Deficiencies (last 5 years)
Deficiencies (over 5 years)
12.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
259% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
82% occupied
Based on a November 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 30, 2025
Visit Reason
An off-site desk audit was conducted on December 30, 2025, to review all previous deficiencies cited on November 26, 2025.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Nov 26, 2025
Visit Reason
The inspection was conducted as part of the annual federal recertification survey to assess compliance with regulatory standards and ensure quality of care at Bethany Home of Rhode Island.
Findings
The facility was found deficient in multiple areas including failure to ensure clinically appropriate self-administration of medications for a resident using an insulin pump, failure to protect resident-identifiable information, failure to meet professional standards of care related to medication administration and monitoring, inadequate nursing staff competencies regarding insulin pump management, unsafe policies regarding food brought in from outside sources, and incomplete and inaccurate resident medical records documentation.
Deficiencies (6)
Failed to ensure self-administration of medications was clinically appropriate for a resident with an insulin pump; no assessment of resident's ability to self-administer was completed.
Failed to protect identifying information about complainants or residents in the survey results binder accessible to the public.
Failed to ensure residents received treatment and care in accordance with professional standards, including lack of physician orders specifying insulin pump details and failure to monitor vital signs as ordered for multiple residents.
Failed to ensure licensed nurses had competencies and training to manage insulin pump for a resident.
Facility policy failed to ensure safe and sanitary storage, handling, and consumption of food brought in from outside sources.
Failed to safeguard resident-identifiable information and maintain complete and accurate medical records, including failure to notify physician when continuous glucose monitor stopped working and inaccurate documentation of blood sugar monitoring.
Report Facts
Opportunities missed for blood pressure monitoring: 20
Date of survey completion: Nov 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Acknowledged failure to complete assessment of resident's ability to self-administer medications and lack of nursing staff training on insulin pump. |
| Staff A | Certified Medication Technician | Failed to obtain resident's systolic blood pressure prior to administering medication as ordered. |
| Staff B | Registered Nurse | Could not provide evidence that blood pressure or heart rate were taken each shift as ordered. |
| Staff D | Registered Nurse | Revealed no training on insulin pump use and could not provide evidence of physician notification regarding blood sugar monitoring changes. |
| Staff E | Registered Nurse | Revealed no training on insulin pump use. |
Inspection Report
Annual Inspection
Census: 27
Capacity: 33
Deficiencies: 6
Date: Nov 26, 2025
Visit Reason
A recertification survey was conducted at Bethany Home of Rhode Island from 11/24/2025 through 11/28/2025 to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to personal food policy, self-administration of medications, comprehensive care plans, medication administration and treatment records, nursing staff competencies, resident records, and protection of resident information. The facility submitted plans of correction for all cited deficiencies. No life safety code deficiencies were identified.
Deficiencies (6)
Failure to have a policy ensuring safe and sanitary handling of food brought in from outside sources.
Failure to ensure self-administration of medications was clinically appropriate and properly assessed.
Failure to meet professional standards of quality in services provided, including insulin pump management and monitoring.
Failure to ensure competent nursing staff with necessary skills and training related to insulin pump use.
Failure to safeguard resident-identifiable information and protect resident privacy.
Failure to maintain complete and accurate medical records, including blood sugar monitoring documentation.
Report Facts
Census: 27
Total Capacity: 33
Survey Dates: Survey conducted from 11/24/2025 through 11/28/2025
Inspection Report
Annual Inspection
Census: 27
Capacity: 33
Deficiencies: 6
Date: Nov 26, 2025
Visit Reason
A recertification survey was conducted at Bethany Home of Rhode Island from 11/24/2025 through 11/26/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to personal food policy, resident self-administration of medications, professional standards of care, competent nursing staff, resident records confidentiality and documentation, and right to survey results and advocate agency information. The facility was found to be in compliance with emergency preparedness and life safety code requirements.
Deficiencies (6)
Facility policy failed to ensure safe and sanitary storage, handling, and consumption of food brought in from outside sources.
Facility failed to ensure self-administration of medications was clinically appropriate for a resident using an insulin pump.
Facility failed to ensure residents received treatment and care in accordance with professional standards, including monitoring and documentation for insulin pump use and medication administration.
