Brentwood Center: Medical Record Failures - ME
The resident returned from the emergency room on August 31 with a packed wound and instructions for continued care. But nurses couldn't find the discharge paperwork, and no wound care orders appeared in the medical record until September 11.
During those 11 days, the resident's right lateral thigh wound went largely untreated despite previous drainage that had sent him to the emergency room.
The abscess had initially healed on August 19. Eleven days later, a nurse found the resident's thigh swollen with new drainage and called an ambulance. Emergency room doctors treated the cellulitis with antibiotics and packed the wound with instructions to leave the dressing in place for 48 to 72 hours.
RN #2 told inspectors she remembered the discharge summary's instructions clearly. "The discharge summary said there was a dressing on his hip and it's supposed to be packed, leave it in place with the dressing on it for about 3 or 4 days, then take it off and have the wound doctor take a look and they're supposed to do new orders."
But she couldn't provide wound care without physician orders.
"At this time, RN #2 stated she has not provided any wound care on that wound until 9/11/25 when the doctor wrote orders," inspectors wrote. The nurse reviewed all current, discontinued and completed orders but found none for the wound care between August 31 and September 11.
More troubling, the discharge paperwork had vanished. RN #2 told inspectors she "physically had the emergency room discharge summary in her hand and is now unable to find it in the hard chart or the electronic medical record."
Unit Manager RN #1 did assess and repack the wound on September 5, six days after the resident's return. He contacted an on-call provider who asked him to photograph the wound and continue packing until a doctor could examine it in person.
But when inspectors asked for documentation of this phone conversation, RN #1 couldn't provide orders or records of the encounter.
The facility failed a second resident in similar fashion. On October 9, nurses discovered a malfunctioning wound vacuum on Resident #1. The negative pressure wound therapy device had a dressing malfunction, so nurses packed the wound with VASHE-soaked gauze instead.
The nursing note stated this was done "per provider in lieu of new NPWT dressing." But inspectors found no physician orders for the VASHE treatment in the medical record.
Director of Nursing confirmed during interviews that RN #1 had called the provider and received verbal orders for the VASHE dressing. The nurse simply failed to document the order.
Federal regulations require nursing homes to obtain physician orders before providing treatments. The missing orders left both residents receiving care that wasn't properly authorized or documented.
For Resident #2, the gap meant 11 days of uncertainty about appropriate wound care for a chronic abscess that had already required emergency treatment. The resident's thigh wound was finally assessed and measured by RN #1 on September 5, but formal physician orders didn't appear until September 11.
The inspection classified the violations as causing minimal harm or potential for actual harm. But the pattern revealed systemic problems with obtaining and documenting required physician orders for wound care.
RN #2's inability to locate critical discharge paperwork compounded the documentation failures. Emergency room instructions that should have guided the resident's care simply disappeared from both paper and electronic records.
Both cases occurred within weeks of each other, suggesting the facility's nurses routinely struggled with the basic requirement of securing physician orders before treating wounds.
The facility must now develop a plan to correct these deficiencies and ensure all wound care receives proper physician authorization and documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brentwood Center For Health & Rehabilitation, LLC from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Brentwood Center For Health & Rehabilitation, LLC in Yarmouth, ME was cited for violations during a health inspection on November 14, 2025.
The resident returned from the emergency room on August 31 with a packed wound and instructions for continued care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.