Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Bethany Home Of Rhode Island during CMS and state inspections, most recent first.
Policy for Outside Food Failed to Address Safe Handling Responsibilities: The facility's policy for food brought in by family and other visitors did not address safe and sanitary storage, handling, or consumption. The policy also did not address staff assistance for a resident who could not eat independently or guidance for visitors and family on safe food handling practices, including cooling, reheating, holding temperatures, cross contamination, and hand hygiene. The Administrator acknowledged the policy did not address the facility's responsibilities for safeguarding outside food.
Failure to assess self-administration of an insulin pump: A resident with type 2 DM and a BIMS score indicating intact cognition stated that they managed their insulin pump independently, but the record lacked a self-medication assessment and did not include physician orders identifying the pump's necessity, type, or insulin used. The DON acknowledged the facility did not complete the required assessment before allowing the resident to self-administer.
Failure to follow ordered monitoring and documentation requirements affected a resident using an insulin pump and three residents receiving medications with specific parameters or symptom checks. The insulin pump resident’s record did not identify the pump’s necessity, type, or insulin used, while a CMT gave losartan without first obtaining the resident’s SBP despite a hold parameter. Two other residents on pregabalin and clonazepam lacked documented BP and HR monitoring every shift, and staff could not provide evidence that the ordered checks were completed.
Lack of RN Competency for Insulin Pump Care: A resident with type 2 DM used a t:slim X2 insulin pump, and the care plan and MD order addressed pump monitoring and insulin administration. However, record review showed no facility training on the pump for multiple RNs, and staff interviews confirmed they had not been trained. The DNS acknowledged that nursing staff had not been trained on the pump and that managing it would be outside their competencies.
A resident with type 2 DM had an order to monitor blood glucose with a Dexcom CGM before meals, but staff were obtaining finger stick readings three times daily instead. The record did not show an order for finger stick monitoring, did not show that the physician was notified when the Dexcom stopped working, and staff documented the finger stick results as if they came from the Dexcom.
A facility kept a black binder titled State Survey Results on the reception counter facing the public in the lobby. The binder contained annual federal recertification survey results and resident rosters with residents' names and corresponding survey number identifiers, and the Administrator acknowledged that this information was available for public viewing.
A resident who required assistance with ambulation using a walker and gait belt fell while being assisted by staff who did not apply the gait belt or provide physical support, contrary to the care plan and facility policy. This resulted in the resident sustaining multiple spinal fractures and a significant decline.
The facility failed to notify the State LTC Ombudsman of hospital transfers for two residents. One resident, with a history of pneumonia and stroke-related conditions, was transferred three times, while another, with urinary retention and atrial fibrillation, was transferred twice. The Social Worker confirmed that notifications were only sent for discharges or non-returning transfers, highlighting a gap in the notification process.
The facility failed to maintain an effective QAPI program, resulting in deficiencies in trauma informed care assessments and infection control practices. A resident with a history of trauma did not receive a trauma screening assessment upon admission, and two residents with MDROs lacked proper isolation precautions. The DON acknowledged these failures, indicating non-compliance with the facility's QAPI plan.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with ESBL, a Multi-Drug Resistant Organism (MDRO) infection. Despite positive urine cultures, surveyor observations revealed no isolation measures or signage for these residents. Staff interviews confirmed the absence of precautions, and the Director of Nursing Services acknowledged the oversight. Additionally, the facility did not conduct an annual review of its Infection Prevention Control Program (IPCP) to include EBP.
The facility failed to maintain the confidentiality of residents' medical information by posting signs outside their rooms indicating the presence of indwelling medical devices. This breach affected three residents with severe cognitive impairments, compromising their right to privacy. The DON acknowledged that such information should not be publicly displayed.
The facility failed to ensure nursing staff had the necessary competencies for Enhanced Barrier Precautions (EBP), crucial for infection control. A review revealed that none of the seven staff members had completed EBP competencies, and interviews confirmed a lack of awareness and education on EBP among staff, including RNs and NAs. The Director of Nursing Services also admitted that EBP competencies were not completed, indicating a significant gap in infection control practices.
A resident with chronic pain syndrome had a physician's order for a daily 4% lidocaine patch, which was refused 21 out of 24 times in September. The facility failed to notify the physician of these refusals, as acknowledged by both a registered nurse and the DON.
A facility failed to provide trauma-informed care to a resident with a history of childhood abuse. Despite the facility's policy, a trauma screening assessment was not completed upon admission, and the resident's trauma history was not addressed in a psychiatry evaluation. Staff interviews revealed a lack of awareness and adherence to the trauma-informed care policy.
