Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brio Of Johnston, Llc during CMS and state inspections, most recent first.
Wheelchair Transfers Without Foot Pedals: Staff transported three residents in wheelchairs without securing their feet on foot pedals, and in two cases the wheelchairs did not have foot pedals attached. The residents had severe cognitive impairment and required staff assistance with wheelchair mobility or used a wheelchair for longer distances. A DON stated staff should use foot pedals whenever transporting a resident in a wheelchair, and the DOSS confirmed there was no policy for wheelchair transfers.
Insulin Pen Removed Too Soon During Administration: An LPN administered ordered Basaglar KwikPen insulin to a resident with DM but removed the pen before holding it in place for the required minimum time. The resident had intact cognition, and both the manufacturer’s instructions and the facility’s insulin pen policy required the pen to remain in place for at least 5 seconds after the dose was delivered.
Unsecured Resident Medication Storage: Two residents’ medication drawers on the CCDI unit were observed not securely locked, and the drawers could be opened easily with medications inside, including medication administration cards for one resident with severely impaired cognition and inhaler and nebulizer medications for another resident. The DON witnessed and acknowledged the unlocked drawers, and the facility policy required prescription and non-prescription medications to remain in a designated locked area accessible only to authorized persons.
Improper Glove Use During Food Preparation: A cook was observed preparing pureed meals and lunch service with the same gloves after touching non-food surfaces and trash, without changing gloves or performing hand hygiene. The cook handled lasagna, garlic bread, a blender, a garbage can lid, and a hamburger with the same gloved hands, contrary to facility policy and the FDA Food Code. The CDM stated staff should not touch surfaces while wearing gloves and then touch ready-to-eat food with the same gloves.
Infection Control Lapses During Wound Care: An LPN failed to follow infection control practices during wound care for a resident with severe cognitive impairment and an unstageable pressure injury to the heel. Hand hygiene was not observed before gloves were donned, and after the wound was cleansed, the resident's heel was placed on the resident's sock while the dressing was labeled. Hand hygiene and a glove change were also not observed before the clean dressing was applied, and the LPN acknowledged the missed steps.
The facility failed to document behaviors related to psychotropic medication use for three residents with severe cognitive impairment, as required by physician orders. The Behavioral Assessment Record (BAR) showed missing documentation on several days, and electronic health records lacked progress notes addressing observed behaviors. Interviews revealed that CMAs, responsible for passing medications on undocumented days, were unaware of the BAR task, leading to incomplete documentation.
A facility failed to securely store medications for a resident on the CCDI Unit, as observed when a medication drawer was found unlocked and easily opened. The drawer contained the resident's medications, contrary to the facility's policy requiring all prescription medications to be kept in a locked cabinet. The DON acknowledged the issue and moved the medications to a securely locked drawer.
Two residents with severe cognitive impairment were able to leave a garden area unnoticed due to a gate that did not latch securely. The facility's Elopement Precautions Policy was not followed, as electronic door alarms were required to remain active. Staff A did not ensure the gate was properly latched, and the Director of Plant Operations found no mechanical issues with the latch.
A resident with hypertension, urinary tract infection, and anxiety disorder did not receive prescribed Clonidine despite multiple elevated blood pressure readings. The LPN was unaware of the specific orders, and the Director of Nursing confirmed the expectation to follow physician's orders, which was not met.
The facility failed to provide RN coverage for eight consecutive hours a day, seven days a week, on specific dates. The Administrator confirmed the lack of RN coverage, stating that an RN was on call but not physically present.
A facility failed to ensure appropriate hand hygiene and glove usage during incontinence care for a resident with hypertension, a recent UTI, and anxiety disorder. A CNA did not change gloves after touching a dirty trash bag and before performing peri care, contrary to the facility's hand hygiene policy. The DON confirmed the expectation for proper hand hygiene and glove usage.
Wheelchair Transfers Without Foot Pedals
Penalty
Summary
The facility failed to provide services to protect residents from accident hazards by transporting residents in wheelchairs without securing their feet on the foot pedals. During observations, Resident #29, who had severe cognitive impairment with a BIMS score of 2 and used a wheelchair with staff assistance, was pushed from the dining area to the common area with their feet dangling between the attached foot pedals. Resident #26, who had severe cognitive impairment with a BIMS score of 3 and whose care plan noted ambulation with a walker and use of a wheelchair for longer distances, was pushed from the dining area to the TV area in a wheelchair that did not have foot pedals attached, and their feet dangled during the transfer. Resident #31, who also had severe cognitive impairment with a BIMS score of 2 and used a wheelchair with staff assistance, was transported by a CNA who held the resident’s hand and pulled the wheelchair along without securing the resident’s feet on foot pedals. The wheelchair did not have foot pedals attached, and the resident’s feet dangled close to the floor during the transfer. The DON stated staff should use foot pedals whenever transporting a resident in a wheelchair, and the Director of Social Services confirmed the facility did not have a policy regarding transferring residents in wheelchairs.
