Yarmouth, ME

Brentwood Center For Health & Rehabilitation, LLC

2-star overall rating with 2-star inspections with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

370 Portland Street, Yarmouth, ME

(207) 846-9021

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

National Health Care Associates

Operator or chain grouping

Approved since

1992-08-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

43 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.75

Registered nurse staffing · state 1.03 · national 0.68

LPN hours / resident day

0.85

Licensed practical nurse staffing · state 0.47 · national 0.87

Aide hours / resident day

2.33

Nurse aide staffing · state 2.86 · national 2.35

Total nurse hours

3.93

All reported nurse hours · state 4.35 · national 3.89

Licensed hours

1.60

RN + LPN hours · state 1.49 · national 1.54

Weekend hours

3.43

Weekend nurse staffing · state 3.91 · national 3.43

Weekend RN hours

0.29

Weekend registered nurse coverage · state 0.73 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.68

CMS adjusted RN staffing hours

Adjusted total hours

3.60

CMS adjusted total nurse staffing hours

Case-mix index

1.50

Higher values indicate more complex resident acuity

RN turnover

38%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,924

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

25.27

Composite VBP score used to determine payment impact.

Payment multiplier

0.9837

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.63

Baseline 18.66% · Performance 20.21% · Measure score 2.63 · Achievement 2.63 · Improvement 0

Healthcare-associated infections

3.68

Baseline 6.53% · Performance 6.73% · Measure score 3.68 · Achievement 3.68 · Improvement 0

Total nurse turnover

1.28

Baseline 43.55% · Performance 58.43% · Measure score 1.28 · Achievement 1.28 · Improvement 0

Adjusted total nurse staffing

2.52

Baseline 3.59 hours · Performance 3.79 hours · Measure score 2.52 · Achievement 2.52 · Improvement 0.44

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.71%	10.72% 1 pts better	No Different than the National Rate · Eligible stays 104 · Observed rate 6.73% · Lower 95% interval 6.15%
Discharge to community	44.21%	50.57% 6.4 pts worse	No Different than the National Rate · Eligible stays 109 · Observed rate 38.53% · Lower 95% interval 36.03%
Medicare spending per beneficiary	0.85	1.02 0.2 pts better
Drug regimen review with follow-up	98.77%	95.27% 3.5 pts better	Numerator 80 · Denominator 81
Falls with major injury	1.23%	0.77% 0.5 pts worse	Numerator 1 · Denominator 81
Discharge self-care score	58.06%	53.69% 4.4 pts better	Numerator 18 · Denominator 31
Discharge mobility score	45.16%	50.94% 5.8 pts worse	Numerator 14 · Denominator 31
Pressure ulcers or injuries, new or worsened	2.47%	2.29% 0.2 pts worse	Numerator 2 · Denominator 81 · Adjusted rate 2.51%
Healthcare-associated infections requiring hospitalization	6.74%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 71 · Observed rate 5.63% · Lower 95% interval 3.93%
Staff COVID-19 vaccination coverage	25.64%	8.2% 17.4 pts better	Numerator 20 · Denominator 78
Staff flu vaccination coverage	100%	42% 58 pts better	Numerator 78 · Denominator 78
Discharge function score	58.06%	56.45% 1.6 pts better	Numerator 18 · Denominator 31
Transfer of health information to provider	96.43%	95.95% 0.5 pts better	Numerator 54 · Denominator 56
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	42.86%	25.2% 17.7 pts better	Numerator 15 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.0	1.4 0.4 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	2.1 1.3 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	63.7%	90.7% 27 pts worse	93.4% 29.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 58.6% · Q2 70.4% · Q3 65.5% · Q4 61.0% · 4Q avg 63.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	88.9%	95.5% 6.6 pts worse	95.5% 6.6 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 88.9%
Percentage of long-stay residents experiencing one or more falls with major injury	7.5%	4.3% 3.2 pts worse	3.3% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.4% · Q3 7.3% · Q4 10.2% · 4Q avg 7.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	37.7%	10.7% 27 pts worse	11.4% 26.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 54.5% · Q3 37.3% · Q4 26.9% · 4Q avg 37.7%
Percentage of long-stay residents who lose too much weight	2.5%	5.5% 3 pts better	5.4% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.1% · Q3 2.3% · Q4 0.0% · 4Q avg 2.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.6%	17.0% 3.6 pts worse	19.6% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 15.4% · Q3 20.5% · Q4 25.0% · 4Q avg 20.6%
Percentage of long-stay residents who received an antipsychotic medication	33.8%	21.0% 12.8 pts worse	16.7% 17.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 34.4% · Q3 37.1% · Q4 29.4% · 4Q avg 33.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.3%	29.6% 11.3 pts better	16.3% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 20.5% · Q3 30.4% · 4Q avg 18.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.3%	25.7% 3.4 pts better	14.9% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 28.6% · Q3 23.1% · Q4 25.0% · 4Q avg 22.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.5%	1.3% 1.2 pts worse	1.0% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 3.0% · Q4 5.5% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	2.7% 2.2 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	35.3%	29.8% 5.5 pts worse	19.8% 15.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 44.0% · Q3 43.3% · Q4 29.3% · 4Q avg 35.3%
Percentage of long-stay residents with pressure ulcers	1.7%	4.4% 2.7 pts better	5.1% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.5% · Q3 0.0% · Q4 1.1% · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	39.5%	71.2% 31.7 pts worse	81.7% 42.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 43.4% · Q2 35.7% · Q3 37.7% · Q4 41.3% · 4Q avg 39.5%
Percentage of short-stay residents who had an outpatient emergency department visit	14.5%	15.6% 1.1 pts better	12.0% 2.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 14.3% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	1.4% 1 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	59.7%	74.5% 14.8 pts worse	79.7% 20 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 59.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.9%	20.5% 10.4 pts worse	23.9% 7 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.9% · Observed 28.6% · Expected 22.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-04 · Fire 2024-12-04