A resident with major depressive disorder experienced a significant medication error when their Sertraline was discontinued without explanation. Despite recommendations to reduce the dosage, the resident's power of attorney chose to maintain the current dose. However, the medication was discontinued in error, which was only discovered during a surveyor interview. The DON acknowledged the mistake, and the resident's physician reinstated the medication after being informed of the error.
Policy for Outside Food Failed to Address Safe Handling Responsibilities
Penalty
Summary
The facility's policy for food brought in from an outside source failed to ensure safe and sanitary storage, handling, and consumption of foods brought to residents by family and other visitors. Record review of the policy titled, "Food Brought in From Outside the Facility Policy," dated 6/1/2021, stated that the facility had no responsibility should any adverse reaction occur from food brought into the facility from an outside source. The policy did not address staff assistance for residents who were not able to access and consume the food independently, and it did not address helping visitors and family understand safe food handling practices, including safe cooling and reheating, hot and cold holding temperatures, preventing cross contamination, and hand hygiene. During interview, the Administrator acknowledged that the policy failed to address the facility's responsibilities in safeguarding food brought in from an outside source for residents.
Failure to Assess Resident Self-Administration of Insulin Pump
Penalty
Summary
The facility failed to ensure that self-administration of medications was clinically appropriate for 1 resident observed with an insulin pump. The resident was admitted in October 2025 with a diagnosis including type 2 diabetes mellitus, and a quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. A facility policy titled, Self-Administration of Medication by Resident, stated that residents may self-administer medications with a physician's order and that the resident must be instructed and assessed on the use, dosing, schedule, and ability to self-medicate before self-administration. Record review showed a physician's order dated 10/17/2025 to monitor the insulin pump site for infection, battery life, insulin chamber levels, and kinks in the tubing every shift. However, the physician's orders did not include evidence of the necessity of the insulin pump, the type of pump being used, or the type of insulin administered through the pump. During interview, the resident stated that the insulin pump was managed independently. The record also failed to show that the resident received a self-administration assessment for the insulin pump, and the DON acknowledged that the facility did not complete an assessment of the resident's ability to self-administer medications.
Failure to Follow Ordered Monitoring and Insulin Pump Documentation Requirements
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of practice for a resident using an insulin pump. Resident #9 was admitted with type 2 diabetes mellitus and had a care plan stating that staff were to ensure proper insulin administration and assist to load the pump if necessary. However, the record did not show an order identifying the necessity of the insulin pump, the type of pump being used, or the type of insulin administered through the pump. During interview, the resident stated the insulin pump was in place and managed independently, and the DNS also stated the pump was managed by the resident but could not provide evidence that the facility had identified the pump details or necessity. The facility also failed to follow ordered monitoring parameters for medications and symptom monitoring for three residents. Resident #22 had an order for losartan with instructions to hold the medication if systolic blood pressure was less than 110 mmHg, but during medication administration the CMT did not obtain the resident’s systolic blood pressure before giving the medication, and the record lacked evidence that systolic blood pressure was taken in 20 of 24 opportunities. Resident #4 had an order for pregabalin with blood pressure and heart rate monitoring every shift, but the vital sign record and MAR/TAR did not show that monitoring was documented every shift. Resident #16 had orders for clonazepam with monitoring every shift for blood pressure, heart rate, behavior changes, rash, fever, or dizziness, but the record failed to show documented blood pressure or heart rate every shift, and the RN could not provide evidence that the monitoring occurred as ordered.
Lack of RN Competency for Insulin Pump Care
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to provide care for a resident who used an insulin pump. The resident was admitted with type 2 diabetes mellitus and had a care plan noting that the resident had an insulin pump and that staff were to ensure proper insulin administration and assist to load the pump if necessary. A physician's order directed staff to monitor the pump site for infection, battery life, insulin chamber levels, and kinks in the tubing every shift, but the orders did not specify the necessity of the pump, the type of pump being used, or the type of insulin administered through it. Record review of nursing staff competencies for multiple RNs did not show training on the insulin pump. The pump user's manual obtained by the facility identified the device as a t:slim X2 insulin pump and stated that it should not be used before reading the User's Guide and receiving appropriate training from a certified trainer. During interviews, the resident stated that the pump was managed independently. RNs stated they had not received facility training on the pump, and one RN said she looked up information online. The DNS stated he had not received or provided nursing staff training on the insulin pump and acknowledged that if facility nursing staff were to manage it, it would be outside their competencies.
Incomplete and Inaccurate Blood Sugar Documentation
Penalty
Summary
Resident ID #9, who was admitted with a diagnosis including type 2 diabetes mellitus, had a physician order dated 10/18/2025 to monitor blood glucose prior to meals using a Dexcom continuous glucose monitor. During surveyor interviews, RN Staff D stated that the resident was instead receiving finger sticks three times daily with meals to obtain blood sugar levels, but the record did not contain an order for finger stick monitoring three times daily with meals. The record also did not show evidence that the physician was notified when the Dexcom stopped working, and RN Staff D could not provide such evidence during interview. In addition, staff were documented as recording the resident's blood sugar results as if they were obtained from the Dexcom monitor, even though the readings were being obtained by finger stick. The DON stated that the Dexcom stopped working on 11/21/2025 and acknowledged that the physician should have been notified and an order obtained for finger stick blood sugar checks before meals.
