Brickyard Healthcare Brandywine: Nebulizer Care Failures - IN
The citation came out of two separate complaints, logged under intake numbers 2659041 and 2649985, suggesting more than one person had reason to contact regulators about the facility's respiratory care before inspectors ever walked through the door.
Nebulizer treatments are not a minor matter for nursing home residents. The small-volume nebulizer, the pressurized metered-dose inhaler, and the dry-powder inhaler are the three common devices used to deliver inhaled medications directly to the lungs. Residents who need them typically have conditions, chronic obstructive pulmonary disease, asthma, recurring respiratory infections, where the difference between a treatment given correctly and one given carelessly can mean the difference between stability and a hospital transfer.
The facility's own policy, handed over by the Director of Nursing at 9:12 a.m. the morning of the inspection, spelled out exactly what staff were supposed to do. Before a treatment, nurses were required to obtain the resident's vital signs and perform a respiratory assessment to establish a baseline. During and after, they were required to document the date, time, and duration of therapy; the type and amount of medication used; oxygen flow if administered; vital signs and a respiratory assessment; the resident's response to the treatment; and any teaching provided to the resident about what was happening and why.
That policy existed. The documentation to show it was being followed did not.
The deficiency was tagged at a level of harm described as minimal harm or potential for actual harm, and inspectors noted that few residents were affected. Neither of those qualifications changes what the failure means in practice. A baseline respiratory assessment exists for a reason: if a resident's breathing worsens during a treatment, the only way to know that is to have measured where they started. Without it, a nurse administering a nebulizer is working without a reference point. Without documentation of the resident's response, there is no record to prompt a call to the physician if something changes, and no trail for the next nurse coming on shift to follow.
The facility's own written policy cross-referenced the obligation to notify a physician of significant changes in a resident's condition. That notification requirement only works if someone is watching closely enough to recognize that a change has occurred.
What the inspection report does not say is also worth noting. It does not say a resident was hospitalized. It does not say anyone was harmed in a way inspectors could document. The citation sits at the lower end of the federal harm scale. But the two complaints that triggered the visit came from somewhere, filed by people who believed something was wrong with the way breathing treatments were being handled at this facility before a single inspector arrived.
Brickyard Healthcare Brandywine Care Center operates at 745 N. Swope Street in Greenfield, a city of roughly 25,000 people east of Indianapolis. The inspection was completed November 13, 2025. The statement of deficiencies was printed April 13, 2026, five months later.
The facility was given the opportunity to submit a plan of correction. Whether that plan addressed the underlying question, why staff were not following a policy the Director of Nursing could produce within the first hour of an inspection, is not reflected in the inspection record.
Somewhere in that building, residents with damaged lungs were breathing through machines, and the people administering those treatments were not writing down what they saw.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brickyard Healthcare - Brandywine Care Center from 2025-11-13 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 21, 2026 · Our methodology
BRICKYARD HEALTHCARE - BRANDYWINE CARE CENTER in GREENFIELD, IN was cited for violations during a health inspection on November 13, 2025.
Nebulizer treatments are not a minor matter for nursing home residents.
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.