Facility failed to ensure sufficient nursing staff competencies and skills to provide safe and quality care, including training on insulin pump use.
Facility failed to maintain resident records that are complete, accurately documented, readily accessible, systematically organized, and confidential.
Facility failed to protect identifying information about complaints or residents in survey results binder.
Report Facts
Census: 27
Total Capacity: 33
Deficiencies cited: 6
Blood pressure monitoring failures: 20
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 5, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall resulting in significant injuries. The visit aimed to determine if the facility ensured adequate supervision and safety measures to prevent accidents.
Complaint Details
The complaint investigation found that Resident ID #1 fell on 11/4/2025 while being assisted by staff who did not use a gait belt as required by the care plan. The resident sustained multiple vertebral fractures and a significant decline. Staff interviews confirmed the failure to follow safety protocols.
Findings
The facility failed to ensure adequate supervision and proper use of assistive devices for Resident ID #1, resulting in a preventable fall that caused multiple spinal fractures and a significant decline in the resident's condition. Staff did not follow the resident's care plan, specifically failing to use a gait belt during ambulation assistance.
Deficiencies (1)
Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Date of fall: Nov 4, 2025
Date of survey: Nov 5, 2025
Number of residents reviewed for falls: 1
Number of spinal fractures: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding resident's need for assistance ambulating |
| Staff B | Nursing Assistant | Interviewed regarding regular assistance to Resident ID #1 and gait belt use |
| Staff C | Occupational Therapist | Interviewed regarding resident's therapy and condition post-fall |
| Staff D | Nursing Assistant | Staff assisting resident at time of fall; admitted failure to use gait belt |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
An off-site desk audit was conducted on November 6, 2024, to review all previous deficiencies cited on September 26, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Routine
Deficiencies: 8
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, notification of transfers, professional standards of care, trauma-informed care, staff competencies, medication management, quality assurance, and infection control.
Findings
The facility was found deficient in multiple areas including failure to protect residents' privacy regarding medical devices, failure to notify the State Long-Term Care Ombudsman of hospital transfers, failure to follow physician orders for medication refusals, lack of trauma-informed care assessments, inadequate staff competencies on Enhanced Barrier Precautions, medication errors involving discontinuation of Sertraline, ineffective Quality Assurance and Performance Improvement (QAPI) program, and failure to implement infection prevention and control measures including Enhanced Barrier Precautions for residents with multi-drug resistant organisms.
Deficiencies (8)
Failed to respect residents' right of personal privacy for 3 residents by posting medical device information on signs outside their rooms.
Failed to provide timely notification to the State Long-Term Care Ombudsman for 2 residents transferred to hospital.
Failed to ensure physician was notified of medication refusals for a lidocaine patch for 1 resident.
Failed to provide trauma-informed care and complete trauma screening assessment for 1 resident with history of trauma.
Failed to ensure nursing staff had competencies related to Enhanced Barrier Precautions for 7 nursing staff.
Failed to ensure resident's drug regimen was free from significant medication errors; Sertraline was discontinued in error for 1 resident.
Failed to implement and maintain an effective QAPI program focusing on trauma assessments and infection control monitoring.
Failed to maintain infection prevention and control program; residents with MDRO infections were not placed on Enhanced Barrier Precautions and annual IPCP review was not conducted.
Report Facts
Medication refusals: 21
Hospital transfers: 3
Hospital transfers: 2
Sertraline dose reductions: 2
Nursing staff: 7
Residents affected: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged resident frequently refused Lidocaine patch and physician was not notified |
| Staff C | Registered Nurse | Unaware of Enhanced Barrier Precautions and had not been educated on them |
| Staff D | Certified Medication Technician | Unaware of current precautions for resident with ESBL infection |
| Staff H | Nursing Assistant | Unaware of Enhanced Barrier Precautions and when they should be implemented |
| Staff I | Registered Nurse | Unaware Sertraline was discontinued until surveyor brought it to attention |
| Director of Nursing Services | Director of Nursing Services | Acknowledged multiple deficiencies including lack of notification to physician, lack of trauma screening, lack of staff competencies, and failure to maintain infection control program |
| Social Worker | Social Worker | Unable to provide evidence of notification to Ombudsman and trauma screening assessments |
| Resident's Physician | Physician | Unable to explain why Sertraline was discontinued; reinstated medication after notification |
Inspection Report
Annual Inspection
Census: 30
Capacity: 33
Deficiencies: 10
Date: Sep 26, 2024
Visit Reason
A recertification survey was conducted at Bethany Home of Rhode Island from 9/23/2024 through 9/26/2024 to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Multiple deficiencies were identified related to personal privacy/confidentiality of records, notice requirements before transfer/discharge, professional standards in care plans, trauma-informed care, competent nursing staff, medication error prevention, and infection control. The facility submitted plans of correction for all cited deficiencies.
