Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Heights At Brattleboro Center For Nursing & R during CMS and state inspections, most recent first.
Surveyors observed a frozen turkey stored on the floor, an open bag of frozen fish left on a shelf, and clean dishes being put away while still wet. The Dietary Manager confirmed these practices did not meet professional food service safety standards.
The facility did not complete annual evaluations for two of three LNAs who had worked at the facility for over a year. Record review found no documentation of evaluations to determine appropriate education or training, and both the Administrator and DON confirmed that annual evaluations are not conducted for staff.
Surveyors found expired medications on two medication carts, including Isopto Atropine Solution 1% and Glutose 15. LPNs confirmed the presence of expired drugs and indicated that the night shift was responsible for checking for outdated medications.
A resident was not included in the development or review of their care plan and reported being unaware of care plan meetings. Documentation from a care conference did not indicate that the resident or their representative was invited, and facility leadership confirmed that invitations are limited to annual or significant change meetings.
A resident receiving IV antibiotics via a PICC line experienced resistance during medication administration due to a kinked and potentially migrated catheter. The facility failed to document the external catheter length at admission and during weekly assessments, as required by policy, resulting in a lack of evidence regarding the line's position and safety.
An LPN handled an indwelling catheter bag for a resident on enhanced barrier precautions without wearing required PPE, including gloves and a gown, as outlined in facility policy. The LPN admitted to not using PPE and was uncertain about glove availability in the resident's room. The Infection Preventionist confirmed that gloves should be worn during such care to comply with infection control protocols.
The facility failed to meet food service safety requirements. A fan above the clean dish drying area was covered in dust and circulated air over clean flatware, creating an unsanitary condition. Additionally, moldy bread was found in the 2nd floor kitchenette, and the facility lacked a process for monitoring and dating bread to prevent use beyond expiration.
A resident with dysphagia and cognitive impairment was left without meal assistance for 25 minutes, during which another resident took their drink without staff intervention. When finally attended to, the resident declined the meal, which had been left uncovered, and was not offered an alternative or reheating. The DON confirmed the resident's dependency on staff for meal assistance and acknowledged the deficiency.
A resident, dependent on staff for transfers, was found on the floor after sliding from their wheelchair due to inadequate supervision. The care plan required assistance to bed and hourly repositioning, but staff failed to perform safety checks and walking rounds, leading to the incident.
The facility failed to support residents' rights to file grievances anonymously, affecting all residents. During a Resident Council meeting, several residents reported they were unaware of how to file grievances anonymously or at all, and they lacked access to forms for independent or anonymous submission. Observations confirmed the absence of grievance forms on all units, preventing residents or their representatives from filing grievances independently or anonymously. The Administrator confirmed the lack of forms and processes for anonymous grievance filing.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
During a kitchen tour with the Dietary Manager (DM), surveyors observed a frozen turkey in a cardboard box stored on the floor and an open bag of frozen fish left on a shelf. The DM confirmed that the turkey had been left over from the previous Thanksgiving and had not yet been discarded, and acknowledged that the bag of fish should not have been left open. Later, clean dishes were seen being put away and placed on food carts while still wet, which the DM also confirmed was not proper procedure. These actions demonstrate failures in storing, preparing, and handling food and dishware according to professional food service safety standards. No specific residents or their medical histories were mentioned as being directly involved or affected in the report.
Failure to Complete Annual Evaluations for LNAs
Penalty
Summary
The facility failed to complete annual evaluations for two out of three Licensed Nursing Assistants (LNAs) who had been employed for over a year. Record review showed no documentation of annual evaluations for these LNAs, which would indicate what education or training was appropriate for each individual. During interviews, both the Administrator and the Director of Nursing confirmed that annual evaluations are not conducted for any staff, including LNAs.
Expired Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that medications were not stored in accordance with accepted professional principles on two of four medication carts. On the Third Floor Unit, a bottle of Isopto Atropine Solution 1% was found to be expired since 4/2025. The LPN assigned to this cart confirmed the medication was expired and stated that the night shift was responsible for checking for outdated medications. On the Fourth Floor Unit, a tube of Glutose 15 was found to be expired since 6/2025, and the LPN assigned to this cart also confirmed the expired medication, again noting that the night shift was responsible for checking for outdated medications. These findings indicate that expired medications were present on medication carts and that the process for checking for outdated medications was not effectively implemented, as confirmed by staff interviews.
Resident Not Involved in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident was involved in the care planning process, as required. During an interview, the resident stated that they were not included in the development or review of their care plan and were unaware of when their care plan was reviewed or revised. Review of documentation from a care conference showed that the section indicating whether the resident or their responsible party was invited to the meeting was left blank. Additionally, the facility administrator confirmed that residents and their responsible parties are only invited to comprehensive care plan meetings conducted annually or when there is a significant change, rather than for all care plan reviews or revisions.