Survey Results Binder Exposed Resident Identifiers
Penalty
Summary
The facility failed to protect identifying information about complainants or residents that was included in the survey results binder. During observation of the main lobby, a black binder titled "State Survey Results" was stored on the reception area countertop facing the public as they entered the facility. Review of the binder showed the 2023 annual federal recertification survey results and the 2024 annual federal recertification survey results. Additional review found resident rosters, described as lists provided to the facility that correspond to number identifiers used in a survey to protect privacy, included in the binder. During interview, the Administrator acknowledged that residents' names and their corresponding number identifiers were in the binder and available for the general public to view.
Failure to Use Gait Belt During Ambulation Results in Resident Fall and Spinal Fractures
Penalty
Summary
A resident with a history of generalized muscle weakness and back pain, who required assistance from one staff member for ambulation using a rolling walker and gait belt, sustained a significant fall resulting in multiple spinal fractures. The incident occurred when the resident was being assisted from the toilet to the sink by a staff member, during which the resident caught their foot on the floor and fell, striking their head and back. Review of the care plan and facility policy indicated that a gait belt was required for ambulation assistance, and this was the standard practice for the resident. Interviews and documentation revealed that the staff member assisting the resident at the time of the fall did not apply the gait belt and did not provide physical support to the resident's trunk or limbs, despite being in close proximity. The staff member acknowledged this deviation from the care plan and standard safety procedures. As a result of this failure to follow established protocols, the resident experienced a severe decline, including multiple vertebral fractures and increased fear of movement.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the Office of the State Long-Term Care Ombudsman for two residents who were transferred to the hospital. Resident ID #16, who was initially admitted in March 2021 with diagnoses including a history of pneumonia, hemiplegia, hemiparesis following a stroke, chronic obstructive pulmonary disease, and gastrostomy status, was transferred to the hospital on three occasions: May 2, 2024, May 30, 2024, and July 2, 2024. The record review did not show evidence that the Ombudsman was notified of these transfers. Similarly, Resident ID #77, admitted in October 2022 with diagnoses of urinary retention, stroke, and atrial fibrillation, was transferred to the hospital on July 12, 2024, and July 29, 2024. Again, there was no evidence that the Ombudsman was informed of these transfers. During an interview, the Social Worker admitted that notifications were only sent to the Ombudsman for residents discharged from the facility or if a resident was transferred to the hospital and did not return, indicating a gap in the notification process for temporary hospital transfers.
Deficiencies in QAPI Program and Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by deficiencies in trauma informed care assessments and infection control practices. Specifically, the facility did not ensure that trauma assessments were completed for new admissions. A review of the QAPI binder revealed a plan to review each new admission chart within 24 hours or by the next weekday to ensure trauma assessments were completed. However, there was no evidence of maintenance of this plan, including tracking and measuring performance, or establishing goals and thresholds for performance measurement. This was highlighted by the case of a resident admitted in September 2024 with a history of trauma, for whom no trauma screening assessment was completed upon admission. Additionally, the facility failed to adhere to its infection control plan regarding Enhanced Barrier Precautions for residents with multi-drug resistant organisms (MDROs). The QAPI plan included monitoring quarantine and isolation compliance, but there was no evidence of implementation or maintenance of this plan. During surveyor observations, two residents with a history of Extended-spectrum beta lactamases (ESBL) in the urine did not have isolation carts or signage posted outside their rooms to indicate the need for Enhanced Barrier Precautions. The Director of Nursing Services acknowledged these failures during an interview, confirming that the facility did not follow its outlined QAPI plan.
Failure to Implement Enhanced Barrier Precautions for Residents with MDRO
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for two residents with a Multi-Drug Resistant Organism (MDRO) infection, specifically Extended Spectrum Beta Lactamase (ESBL). Resident ID #17, who was readmitted in March 2022 with a urinary tract infection, had urine cultures positive for ESBL on two occasions in 2024. Despite this, surveyor observations from September 23 to September 25, 2024, revealed no isolation cart or signage indicating the need for EBP. Interviews with staff confirmed that the resident was not on precautions, and there was no evidence of a follow-up urine culture to test for ESBL. Similarly, Resident ID #18, readmitted in August 2023 with a urinary tract infection and ESBL, was also not placed on EBP. The resident's care plan indicated colonization with ESBL, yet surveyor observations during the same period showed no isolation measures in place. The Director of Nursing Services acknowledged the oversight for both residents. Additionally, the facility failed to conduct an annual review of its Infection Prevention Control Program (IPCP) and update it to include enhanced barrier precautions, as required by the State Operations Manual.
