Pine Heights at Brattleboro Center for Nursing & R

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. On 9/15/2025 at approximately 10:15 AM on return to the kitchen, it was noted that clean dishes were being put away and placed on food carts while wet. At this time the DM confirmed that the dishes were being put away wet and that they should not be.

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 They stated the process for checking for outdated medications was a task completed by the night shift.Observation on [DATE] at 11:51 AM for one of the Fourth Floor Unit medication carts revealed that a tube of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. Per interview on [DATE] at 11:51 AM with the 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.

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. Per interview with the facility Administrator on 9/17/2025 at 2:27 PM, residents and/or their responsible parties are only invited to the comprehensive care plan meetings which are done annually and with a significant change.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice related to care and maintenance of a PICC line for 1 of 1 resident (Resident #23). Findings include:Per record review, Resident # 23 has diagnoses that include acute osteomyelitis, left ankle and foot, and non-pressure chronic ulcer of the other part of the left foot. Resident #23 is receiving wound care and intravenous (IV) antibiotics through a PICC line. On 9/16/25 at 9:35 AM, a Licensed Practical Nurse (LPN) was observed preparing to administer an antibiotic via Resident #23's PICC line. She encountered resistance while trying to clear the catheter line to allow the antibiotic to pass through. This surveyor noticed that the line was very long and coiled, causing it to kink under the dressing, thus preventing the flow of liquid to flush the line. When the line was uncoiled, it measured 42 cm at the indicator marked on the line, indicating that the line could have potentially migrated out of…

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, policy review, and staff interviews, the facility failed to implement infection control policies and procedures when staff didn't don personal protective equipment to handle an indwelling device for a resident on enhanced barrier precautions for 1 of 7 residents (Resident #11). Findings include:Per observation on 9/16/2025 at 9:48 AM, a Licensed Practical Nurse (LPN) was observed picking up an indwelling catheter bag (collection bag for urine connected to a catheter, which is a thin, flexible tube that a healthcare provider inserts into the bladder to drain and collect urine) from the floor without wearing any personal protective equipment (PPE). Per interview on 09/17/2025 at 10:34 AM with the Infection Preventionist (IP), she confirmed that indwelling catheter bag handling, whether it is in a privacy pouch or not, requires gloves worn when handling, and Enhanced Barrier Precautions (EBP) should be utilized during care of the catheter. The facility policy Urinary Catheterization policy dated 1/2023/4-24 defines EBP as the use of gown and gloves.Per interview…

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 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. The observation on 9/11/24 was conducted with the facility's Dietary Manager, who confirmed the fan blowing on the clean flatware represented an unsanitary condition, and stated that Maintenance had been notified about the fan needing cleaning the day before, on 9/10/24, but the cleaning had not been done. 2.) Per observation on 9/9/24 at 12:31 PM, a bag of white bread slices was noted to have visible green mold on it in the facility's 2nd floor…

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 upon observation, interview, and record review, the facility failed to provide Activities of Daily Living [ADL] care and assistance to maintain good nutrition for 1 dependent resident [Res.#39] of 3 sampled residents dependent on ADL assistance. Findings include: Per review of Res.#39's Care Plan, the resident is identified as having as having Dysphagia [Dysphagia is a medical term for difficulty swallowing. Difficulty swallowing can lead to: Malnutrition, weight loss and dehydration. ]*, has risk for weight loss and malnutrition due to variable meal intake and dysphagia as well as cognitive impairment, at risk for dehydration, has impaired cognitive function/dementia or impaired thought processes, has an ADL [Activities of Daily Living] self-care performance deficit related to dementia, and has impaired visual function related to left eye blindness. Care Plan interventions to counteract Res.#39's nutritional risks include EATING: Continual supervision, May need more cues/assist, Provide feeding/dining assistance as needed. Set up for meals, Ensure the resident has access 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 interview and record review the facility failed to provide services that included supervision, monitoring, and ADL (Activities of Daily Living) care necessary to prevent a fall from a wheelchair for 1 of 10 residents in the applicable sample (Resident #19). Findings include: Per record review Resident #19 was found on the floor of her/his room at 1:45 AM on 8/7/24. Review of Resident #19's care plan reveals that s/he is totally dependent on two staff with a mechanical lift for transfers to and from a wheelchair. The care plan also indicates that s/he has an ADL self-care performance deficit, with interventions that include, ensure resident is assisted to bed by 11 PM unless resident requests otherwise, intentional rounding every 1 hour for repositioning, and monitor positioning while in room. A Health Status Note written on 8/7/2024 states that the Resident was found on the floor next to her/his wheelchair in her/his room at 1:45 AM. The note further states that the call light was out of reach and the mechanical lift was in the room. Another Health Status Note written on…

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.