Insulin Pen Removed Too Soon During Administration
Penalty
Summary
The facility failed to administer insulin using an insulin pen as recommended for one resident with diabetes mellitus and intact cognition. The resident had an order for 20 units of Basaglar KwikPen insulin subcutaneously daily. During observation, an LPN injected the insulin into the resident’s abdomen using the Basaglar KwikPen, but removed the pen before waiting a minimum of 5 seconds after the injection. When questioned, the LPN first stated the pen should remain in place for a few seconds and then said 5-10 seconds. The manufacturer’s instructions for the Basaglar KwikPen directed staff to insert the needle, push the dose knob all the way in, continue to hold the dose knob in, and slowly count to 5 before removing the needle. The facility’s insulin pen policy also required holding the pen in place for 5-10 seconds, and the ADON stated she expected an insulin pen to remain in place a minimum of 5 seconds after administration.
Unsecured Resident Medication Storage
Penalty
Summary
The facility failed to securely store resident medications for 2 of 6 residents reviewed for medication administration. Resident #29 had an MDS assessment showing a BIMS score of 2, indicating severely impaired cognition, and on 4/6/26 at 12:45 PM on the CCDI unit, the resident’s medication drawer was observed not to be securely locked and could be opened easily, with medication administration cards inside. Later that day at 2:45 PM on the CCDI unit, Resident #19’s medication drawer was also observed not to be securely locked and could be opened easily, with the resident’s inhaler and nebulizer medications inside. During an interview at 3:30 PM, the DON witnessed and acknowledged both unlocked drawers and stated medication drawers should not remain unlocked; if a drawer lock breaks, medications should be moved to another drawer with a working lock and a work order should be initiated immediately or the Administrator alerted to initiate one. The facility policy stated prescription and non-prescription medications must remain in a designated locked area within the resident’s room and only authorized persons should have access to the medication supply.
Improper Glove Use During Food Preparation
Penalty
Summary
The facility failed to protect food from contamination during preparation, with three observed instances of improper glove use and potential cross-contamination. On 4/8/26 at 10:30 AM, Staff B, a cook, was observed preparing pureed lunch meals. Staff B removed lasagna from the oven with gloved hands, then without changing gloves or performing hand hygiene, placed three servings of lasagna in a blender, added a piece of garlic bread with the left gloved hand, attempted to puree the lasagna, and after the blender cracked, wiped the side of the blender with the right gloved hand. Staff B then transferred the pureed lasagna to a second blender and again added garlic bread with the left gloved hand. On 4/8/26 at 12:13 PM, Staff B was observed during lunch service wearing a glove on the right hand, throwing trash away and touching the garbage can lid with the gloved hand, and failing to remove the glove or perform hand hygiene. Staff B then removed a hamburger from the warmer, removed the wrapping, picked up the hamburger with the same gloved right hand, cut it in half, placed it on a resident's plate, and added fries using the same gloved hand. Facility policy directed staff to be aware of poor personal hygiene and poor hand washing practices, and the 2022 FDA Food Code states single-use gloves are to be used for only one task and discarded when damaged or soiled or when interruptions occur. The CDM stated she expected staff not to touch surfaces while wearing gloves and then touch ready-to-eat food with the same gloves.
Infection Control Lapses During Wound Care
Penalty
Summary
Infection control practices were not followed during wound care for a resident with severe cognitive impairment, non-Alzheimer's dementia, and a history of stroke. The resident's care plan identified an unstageable pressure injury to the right heel. During observation, a LPN entered the resident's room, put on a gown and gloves, and began wound care without observed hand hygiene before donning gloves. After removing the soiled dressing and cleansing the heel as ordered, the LPN realized the new dressing was not dated and placed the resident's heel on the resident's sock while labeling the dressing. Once the dressing was labeled, the heel was removed from the sock and the dressing was applied. Hand hygiene and glove change were not observed before the clean dressing was placed. In interview, the LPN acknowledged the lack of hand hygiene and glove change during the wound care and stated the cleansed heel should have been placed on a barrier, such as a clean absorbent pad, rather than on the resident's sock while the dressing was being labeled. The facility's Dressing Change Competency procedure required hand hygiene and glove changes at specific points during the dressing change process.
