Brio of Johnston, LLC

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. During an observation on 4/6/26 at 12:55 PM, Staff D, Certified Nursing Assistant (CNA), pushed Resident #29 from the dining area to the common area without securing their feet on the attached foot pedals. Resident #29's feet dangled between the two pedals. 2. The MDS Assessment completed on 3/13/26 revealed Resident #26 had a BIMS score of 3, indicating severe cognitive impairment. The MDS indicated Resident #26 didn't use a wheelchair for ambulation but walked with staff supervision. The Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. On 4/8/26 at 9:15AM, observed Staff A, Licensed Practical Nurse (LPN), inject 20 units of insulin into Resident #4's abdomen utilizing the Basaglar KwikPen. After the injection, Staff A removed the insulin pen prior to waiting a minimum of 5 seconds. Following the removal of the insulin pen, when asked how long the pen is to remain in place following the injection,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The drawer opened easily and contained Resident #19's inhaler and nebulizer medications.During an interview on 4/6/26 at 3:30 PM, the Director of Nursing (DON) witnessed and acknowledged the unlocked drawers in Resident #19 and Resident #29's rooms. The DON explained medication drawers shouldn't stay unlocked. If a drawer lock broke, the staff should move…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Staff B wiped the side of the blender off with their right gloved hand.Transferred the pureed lasagna to a second blender and added one piece of garlic bread with their left gloved hand.On 4/8/26 at 12:13 PM: observed Staff B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, and policy review, the facility failed to apply infection control practices during wound care for 1 of 1 residents reviewed for pressure injuries (Resident #29). The facility reported a census of 34. Findings include: The Minimum Data Set (MDS) Assessment completed on 3/2/26 revealed Resident #29 with a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. Diagnoses include non-Alzheimer's dementia and stroke. The Care Plan, last revised on 4/6/26, reported Resident #29 developed an unstageable pressure injury (a deep wound where the base is completely hidden by dead tissue) to the right heel. During an observation on 4/8/26 at 10:00 AM, Staff F, Licensed Practical Nurse, entered Resident #29's room to initiate wound cares and immediately put on a gown and gloves. Hand hygiene was not observed before putting on gloves. After the old, soiled dressing was removed, Staff F cleansed the right heel, as ordered, and began to apply the new dressing. Staff F realized the dressing was not dated and placed Resident #29's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on electronic health record review, staff interview, and policy review, the facility failed to document on the Behavior Assessment Record, as ordered, behaviors related to psychotropic medication use (drugs which alter a person's mental state, emotions, or behavior) for 3 out of 3 residents reviewed for unnecessary medications (Residents #17, #24, and #25). The facility reported a census of 33 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment, dated 2/6/25, revealed Resident #17 with a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. Diagnoses on the MDS include Alzheimer's Dementia, anxiety, and depression. The MDS listed the use of an antidepressant and an antipsychotic medication. Summary of Physician Orders for Resident #17, obtained on 3/13/25, listed orders for Divalproex (anticonvulsant used as a mood stabilizer) 125 mg tablet two times daily, Olanzapine (antipsychotic) 2.5 mg tablet daily and Sertraline (antidepressant) 50 mg tablet daily. The Physician Orders direct staff to Monitor and document for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, and policy review, the facility failed to securely store resident medications for 1 of 6 residents reviewed for medication administration. The facility reported a census of 33 residents. Findings include: During an observation on 3/10/25 at approximately 10:00 AM, on the Chronic Confusion or Dementing Illness (CCDI) Unit, the medication drawer in Resident #18's room was not securely locked and was easily opened. The unsecured drawer was full of Resident #18's medications. During an interview on 3/10/25 at 10:05 AM, the Director of Nursing, DON, witnessed and acknowledged the unlocked drawer. The DON removed the medications and placed them in another drawer that was securely locked. The DON stated medication drawers are to be locked when actively filled with medications and supplies. The policy Medication Administration, Storage, Disposal, and Nurse Review, revised 09/2020, stated all prescription medications must be kept in a locked cabinet.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review and staff interview the facility failed to ensure the garden gate closed securely allowing 2 residents to leave the garden unnoticed. (Resident#1 and #2) The facility reported a census of 35 residents. Findings Include: 1. The admission Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 6 which indicated severe cognitive impairment. The MDS documented diagnosis including non-traumatic brain dysfunction, Alzheimer's disease and hypertension (high blood pressure). The MDS documented that the resident was independent with walking. The Care Plan for Resident #1 included a focus area of elopement risk/wanderer related to history of attempts to leave the facility and impaired safety awareness dated 5/2/24. The Care Plan interventions included use of wander guard, provide structured activities, redirect/distract when wandering and provide an assortment of nuts/bolts/washers for resident to sort. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, record review, and policy review the facility failed to follow a physician's order for one (Resident #26) of twelve residents reviewed. The facility reported a census of 33 residents. Findings include: A Minimum Data Set (MDS) for Resident #26 dated 4/5/24, included diagnoses of hypertension (high blood pressure), urinary tract infection in last 30 days, and anxiety disorder. The MDS identified the resident required partial to substantial assistance for transfers, toileting, and personal hygiene. The MDS documented the resident had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Resident's Order Summary Report dated 4/24/24 documented the following current physician orders: 1. Clonidine (blood pressure medication) 0.1milligrams (mg) every 6 hours as need (PRN) for systolic blood pressure (SBP) (top number of BP) greater than 160 or diastolic blood pressure (DBP) (lower number of BP) greater than 100 starting 4/1/24. 2. Check BP every 6 hours and administer PRN clonidine per parameters every 6 hours related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on document review and staff interview the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. The facility reported a census of 33. Findings include: Review of facility's PBJ (Payroll Based Journal) Staffing Data Report (staffing numbers reported to Centers for Medicare and Medicaid Services) for the fiscal quarter of 2024 (October 1, 2023-December 31, 2023) identified a No RN hours trigger for 11/12, 12/9, 12/10, 12/23, and 12/24/23. Review of facility's schedule for the following dates revealed no RN scheduled to work: 11/12, 12/9, 12/10, 12/23, and 12/24/23. Interview on 4/23/24 at 2:42 PM, the Administrator confirmed the facility did not have 8 hours of RN coverage on the days reported on the PBJ report of 11/12,12/9, 12/10, 12/23, and 12/24/23. The Administrator stated there was a RN on call but not in the facility. The Administrator stated they do not have a policy for RN coverage that they follow the federal regulations for RN coverage 8 hours a day and her expectation for RN coverage 8 hours a day/7 days a week.

Based on observation, staff interviews and policy reviews the facility failed to ensure staff completed appropriate hand hygiene and glove usage prior to incontinence care for 1 of 1 residents (Resident #26) reviewed. The facility reported a census of 33 residents. Findings Include: A Minimum Data Set (MDS) for Resident #26, dated 4/5/24, included diagnoses of hypertension (high blood pressure), urinary tract infection in last 30 days, and anxiety disorder. The MDS identified the resident required partial to substantial assistance for transfers, toileting, and personal hygiene. The MDS documented the resident had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Observation on 04/24/24 at 1:32 PM, Staff B, Certified Nurse Aide entered room to assist Resident #26 during toileting. Staff B washed hands, applied gloves, removed the resident's shoes and pants, applied a new attend, reapplied the resident's shoes, touched the dirty trash bag, and with the same gloves on proceeded to complete peri care on the resident. After cares completed, Staff B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.