Deficiencies (10)
Personal Privacy/Confidentiality of Records not maintained for residents #16, 77, and 179.
Notice requirements before transfer/discharge not met for residents #16 and 77.
Facility failed to ensure residents receive treatment and care in accordance with professional standards for resident #179.
Facility failed to ensure trauma-informed care for resident #21.
Facility failed to ensure sufficient nursing staff competencies related to Enhanced Barrier Precautions for 7 of 7 nursing staff reviewed.
Facility failed to ensure resident #7 was free from significant medication errors.
Facility failed to complete trauma assessments for residents #17 and 18 and provide trauma-informed care.
Facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program.
Facility failed to maintain an infection prevention and control program including surveillance, reporting, and annual review.
Facility failed to notify Office of State Long-Term Care Ombudsman of hospital transfers for residents #16 and 77.
Report Facts
Capacity: 33
Census: 30
Dates of hospital transfers: Resident #16 transferred on 5/2/2024, 5/30/2024, and 7/2/2024; Resident #77 transferred on 7/12/2024 and 7/29/2024
Medication Administration Record refusals: 21
BIMS score: 6
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 15, 2023
Visit Reason
An off-site desk audit was conducted on December 15, 2023, to review all previous deficiencies cited on November 7 and November 8, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, all previously cited deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Routine
Deficiencies: 4
Date: Nov 8, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in a nursing facility, including adherence to physician orders, trauma-informed care, drug regimen appropriateness, and food safety practices.
Findings
The facility failed to follow physician orders for wearing compression stockings for one resident, did not complete trauma-informed care assessments for three residents, failed to adjust a resident's medication dosage as ordered causing unnecessary drug administration, and did not follow proper food thawing procedures in the kitchen.
Deficiencies (4)
Failed to meet professional standards of quality relative to following physician orders for wearing compression stockings for 1 of 3 residents reviewed.
Failed to ensure residents who are trauma survivors receive culturally competent, trauma-informed care for 3 of 12 residents reviewed.
Failed to ensure a resident's drug regimen was free from unnecessary drugs related to pharmacy recommendations for 1 of 5 residents reviewed.
Failed to ensure food is stored and distributed in accordance with professional standards for food service safety, specifically thawing frozen pork tenderloins without running water as required.
Report Facts
Days extra medication administered: 11
Residents reviewed for trauma informed care: 12
Residents affected by deficiencies: 1
Residents affected by deficiencies: 3
Residents affected by deficiencies: 1
Residents affected by deficiencies: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding resident wearing incorrect stockings. |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding medication administration and trauma informed care assessments. |
| Staff B | Food Service Manager | Interviewed regarding thawing procedures for frozen pork tenderloins. |
Inspection Report
Annual Inspection
Census: 28
Capacity: 33
Deficiencies: 7
Date: Nov 8, 2023
Visit Reason
A Recertification Survey was conducted from 11/06/2023 through 11/08/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey. Additionally, an annual Federal Life Safety Code survey was conducted.
Findings
Deficiencies were cited in multiple areas including failure to meet professional standards for comprehensive care plans, trauma-informed care, drug regimen management, food safety and thawing procedures, and life safety code violations related to stairways, smokeproof enclosures, fire drills, and emergency power supply system maintenance. Plans of correction were provided for all cited deficiencies.
Deficiencies (7)
Facility failed to meet professional standards of quality related to physician orders for wearing Ted stockings for Resident ID #22.
