John Clarke Senior Living
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
placement on a secured unit at another facility, however, she was unable to provide evidence that any additional interventions or safety measures were in place to prevent the resident from wandering into areas of the facility where s/he should not be and eloping again while s/he was still a resident at the facility. A surveyor observation on 9/24/2025 at 11:19 AM, of the surveillance footage from 9/20/2025, revealed Resident ID #1 self-propelled in his/her wheelchair to the front door and was noted to be sitting at the front door, without the doors opening. Further review revealed a visitor entered the facility, causing the main doors to open, the resident was then able to self-propel outside and elope from the facility. Additionally, no staff were present in the video, when the resident successfully eloped from the facility. 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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John Clarke Senior Living in Middletown, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.