17 health deficiencies

Top issue: Resident Assessment and Care Planning (7 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2022-05-18 · Fire 2022-05-18

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-07-25 · Fire 2019-07-25

7 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-04

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2024-12-26

F · Potential for more than minimal harm 2024-12-04

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-01-15

F · Potential for more than minimal harm 2024-12-04

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-01-15

F · Potential for more than minimal harm 2024-12-04

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-12-09

F · Potential for more than minimal harm 2024-12-04

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-04

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-04

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-15

D · Potential for more than minimal harm 2024-12-04

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-12-13

D · Potential for more than minimal harm 2022-05-18

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-05-27

D · Potential for more than minimal harm 2022-05-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-05-27

E · Potential for more than minimal harm 2019-07-25

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2019-09-09

D · Potential for more than minimal harm 2019-07-25

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2019-09-09

D · Potential for more than minimal harm 2019-07-25

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2019-09-09

D · Potential for more than minimal harm 2019-07-25

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2019-09-09

D · Potential for more than minimal harm 2019-07-25

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-09-09

D · Potential for more than minimal harm 2019-07-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-09-09

D · Potential for more than minimal harm 2019-07-25

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-09-09

D · Potential for more than minimal harm 2019-07-25

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2019-09-09

C · Minimal harm 2019-07-25

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2019-09-09

Inspection history

Recent health citations

E · Potential for more than minimal harm 2026-01-06

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2026-01-29

E · Potential for more than minimal harm 2026-01-06

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2026-01-29

E · Potential for more than minimal harm 2026-01-06

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2026-01-29

E · Potential for more than minimal harm 2026-01-06

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2026-01-29

D · Potential for more than minimal harm 2026-01-06

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2026-01-29

E · Potential for more than minimal harm 2025-11-14

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-11-25

E · Potential for more than minimal harm 2025-11-14

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-11-25

E · Potential for more than minimal harm 2025-11-14

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-11-25

E · Potential for more than minimal harm 2024-12-04

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-01-02

E · Potential for more than minimal harm 2024-12-04

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-01-02

E · Potential for more than minimal harm 2024-12-04

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-01-02

E · Potential for more than minimal harm 2024-12-04

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-12-04

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-12-04

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-12-04

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-01-02

D · Potential for more than minimal harm 2024-12-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-02

B · Minimal harm 2024-12-04

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2025-01-02

F · Potential for more than minimal harm 2022-05-18

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-18

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-06-24

D · Potential for more than minimal harm 2022-05-18

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2022-06-24

E · Potential for more than minimal harm 2019-07-25

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2019-09-08

D · Potential for more than minimal harm 2019-07-25

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2019-09-08

D · Potential for more than minimal harm 2019-07-25

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2019-09-08

D · Potential for more than minimal harm 2019-07-25

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2019-09-08

C · Minimal harm 2019-07-25

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-09-08

C · Minimal harm 2019-07-25

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2019-09-08

C · Minimal harm 2019-07-25