John Clarke Senior Living

In the surveyor’s words

From the most serious findings on record at John Clarke Senior Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jun 18, 2026

  Based on clinical record review, resident interview, and staff interview, the facility failed to ensure that residents were free from significant medication errors for 1 of 1 resident reviewed, Resident ID #1. Specifically, the facility administered 50 units of short-acting insulin to the resident instead of the prescribed 50 units of long-acting insulin. This medication error resulted in the resident receiving a medication with a substantially different onset, peak, and duration of action than ordered. The facility's failure to administer the medication as prescribed placed the resident at immediate risk for serious hypoglycemia, loss of consciousness, hospitalization, or death. […]

• Immediate jeopardy, isolatedF689Sep 25, 2025

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide adequate supervision for one of one resident reviewed, Resident ID #1. This resident successfully eloped from the facility on two separate occasions and later entered an unsecured area within the facility, where they sustained a fall that required a hospital transfer for evaluation.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 9/21/2025 alleges that Resident ID #1 has eloped out of the facility multiple times, and indicated the resident is not appropriate for the facility.Review of an undated facility policy titled, Elopement of Resident, states in part, .All residents will be assessed for… […]

• Actual harm, isolatedF689Oct 18, 2022

  Based on record review and staff interview, it has been determined that the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents, for 1 of 1 residents reviewed for falls, Resident ID #1. Findings are as follows: Review of a facility reported incident submitted to the Rhode Island Department of Health dated [DATE] states in part, [DATE] Rolled off bed sustained 2 femur fracture, hit head on cabinet XXX[DATE] died in facility. Record review revealed the resident was admitted to the facility in September of 2019 with diagnoses including, but not limited to, neurocognitive disorder with Lewy Bodies (also known as Lewy body dementia), and senile degeneration of the brain. […]

• No harm, potential for more than minimal, patternF656Feb 7, 2022

  Based on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan to meet resident's needs relative to obtaining weights for 1 of 5 sample residents, Resident ID #36. Findings are as follows: Record review revealed the resident was readmitted to the facility in December of 2020 and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed a care plan, last revised 3/16/2021, for .has nutritional problem r/t hx of wt [weight] loss/gain trends, [CONDITION(S)] trends, . […]

• No harm, potential for more than minimal, isolatedF880Apr 10, 2026

  Based on surveyor observation, clinical record review, and staff interview, the facility failed to maintain an infection control program to help prevent the transmission of infections related to contact precautions (an infection control intervention designed to reduce the transmission of multidrug-resistant organisms in nursing homes) and standard precautions (the minimum infection prevention practices applied to all patients in all healthcare settings, at all times, to protect healthcare workers and patients from the transmission of infectious agents, regardless of the patient's infection status) for 2 of 2 residents reviewed, Resident ID #'s 61 and 19.Findings are as follows: 1. […]