not accounted for during narcotic counts. The issue was substantiated with interviews confirming procedural lapses and the possible accidental disposal of medication.
Findings
The facility failed to store drugs and biologicals according to accepted professional principles, resulting in a missing controlled medication dose for one resident. Interviews revealed lapses in narcotic count procedures and documentation, and the facility implemented corrective education and auditing measures.
Deficiencies (1)
F 0761: The facility failed to store drugs and biologicals in locked compartments and maintain accurate controlled medication counts, leading to a missing dose of Lyrica for Resident ID #1 on July 18, 2024.
Report Facts
Medication pills missing: 16
Date of incident: Jul 18, 2024
Date of complaint report: Jul 19, 2024
Date of survey: Aug 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Documented removal of missing medication from narcotic count and provided interview about the incident |
| Licensed Practical Nurse Staff A | Licensed Practical Nurse | Interviewed regarding narcotic count procedures and medication administration |
| Licensed Practical Nurse Staff B | Licensed Practical Nurse | Interviewed regarding narcotic count procedures and medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 1, 2024
Visit Reason
The inspection was conducted following a complaint regarding a resident who sustained burns from a radiator in the facility.
Complaint Details
The complaint involved a resident who was found with burns on his/her knees and legs caused by contact with a hot radiator. The resident was admitted to hospice care and later expired. The complaint investigation included review of medical records, physician orders, and interviews with facility staff.
Findings
The facility failed to ensure a safe environment free from accident hazards, resulting in a resident sustaining burns from a hot radiator. Additionally, the facility failed to ensure licensed nurses had the appropriate competencies to care for residents requiring non-rebreather oxygen masks.
Deficiencies (2)
F 0689: The facility failed to ensure the environment was free from accident hazards, resulting in a resident sustaining burns from a hot radiator with temperatures between 133.5-153 degrees Fahrenheit.
F 0726: The facility failed to ensure licensed nurses had the appropriate competencies to care for residents requiring non-rebreather oxygen masks, with staff unaware of the correct oxygen flow rates.
Report Facts
Radiator temperature: 133.5
Radiator temperature: 153
Burn measurements: 20
Burn measurements: 16
Burn measurements: 25
Burn measurements: 5
Burn measurements: 1.8
Burn measurements: 3
Morphine Concentrate dosage: 100
Oxygen flow rate applied: 5
Pulse oximetry reading: 47
Pulse oximetry reading: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Interviewed regarding knowledge of non-rebreather oxygen mask flow rates |
| Staff B | RN and Admissions Director | Interviewed about expected oxygen flow rates for non-rebreather masks |
| Director of Nursing Services | Director of Nursing Services | Interviewed about nursing staff competencies and oxygen mask use |
| Environmental Director | Environmental Director | Interviewed about radiator heat and facility heating system |
| Administrator | Administrator | Interviewed about safety measures to prevent burns from radiators |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 5, 2023
Visit Reason
Routine inspection of Cedar Crest Nursing Centre to assess compliance with regulatory standards including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, failure to update care plans after hospital stays, failure to meet professional standards for physician orders and wound care, inadequate activity programming, unsafe environment related to falls, improper IV medication administration, food safety violations, inaccurate medical record documentation, and failure to maintain infection prevention and control protocols.
Deficiencies (10)
F0604: Facility failed to ensure residents are free from physical restraints not required for medical treatment, evidenced by Resident #41 being placed in a reclined Geri Chair with elevated footrest restricting movement.
F0657: Facility failed to revise and update the comprehensive care plan after a hospital stay for Resident #45, missing updates related to transfer status and use of Hoyer lift.
F0658: Facility failed to meet professional standards for physician orders and equipment use for multiple residents, including suctioning without active orders, wheelchair equipment not applied as ordered, and incomplete psychiatric medication transcription.
F0679: Facility failed to provide an ongoing activity program meeting resident preferences and needs for Resident #31, who did not receive group or one-on-one stimulation as per care plan.
F0684: Facility failed to provide appropriate wound care and documentation for Resident #395 and failed to ensure free floating of heels for Resident #45 as ordered.
F0689: Facility failed to maintain a safe environment free from accident hazards related to falls for Resident #41, who fell from a reclined Geri Chair with elevated footrest despite physician orders to use the chair without footrest elevated.
F0694: Facility failed to meet professional standards for safe administration of IV fluids for Residents #345 and #349, including improper aseptic technique and failure to report PICC line site infection.
F0812: Facility failed to ensure food safety in the kitchen and kitchenette, including storing food beyond safe dates and unclean equipment such as ice machine, toaster oven, and microwave.
F0842: Facility failed to maintain accurate medical records for wounds, restraint/adaptive equipment assessments, and wheelchair equipment use for multiple residents, including undocumented wounds and uncompleted assessments.
F0880: Facility failed to maintain infection prevention and control program, including staff not wearing full PPE (N95 respirators, eye protection) when caring for COVID-19 positive residents and improper aseptic technique during IV medication administration.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 5
Food items observed past safe date: 3
Dates food items were past safe date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding Resident #41's ambulation and restraint use |
| Staff B | Nursing Assistant | Observed and interviewed regarding Resident #41's behavior in Geri Chair |
| Staff C | Nursing Assistant | Observed assisting Resident #41 in Geri Chair and interviewed |
| Staff D | Registered Nurse | Interviewed regarding Resident #45's care plan update |
| Staff E | Registered Nurse | Authored progress note on Resident #31's suctioning |
| Staff F | Speech Licensed Therapist | Authored progress note on Resident #31's suctioning |
| Staff G | Licensed Practical Nurse | Interviewed regarding suctioning for Resident #31 |
| Staff H | Licensed Practical Nurse | Interviewed regarding wheelchair buddy use for Resident #9 |
| Staff I | Licensed Practical Nurse | Signed off restraint/adaptive equipment assessment for Resident #22 |
| Staff J | Activity Staff | Interviewed regarding Resident #31's activity participation |
| Staff K | Nursing Assistant | Observed and interviewed regarding Resident #31 and PPE use for Resident #41 |
| Staff L | Nursing Assistant | Interviewed regarding free floating heels for Resident #45 |
| Staff M | Licensed Practical Nurse | Observed and interviewed regarding improper IV medication administration for Resident #349 |
| Staff N | Nursing Assistant | Observed PPE use for Resident #125 and COVID-19 precautions |
| Director of Nursing Services | Director of Nursing Services | Interviewed multiple times regarding deficiencies and facility practices |
| Infection Preventionist | Infection Preventionist | Interviewed regarding PPE and infection control practices |
| Food Service Director | Food Service Director | Interviewed regarding food safety observations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 6, 2023
Visit Reason
The inspection was conducted to investigate an allegation of abuse involving a resident who reported that a Nursing Assistant was rough and threw them in bed.
Complaint Details
The complaint involved an allegation that a Nursing Assistant was rough and threw a resident in bed. The investigation lacked evidence that the resident was interviewed or assessed for injury. The Director of Nursing Services was unable to provide evidence of a comprehensive investigation.
Findings
The facility failed to provide evidence that the alleged abuse was thoroughly investigated, specifically that the resident was interviewed or assessed for injury following the allegation.
Deficiencies (1)
F 0610: The facility failed to provide evidence that all alleged violations were thoroughly investigated for one resident regarding an allegation of abuse. The resident was not interviewed or assessed for injury following the allegation that a Nursing Assistant threw them on the bed.
Report Facts
Residents Affected: 2
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