Brentwood Center: Care Quality Deficiencies - ME
The resident had returned from the hospital on August 31 with a chronic abscess on the right lateral thigh that required packing and antibiotics for cellulitis. But Brentwood Center For Health & Rehabilitation nurses couldn't locate the discharge orders and provided no wound care until September 11, when a doctor finally wrote new orders.
RN #2 told state inspectors on October 20 that she remembered the emergency room discharge summary instructed staff to leave the wound dressing in place for three or four days, then remove it and have the wound doctor examine it for new orders. She confirmed she provided no wound care on that wound until September 11.
"RN#2 reviewed Resident #2's orders, including current, discontinued and completed orders and could not locate any wound care orders for the right lateral hip from 8/31/25 until 9/11/25 and confirmed 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," inspectors wrote.
The resident's wound had initially healed on August 19. But on August 30, a nursing note documented that the right lateral thigh appeared swollen with new drainage, prompting the emergency room visit.
Unit Manager RN #1 told inspectors he had unpacked, assessed and repacked the wound on September 5. He said he contacted the on-call provider, who asked him to photograph the wound and pack it until a provider could assess it in person.
But RN #1 couldn't provide orders or documentation of that encounter with the on-call provider.
When inspectors asked if wound care was provided between August 31 and September 11, "he stated he was unable to find any information that wound care was provided with the exception of his assessment on 9/5/25."
A second resident experienced similar problems when a negative pressure wound therapy device malfunctioned. On October 9, a nursing note stated the wound vacuum "appears to not be functioning correctly" due to a dressing malfunction. The nurse packed the wound with VASHE-soaked gauze "per provider in lieu of new NPWT dressing."
No physician orders existed for the VASHE treatment.
The Director of Nursing confirmed during an October 20 interview that RN #1 had called the provider and received verbal orders for the VASHE dressing but failed to document the order properly.
State inspectors reviewed three residents for wound care and found two cases where the facility failed to obtain proper physician orders. The violations occurred during a complaint investigation completed November 14.
Federal regulations require nursing homes to provide treatment and care according to physician orders and resident preferences. The inspection found minimal harm or potential for actual harm to residents.
The missing emergency room discharge instructions created an 11-day gap in wound care orders for a resident with an infected abscess that had previously required hospital treatment. During this period, nurses either provided no care or treated the wound without documented physician authorization.
RN #1's assessment on September 5 occurred without written orders, despite the chronic nature of the resident's condition and recent emergency room visit for the same wound.
The facility's inability to locate critical discharge instructions in either paper or electronic records raised questions about documentation systems designed to ensure continuity of care for residents with complex medical needs.
Both cases involved wounds requiring specialized care. The chronic thigh abscess had a history of healing and recurrence, while the negative pressure wound therapy represented an advanced treatment method that requires specific protocols and physician oversight.
The inspection revealed gaps in the facility's systems for obtaining, documenting and implementing physician orders for wound care, affecting residents who depended on consistent medical treatment for serious conditions.
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.
She confirmed she provided no wound care on that wound until September 11.
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.