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Complaint Investigation

Bethany Home Of Rhode Island

November 5, 2025 · Providence, RI · 111 South Angell Street
Citations 1
CMS Rating 3/5
Beds 33
Provider ID 415096
Healthcare Facility
Bethany Home Of Rhode Island
Providence, RI  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Bethany Home of Rhode Island in Providence, RI — inspection on November 5, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Actual Harm

revealed that she regularly assists Resident ID #1 and utilizes a gait belt when she ambulates with him/her.During surveyor interviews on 11/5/2025 at 12:00 PM and 12:44 PM with the Occupational Therapist, Staff C, she revealed that the resident has been receiving therapy in order to maintain his/her highest level of functioning and has never complained of back pain.

Additionally, she revealed that the resident is now complaining of pain and had a significant decline after the fall on 11/4/2025.

Furthermore, she revealed that she would expect staff to use a gait belt to ambulate the resident, as it is a standard of practice for all residents who require assistance.During a surveyor interview on 11/5/2025 at 12:22 PM with NA, Staff D, she revealed that she was the staff assisting the resident at the time of the fall and did not assist lift, hold, or support the trunk or limbs of Resident ID #1.

Additionally, Staff D acknowledged that she had not applied the gait belt to the resident and was unable to assist in preventing the fall despite being near the resident.

Staff D indicates that she normally utilizes a gait belt when assisting the resident.

The facility's failure to ensure that staff followed the resident's care plan and implemented proper safety measures specifically, the use of a gait belt when assisting Resident ID #1 with ambulation resulted in the resident sustaining multiple spinal fractures and a significant decline, due to a preventable fall.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Providence, RI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Bethany Home of Rhode Island or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.