Breach of Resident Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information, specifically concerning indwelling medical devices, for three residents. The deficiency was identified through surveyor observations, record reviews, and staff interviews. Resident ID #16, who has severe cognitive impairment and a feeding tube, had a sign outside their door indicating the presence of a tube feed and foley catheter. Similarly, Resident ID #77, also with severe cognitive impairment and an indwelling catheter, had the same type of sign posted outside their room. Resident ID #179, with acute kidney failure and an indwelling catheter, was also found to have a sign outside their door displaying medical information. These signs were visible to staff, residents, and visitors passing by, thus compromising the residents' right to privacy. The facility's policy on confidentiality states that resident health information should not be left in public areas where unauthorized personnel may see it. During an interview, the Director of Nursing Services acknowledged that medical information should not be posted outside resident rooms, confirming the breach of confidentiality for these residents.
Deficiency in Enhanced Barrier Precautions Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide appropriate nursing and related services, specifically regarding Enhanced Barrier Precautions (EBP) for infection control. This deficiency was identified through a review of records and staff interviews, revealing that none of the seven nursing staff members reviewed had completed the required competencies for EBP. The Centers for Medicare and Medicaid Services (CMS) memorandum highlights the importance of EBP in reducing the transmission of multidrug-resistant organisms (MDROs) through targeted gown and glove use during high-contact resident care activities. However, the facility did not provide evidence of completed EBP competencies for the registered nurses, certified medication technician, and nursing assistants involved. Interviews with nursing staff and the Director of Nursing Services further confirmed the lack of awareness and education regarding EBP. Staff members, including a registered nurse and a nursing assistant, admitted to being unaware of what EBP entailed or when it should be implemented. The Director of Nursing Services also acknowledged that competencies related to EBP had not been completed for any nursing staff. This lack of training and awareness among the staff indicates a significant gap in the facility's infection control practices, potentially compromising resident safety and well-being.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding a physician's order for a lidocaine patch. The resident, who was admitted with a diagnosis including chronic pain syndrome, had a physician's order for a 4% lidocaine patch to be applied once daily for pain management. However, the medication administration record for September 2024 showed that the resident refused the lidocaine patch on 21 out of 24 opportunities. There was no evidence that the physician was notified of these refusals. During interviews, both a registered nurse and the Director of Nursing Services acknowledged that the physician should have been informed of the medication refusals.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident with a history of trauma. The resident, admitted in September 2024, had a diagnosis of dementia with psychotic disturbance and a documented history of childhood abuse. Despite the facility's policy requiring a trauma screening assessment by a social worker upon admission, no such assessment was completed for this resident. The care plan acknowledged the resident's past trauma, but a psychiatry progress note did not address the trauma history during evaluation. Interviews with facility staff revealed a lack of awareness and adherence to the facility's trauma-informed care policy. The social worker admitted to not completing the required trauma screening assessment and was unaware of the policy. The Director of Nursing Services was unable to provide evidence that the assessment had been conducted. This oversight indicates a failure to incorporate the resident's trauma history into their care plan, potentially leading to re-traumatization.
Medication Error: Unexplained Discontinuation of Sertraline
Penalty
Summary
The facility failed to ensure a resident's drug regimen was free from significant medication errors. The resident, who was admitted in April 2023 with diagnoses including major depressive disorder and adjustment disorder with mixed anxiety and depressed mood, was receiving Sertraline 125 mg daily for depression. A psychiatric consultation on August 16, 2024, recommended reducing the Sertraline to 100 mg daily, which was implemented the following day. A subsequent consultation on September 6, 2024, recommended further reducing the Sertraline to 50 mg daily. However, a nursing progress note on September 13, 2024, indicated that the resident's power of attorney did not want the reduction implemented, so the resident continued on 100 mg daily. On September 17, 2024, the Sertraline was discontinued without documented evidence explaining the reason for this action. During a surveyor interview on September 24, 2024, a registered nurse was unaware of the discontinuation until informed by the surveyor, and the Director of Nursing Services acknowledged that the discontinuation was an error. The resident's physician, interviewed on September 26, 2024, was also unable to explain the discontinuation but reinstated the medication as previously ordered after being notified of the error.
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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 Providence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastgate Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Tockwotton On The Waterfront | 1 mi | ★★★★★ | 5 | 0 |
| Harris Health Center Llc | 1.1 mi | ★★★★★ | 13 | 0 |
| Adviniacare Waterview Villas, Llc | 1.7 mi | ★★★★★ | 12 | 0 |
| Steere House Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 5 | 0 |
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