Inspection Report
Plan of Correction
Deficiencies: 0
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
Census: 27
Capacity: 33
Deficiencies: 6
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)
| Description |
|---|
| 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
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.
Severity Breakdown
F: 1
E: 3
D: 1
B: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility policy failed to ensure safe and sanitary storage, handling, and consumption of food brought in from outside sources. | F |
| Facility failed to ensure self-administration of medications was clinically appropriate for a resident using an insulin pump. | E |
| 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. | E |
| Facility failed to ensure sufficient nursing staff competencies and skills to provide safe and quality care, including training on insulin pump use. | E |
| Facility failed to maintain resident records that are complete, accurately documented, readily accessible, systematically organized, and confidential. | D |
| Facility failed to protect identifying information about complaints or residents in survey results binder. | B |
Report Facts
Census: 27
Total Capacity: 33
Deficiencies cited: 6
Blood pressure monitoring failures: 20
Inspection Report
Plan of Correction
Deficiencies: 0
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
Annual Inspection
Census: 30
Capacity: 33
Deficiencies: 10
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)
| Description |
|---|
| 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
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
Annual Inspection
Census: 28
Capacity: 33
Deficiencies: 7
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)
| Description |
|---|
| 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
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
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)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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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