Failure to Document Behavioral Assessments for Psychotropic Medication Use
Penalty
Summary
The facility failed to document behaviors related to psychotropic medication use for three residents with severe cognitive impairment, as required by physician orders. These residents, diagnosed with conditions such as Alzheimer's Dementia, anxiety, and depression, were prescribed various psychotropic medications including antidepressants, antipsychotics, and antianxiety drugs. The Behavioral Assessment Record (BAR) for these residents showed missing documentation on several days across December 2024, January 2025, and February 2025. The electronic health records also lacked progress notes addressing whether behaviors were observed on the days with missing BAR documentation. Interviews with facility staff revealed that the task of completing the BAR was flagged as a reminder during medication rounds. However, on the days when documentation was missing, Certified Medication Aides (CMAs) were responsible for passing medications and did not have access to the BAR or awareness of the task to alert nursing staff. The Director of Nursing acknowledged the incomplete documentation and noted that the missing entries occurred on the same days for all three residents. The facility's policy on Adverse Effects Monitoring Process required professional team members to record adverse effects as indicated, but this was not adhered to in the cases reviewed.
Failure to Securely Store Resident Medications
Penalty
Summary
The facility failed to securely store medications for one of the six residents reviewed for medication administration. During an observation on the Chronic Confusion or Dementing Illness (CCDI) Unit, it was found that the medication drawer in a resident's room was not securely locked and could be easily opened. The drawer contained the resident's medications, which were not stored according to the facility's policy. The Director of Nursing (DON) acknowledged the issue upon witnessing the unlocked drawer and subsequently removed the medications to a securely locked drawer. The facility's policy, revised in September 2020, mandates that all prescription medications must be kept in a locked cabinet.
Failure to Secure Garden Gate Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure the garden gate closed securely, which allowed two residents to leave the garden area unnoticed. Resident #1, who had severe cognitive impairment due to non-traumatic brain dysfunction and Alzheimer's disease, was documented as an elopement risk with a history of attempts to leave the facility. The resident was found outside the designated patio area and returned inside within five minutes. Resident #3, also with severe cognitive impairment and Alzheimer's disease, was documented as an elopement risk. This resident was found walking along the side of the building after escaping through a locked gate on the patio. On the day of the incident, Staff A, the Activities and Lifestyles Coordinator, entered the garden area and did not ensure the gate was properly latched upon leaving. The Director of Plant Operations inspected the latch the following day and found no structural or mechanical issues. Security camera footage confirmed the residents' movements and the timeline of the incident. The facility's Elopement Precautions Policy requires electronic door alarms to remain active at all times, and the Executive Director stated an expectation for staff to follow facility policies.
Failure to Follow Physician's Orders for Blood Pressure Management
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with hypertension, urinary tract infection, and anxiety disorder. The resident required partial to substantial assistance for transfers, toileting, and personal hygiene and had moderate cognitive impairment. The physician's order included administering Clonidine 0.1 mg every 6 hours as needed for systolic blood pressure greater than 160 or diastolic blood pressure greater than 100, and to check blood pressure every 6 hours. Despite multiple instances of elevated blood pressure readings, the Clonidine was not administered at any point during the month of April 2024. Staff interviews revealed that the Licensed Practical Nurse (LPN) responsible for the resident's care was unaware of the specific orders to check blood pressure every 6 hours and to administer Clonidine as needed. On one occasion, the LPN recorded a blood pressure of 180/100 but did not administer the Clonidine. The Director of Nursing confirmed that the expectation was to follow the physician's orders, which was not done in this case. The facility's policy on medication administration, revised in November 2022, mandates that prescribed medication be administered per physician order, which was not adhered to in this instance.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required by federal regulations. The facility, which reported a census of 33, had no RN coverage on specific dates: 11/12, 12/9, 12/10, 12/23, and 12/24/23. This deficiency was identified through a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for the fiscal quarter of 2024 and confirmed by the facility's schedule for the mentioned dates. During an interview on 4/23/24, the Administrator acknowledged the lack of RN coverage on the specified days, stating that an RN was on call but not physically present in the facility. The Administrator also mentioned that the facility follows federal regulations for RN coverage but did not have a specific policy in place for ensuring this coverage.
Inappropriate Hand Hygiene and Glove Usage During Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate hand hygiene and glove usage during incontinence care for a resident. The resident, who had diagnoses of hypertension, a recent urinary tract infection, and anxiety disorder, required assistance with transfers, toileting, and personal hygiene. During an observation, a Certified Nurse Aide washed hands and applied gloves before assisting the resident but did not change gloves after touching a dirty trash bag and before performing peri care. The facility's hand hygiene policy required hand hygiene after touching contaminated items and before providing personal care. The Director of Nursing confirmed the expectation for staff to complete hand hygiene and apply new gloves before peri care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Johnston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bishop Drumm Retirement Center | 2.6 mi | ★★★★★ | 18 | 0 |
| Childserve Habilitation Center | 2.9 mi | ★★★★★ | 1 | 0 |
| Royal Oaks Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 15 | 1 |
| Kennybrook Village | 3.2 mi | ★★★★★ | 5 | 0 |
| Karen Acres Care Center | 4.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.