Facility failed to ensure trauma survivors receive culturally competent, trauma-informed care for 3 of 12 residents reviewed.
Facility failed to ensure a resident's drug regimen was free from unnecessary drugs related to pharmacy recommendations for Resident ID #3.
Facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety, including thawing procedures.
Facility failed to maintain stairways and smokeproof enclosures free from storage of combustible objects affecting 28 residents and an indeterminable number of staff and visitors.
Facility failed to provide evidence that fire drills were conducted as required by NFPA 101 2012 Edition, potentially affecting 28 residents and an indeterminable number of staff and visitors.
Facility failed to ensure the Emergency Power Supply System (EPSS) generator was maintained and tested in accordance with NFPA standards, affecting 28 residents and an indeterminable number of staff and visitors.
Report Facts
Capacity: 33
Census: 28
Residents reviewed for trauma informed care: 12
Residents affected by stairway storage deficiency: 28
Residents affected by fire drill deficiency: 28
EPSS generator load testing opportunities: 12
EPSS generator load testing failures: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Interviewed regarding resident wearing Ted stockings and trauma informed care assessments | |
| Maintenance Director | Interviewed regarding stairway storage, fire drills, and EPSS generator maintenance | |
| Food Service Manager | FSM | Interviewed regarding food thawing procedures and kitchen observations |
| Staff B | Identified in food thawing education and kitchen procedure observations |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on September 23, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 28
Capacity: 33
Deficiencies: 6
Date: Sep 22, 2022
Visit Reason
A Recertification Survey was conducted at Bethany Home of Rhode Island from 9/21/2022 through 9/23/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure, vaccination, and emergency preparedness surveys.
Findings
Deficiencies were cited related to dietetic services, professional standards of care, dental services, food preparation, food safety, and COVID-19 vaccination tracking for staff. No Life Safety Code deficiencies were identified during the survey.
Deficiencies (6)
Facility failed to have a complete diet manual available to all dietetic and nursing services personnel.
Facility failed to ensure services met professional standards of quality related to oxygen tubing changes and meal assistance for residents.
Facility failed to provide or obtain routine and emergency dental services for residents.
Facility failed to provide food prepared in a form designed to meet individual needs for one resident.
Facility failed to comply with food safety requirements including proper hand hygiene and glove use by dietary staff.
Facility failed to develop and implement policies ensuring all staff were fully vaccinated for COVID-19 and failed to track vaccination status for contracted staff and vendors.
Report Facts
Census: 28
Total Capacity: 33
Deficiencies cited: 6
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 2
Facility staff vaccination status: 4
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jul 9, 2021
Visit Reason
A Recertification Survey was conducted at Bethany Home of Rhode Island from 07/06/2021 through 07/09/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. A State licensure and emergency preparedness survey were also conducted at this facility.
Findings
The facility was determined not to be in compliance with the requirements. Deficiencies were identified related to failure to complete a Significant Change in Status Assessment within 14 days, inaccurate coding of assessments, failure to ensure pressure ulcer prevention and treatment, failure to provide respiratory care consistent with professional standards, failure to ensure proper drug regimen review, and failure to ensure residents' drug regimens were free from unnecessary psychotropic drugs.
Deficiencies (7)
Failure to complete a Significant Change in Status Assessment within 14 days after a significant change in resident's physical or mental condition.
Inaccurate coding of Minimum Data Set (MDS) assessments related to pressure ulcers and medication administration.
Failure to ensure residents with pressure ulcers receive necessary treatment and services consistent with professional standards to promote healing and prevent new ulcers.
Failure to provide respiratory care consistent with professional standards for a resident receiving oxygen therapy.
Failure to conduct proper drug regimen reviews and act upon irregularities for residents' medications.
Failure to ensure residents' drug regimens are free from unnecessary psychotropic drugs and failure to properly manage PRN psychotropic medication orders.
Failure to properly store and label drugs and biologicals in medication carts.
Report Facts
Survey dates: 4
Significant Change in Status Assessment timeframe: 14
Residents reviewed for drug regimen irregularities: 3
Residents with psychotropic medication issues: 4
Oxygen therapy flow rate: 2
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