Pine Heights at Brattleboro Center for Nursing & R

In the surveyor’s words

From the most serious findings on record at Pine Heights at Brattleboro Center for Nursing & R, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 17, 2025

  Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of food service safety. This has the potential to impact all residents. Findings include:During the initial tour of the kitchen with the Dietary Manager (DM) on 9/15/2025 at 9:49 AM a frozen turkey in a cardboard box was noted on the floor and an open bag of frozen fish was seen on the shelf. When asked about the frozen turkey on the floor, the DM stated that it was left over from last Thanksgiving, and that she had just not discarded it yet. The DM also confirmed that the bag of fish had been left open and that it should not have been. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2024

  Based upon observation and interview, the facility failed to meet food service safety requirements. Findings include: 1.) Per observation on 9/8/24 at 9:30 PM and again on 9/11/24 at 9:45 AM, a fan located above the clean dish drying area in the facility's kitchen was noted to have a notable covering of dark gray dust-like material on the fan blades and the outer surface of the fan guard/grill. On 9/11/24 at 9:45 AM, the fan was noted to be circulating air directly above a tray of clean flatware. The dirt on the fan guard was noted to include a strand of dark, stringlike material extended from the guard while the fan was operating. […]

• No harm, potential for more than minimal, patternF730Sep 17, 2025

  Based on interview and record review, the facility failed to complete annual evaluations for two of three Licensed Nursing Assistants sampled. Findings include: Per record review of three Licensed Nursing Assistants' (LNA) personnel files that had worked at the facility for over a year, there was no documentation of annual evaluations for 2 of the 3 LNAs to indicate what education or trainings were appropriate for each LNA. Per interview on 9/17/2025 at 12:19 PM, the facility Administrator confirmed that they do not conduct annual evaluations for any staff. Per interview on 9/17/2025 at 12:48 PM, the Director of Nursing confirmed that the facility does not conduct annual evaluations for Licensed Nursing Assistants.

• No harm, potential for more than minimal, patternF761Sep 17, 2025

  Based on observation and interview, it was determined that the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 2 of 4 medication carts. Findings include:Observation on [DATE] at 8:17 AM for one of the Third Floor Unit medication carts revealed that the Isopto Atropine Solution 1% bottle had expired on 4/2025. Per interview on [DATE] at 8:17 AM with the Licensed Practical Nurse (LPN) assigned to this medication cart, they confirmed that the above medication had expired. They stated the process for checking for outdated medications was a task completed by the night shift.Observation on [DATE] at 11:51 AM for one of the Fourth Floor Unit medication carts revealed that a tube of Glutose 15 had expired on 6/2025. […]

• No harm, potential for more than minimal, isolatedF657Sep 17, 2025

  Based on interview and record review, the facility failed to ensure resident involvement in the care planning process for 1 of 20 residents (Resident #38). Findings include:Per interview on 9/15/2025 at 11:39 AM, Resident #38 reported that s/he is not involved in her/his care plan development or review. S/he stated that s/he feels that decisions involving her/his care are made without her/him and that s/he does not know when the facility reviews or revises her/his care plan. Review of a Care Conference/Care Plan meeting note dated 7/8/2025 reveals that a Nurse, Social Services, and Recreation was in attendance at the meeting. Section 2. of the form that states Was the resident/responsible party invited to the resident care conference? was left blank. […]