Cycle 1
Health 2025-11-26 · Fire 2025-11-26
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Providence, RI
Bethany Home of Rhode Island
4-star overall rating with 3-star inspections with 7 recent health deficiencies
111 South Angell Street, Providence, RI
(401) 831-2870
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
33
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-05-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.41
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
2.99
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.25 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
1.04
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.54
CMS adjusted RN staffing hours
Adjusted total hours
4.80
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
12%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,877
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.21
Composite VBP score used to determine payment impact.
Payment multiplier
1.0007
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.66
Baseline 17.17% · Performance 20.20% · Measure score 2.66 · Achievement 2.66 · Improvement 0
Healthcare-associated infections
0
Baseline 6.63% · Performance 7.83% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 25.00% · Performance 10.35% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6.22
Baseline 4.52 hours · Performance 4.85 hours · Measure score 6.22 · Achievement 6.22 · Improvement 2.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.92% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 5.69% · Lower 95% interval 6.36% |
| Discharge to community | 61.22% |
50.57%
10.6 pts better
|
Better than the National Rate · Eligible stays 125 · Observed rate 64% · Lower 95% interval 54.94% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 83 · Denominator 83 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 83 |
| Discharge self-care score | 47.06% |
53.69%
6.6 pts worse
|
Numerator 32 · Denominator 68 |
| Discharge mobility score | 44.12% |
50.94%
6.8 pts worse
|
Numerator 30 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 83 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.83% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 6.74% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 20% |
8.2%
11.8 pts better
|
Numerator 13 · Denominator 65 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 32.35% |
56.45%
24.1 pts worse
|
Numerator 22 · Denominator 68 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 25.71% |
25.2%
0.5 pts better
|
Numerator 9 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
93.2%
5.3 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.6%
2.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
14.6%
14.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.3%
1.9 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
16.4%
4.8 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.8% |
23.6%
21.8 pts better
|
16.7%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.9% |
17.0%
11.9 pts worse
|
16.3%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.0% |
18.4%
3.6 pts worse
|
14.9%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.0%
0.9 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.6% |
2.2%
4.4 pts worse
|
1.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
22.3%
1.4 pts worse
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.7%
4.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
77.2%
20.5 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 96.3% · Q3 100.0% · Q4 98.7% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
15.8%
0.4 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 13.7% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
78.2%
18.2 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.1%
1 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 19.2% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-26 · Fire 2024-09-26
8 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-11-08 · Fire 2023-11-08
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-11-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-26
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-11-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-11-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-11-26
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-26
B · Minimal harm
2025-11-26
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-12-26
G · Actual harm
2025-11-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-05
F · Potential for more than minimal harm
2024-09-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-26
F · Potential for more than minimal harm
2024-09-26
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-10-26
F · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-26
E · Potential for more than minimal harm
2024-09-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-26
E · Potential for more than minimal harm
2024-09-26
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-09-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-09-26
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-26
D · Potential for more than minimal harm
2024-09-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-26
F · Potential for more than minimal harm
2023-11-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-08
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-08
Penalties and ownership
What sits behind the stars
Ownership
Bethany Home Of Rhode Island
Operational/Managerial Control · Organization
Igoe, Stephanie
Operational/Managerial Control · Individual
Igoe, Stephanie
Corporate Officer · Individual
Wilson, Linda
Corporate Director · Individual
Nearby options
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#2
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#3
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