Brio of Johnston, LLC

In the surveyor’s words

From the most serious findings on record at Brio of Johnston, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689Sep 14, 2023

  Based on clinical record review, staff interviews, facility policy review and Pharmacist interview, the facility failed to assure narcotic medication was in a secure location and not accessible to a dependent resident resulting in the possible ingestion of up to 18 Hydrocodone/APAP (Tylenol) 5-325 milligrams (MG) unsupervised in less than 24 hours for 1 of 1 residents with a history of drug seeking behavior (Resident #1). This failure resulted in 72 hours of monitoring of Resident #1 causing an Immediate Jeopardy (IJ) to the health, safety and security of the resident. The State Agency informed the facility of the IJ that began on April 27,2023 on September 13, 2023 at 4:30 PM. The facility staff removed the IJ on April 28, 2023 through the following actions: a. […]

• No harm, potential for more than minimal, isolatedF689Apr 9, 2026

  Based on observations and staff interview, the facility failed to provide services to protect residents from accident or hazards by transferring residents in a wheelchair without foot pedals for 3 out of 12 residents observed in wheelchairs (Residents #26, #31, and #29). The facility reported a census of 34.Findings include: 1. The Minimum Data Set (MDS) Assessment completed on 3/2/26 revealed Resident #29 had a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. The MDS reported Resident #29 utilized a wheelchair and required staff assistance to operate. […]

• No harm, potential for more than minimal, isolatedF760Apr 9, 2026

  Based on observation, clinical record review, manufacturer's recommendation and staff interview, the facility failed to administer insulin utilizing an insulin pen as recommended for 1 of 1 resident reviewed for insulin administration (Resident #4). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. The MDS included a diagnosis of Diabetes Mellitus (DM). Resident #4's Physician Orders included an order dated 1/27/26 to inject 20 units of Basaglar KwikPen insulin subcutaneously daily. […]

• No harm, potential for more than minimal, isolatedF761Apr 9, 2026

  Based on observations, staff interviews, and policy review, the facility failed to securely store resident medications for 2 of 6 residents reviewed for medication administration. The facility reported a census of 34. Findings include:1. Resident #29's Minimum Data Set (MDS) assessment identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. On 4/6/26 at 12:45 PM, on the Chronic Confusion or Dementing Illness (CCDI) unit, observed Resident #29's medication drawer wasn't securely locked. The drawer opened easily and contained Resident #29's medication administration cards.2. On 4/6/26 at 2:45 PM, on the CCDI unit, observed Resident #19's medication drawer wasn't securely locked. […]

• No harm, potential for more than minimal, isolatedF812Apr 9, 2026

  Based on observation, staff interview, policy review, and the 2022 Food Code United States (U.S.) Food & Drug Administration (FDA), the facility failed to protect food from contamination during preparation as evidenced by 3 observed instances of improper glove use and potential cross-contamination. The facility reported a census of 34 residents.Findings include: On 4/8/26 at 10:30 AM: observed Staff B, Cook, preparing the pureed meals for lunch. Staff B removed lasagna from the oven with gloved hands. Without performing changing their gloves or performing hand hygiene, Staff B completed the following:Placed three servings of lasagna in the blender and added a piece of garlic bread to the lasagna with their left gloved hand.Attempted to pureed the lasagna in the blender, which cracked. […]