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Complaint Investigation

John Clarke Senior Living

September 25, 2025 · Middletown, RI · 600 Valley Road
Citations 1
CMS Rating 2/5
Beds 60
Provider ID 415076
Healthcare Facility
John Clarke Senior Living
Middletown, 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

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

FF0689
Quality of Life and Care Deficiencies

During a surveyor interview on 9/24/2025 at 12:23 PM, with the Administrator and DNS, the

jeopardy to resident health or resident exited through the front door perimeter.

The Administrator further revealed that she had safety 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

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.

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 Middletown, 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 John Clarke Senior Living 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.