Brentwood Center: Care Plan Deficiencies - ME
Resident #2 had been sent to the emergency room on August 30 when nurses discovered his previously healed right thigh abscess had reopened with swelling and drainage. He returned the next day with antibiotics for cellulitis and packing that was supposed to remain in place for 48 to 72 hours.
But the facility's clinical records contained no evidence of the emergency room discharge instructions or any wound care orders for the resident's right lateral thigh from August 31 until September 11.
RN #2 told inspectors on October 20 that she remembered the discharge summary specified the dressing should be packed and left in place for three or four days, then removed so "the wound doctor" could examine it and write new orders. She confirmed she provided no wound care on the wound until September 11, when a doctor finally wrote orders.
The nurse said she had physically held the emergency room discharge summary but could no longer find it in either the hard chart or electronic medical record.
Meanwhile, RN #1, the unit manager, told inspectors he had unpacked, assessed and repacked the wound on September 5. He said he reached out to an on-call provider to obtain wound care orders, and the provider asked him to photograph the wound and pack it until a provider could assess it in person.
But RN #1 could not provide orders or documentation of this encounter with the provider. When inspectors asked whether wound care was provided and physician orders were obtained between August 31 and September 11, he said he could find no information that wound care was provided except for his assessment on September 5.
A separate resident experienced similar problems with wound care orders. On October 9, nurses discovered that Resident #1's negative pressure wound therapy machine was malfunctioning due to a dressing problem. With supplies scheduled for delivery the next day, staff packed the wound with VASHE-soaked gauze "per provider."
The facility's provider orders contained no evidence of any orders for VASHE-soaked gauze.
The Director of Nursing confirmed to inspectors on October 20 that RN #1 had called the provider and received verbal orders for the VASHE dressing but failed to document the order in writing.
Federal regulations require nursing homes to provide treatment and care according to physician orders. The inspection found the facility failed to obtain proper physician orders for wound care for two of three residents reviewed.
For Resident #2, the gap in physician orders lasted from August 31 through September 11, covering the critical period when emergency room packing was supposed to be monitored and transitioned to ongoing wound care. Documentation showed the wound was measured on September 5, but without proper orders governing the treatment.
The facility received a citation for minimal harm or potential for actual harm, affecting some residents. Inspectors completed their review on November 14.
RN #2's inability to locate the emergency room discharge instructions meant staff lost access to the specific treatment plan developed by emergency physicians who had directly examined the resident's reopened abscess. The missing documentation left nurses without clear guidance on when to remove packing, how to assess healing, or when to contact providers for follow-up orders.
The violations occurred despite the facility having multiple registered nurses involved in the residents' care, including unit managers responsible for coordinating treatment plans and ensuring proper documentation of physician orders.
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.
He returned the next day with antibiotics for cellulitis and packing that was supposed to remain in place for 48 to 72 hours.
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.