John Clarke Senior Living
John Clarke Senior Living in Middletown, RI — inspection on September 25, 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
During a surveyor interview on 9/24/2025 at 12:23 PM, with the Administrator and DNS, the Administrator acknowledged that the wander guard system did not alarm on 9/20/2025, when the resident exited through the front door perimeter.
The Administrator further revealed that she had placed one of the two wander guards on the back of the resident's wheelchair but was unable to recall when she had placed it.
Additionally, they were unable to provide evidence that Resident ID #1 received adequate supervision to prevent him/her from eloping from the facility, twice, once on 8/26/2025 and again on 9/20/2025, also they failed to prevent him/her from wandering into an unsecured area of the facility on 9/21/2025.
The facility failed to reassess the resident's risk for elopement following a significant change in condition and did not implement adequate supervision interventions. As a result, a cognitively impaired resident previously identified as a wander risk was able to exit the facility through the main doors on two occasions, 8/26/2025 and 9/20/2025.
During the second incident, the resident was found in the parking lot, having been stopped by another resident.
The facility's continued failure to provide adequate supervision led to the resident being found on the floor of the therapy room on 9/21/2025, following an unwitnessed fall one day after the most recent elopement.
This incident required the resident to be transferred to the hospital for further evaluation.
These systemic failures placed Resident ID #1 at risk for more than minimal harm, serious injury, or death.
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