Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 August 2026) and official state health department websites.