Failure to Follow PICC Line Assessment and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice regarding the care and maintenance of a peripherally inserted central catheter (PICC) line for a resident with acute osteomyelitis and a chronic foot ulcer who was receiving intravenous antibiotics. During an observation, an LPN encountered resistance while attempting to administer an antibiotic through the resident's PICC line. The line was found to be excessively long and coiled, causing it to kink under the dressing and impede fluid flow. Upon uncoiling, the line measured 42 cm at the indicator, suggesting possible migration of the catheter. Record review revealed that there was no documentation of the external catheter length at the insertion site upon admission or during subsequent weekly assessments, as required by facility policy. The Assistant Director of Nursing confirmed that the line should have been measured at admission and weekly thereafter, but no such measurements were documented in the medical record. This lack of assessment and documentation meant there was no evidence to determine whether the line had migrated or if it was safe to use.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A Licensed Practical Nurse (LPN) was observed handling an indwelling catheter bag for a resident on enhanced barrier precautions without wearing any personal protective equipment (PPE), specifically gloves or a gown, as required by facility policy. The LPN picked up the catheter bag from the floor without donning PPE, despite the facility's urinary catheterization policy defining enhanced barrier precautions as the use of both gown and gloves during such care. The Infection Preventionist confirmed that gloves should be worn when handling indwelling catheter bags, and the LPN acknowledged that PPE should have been used but stated she did not have gloves in her pocket and was unsure if gloves were available in the resident's bathroom. The Centers for Disease Control and Prevention guidance was referenced regarding the importance of enhanced barrier precautions to reduce the transfer of multi-drug resistant organisms.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to meet food service safety requirements as observed during a survey. On two separate occasions, a fan located above the clean dish drying area in the kitchen was found to have a significant accumulation of dark gray dust-like material on its blades and outer surface. This fan was circulating air directly over a tray of clean flatware, creating an unsanitary condition. The facility's Dietary Manager confirmed the unsanitary condition and noted that maintenance had been notified about the need for cleaning, but it had not been completed. Additionally, a bag of white bread slices with visible green mold was found in the facility's 2nd floor kitchenette. The Dietary Manager confirmed the presence of mold and acknowledged that the facility lacked a process for monitoring and dating bread to ensure it was not used beyond its expiration date.
Failure to Provide Adequate Meal Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) care, specifically in maintaining good nutrition for a resident identified as having dysphagia, cognitive impairment, and a risk for weight loss and malnutrition. The resident's care plan required continual supervision and assistance during meals. However, during a meal observation, the resident was left unattended for 25 minutes without any cueing or assistance from staff, despite being seated with a meal and drink in front of them. During this time, another resident took the drink from the resident without any staff intervention. When a Licensed Nursing Assistant (LNA) finally attended to the resident, the meal had been sitting uncovered for 25 minutes, and the resident declined the food when offered. The LNA did not inquire about the resident's refusal, offer an alternative meal, or reheat the food. The Director of Nursing confirmed the resident's dependency on staff for meal assistance and acknowledged the lack of appropriate care during the observed meal, which contributed to the deficiency in providing necessary ADL support.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent a fall for a resident who was totally dependent on two staff members with a mechanical lift for transfers. The resident was found on the floor of their room at 1:45 AM, having apparently slid out of their wheelchair. The care plan for the resident indicated that they required assistance to bed by 11 PM, intentional rounding every hour for repositioning, and monitoring of positioning while in the room. However, the resident was not assisted to bed or reevaluated until they were found on the floor. The facility's internal investigation revealed that a staff member had brought the resident to their room after the evening meal, but the Licensed Nursing Assistant (LNA) assigned to the resident's care had falsely documented performing safety checks. Additionally, the evening and night shift staff failed to conduct walking rounds at the change of shift as expected. These lapses in supervision and adherence to the care plan contributed to the resident's fall.
Failure to Provide Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to support residents' rights to file grievances anonymously, affecting all residents. During a Resident Council meeting, five residents reported they were unaware of how to file grievances anonymously or at all, and they lacked access to forms for independent or anonymous submission. Observations confirmed the absence of grievance forms on all units, preventing residents or their representatives from filing grievances independently or anonymously. The facility's Grievance/Concern Policy stated that forms should be available on nursing units and in the front lobby, but there was no evidence of such availability. The Administrator confirmed the lack of forms and processes for anonymous grievance filing.
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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 Brattleboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thompson House Nursing Home | 0.2 mi | ★★★★★ | 3 | 3 |
| Vernon Green Nursing Home | 6.1 mi | ★★★★★ | 12 | 0 |
| Cheshire County Home | 10.3 mi | ★★★★★ | 4 | 0 |
| Applewood Center | 10.6 mi | ★★★★★ | 0 | 0 |
| Covenant Living Of Keene | 14.5 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.