The facility's director of nursing confirmed that staff had no backup supply of the essential monitoring strips when they ran out on the morning of October 21, 2025. The resident's doctor had ordered regular blood glucose checks, but none were completed that entire day or during the morning and midday checks the following day.
Federal inspectors found no evidence that facility staff notified the resident's healthcare provider about their inability to follow the doctor's orders for blood sugar monitoring on either October 21 or October 22.
The nurse practitioner who treated the resident happened to be in the facility around 11:30 AM on October 21 and overheard staff discussing their supply problem. Facility employees told the NP they had already ordered replacement strips and expected them to arrive later that day.
Staff made a backup promise. If the strips didn't arrive by suppertime, they assured the nurse practitioner, someone would drive to the pharmacy to purchase them.
Nobody did.
When the nurse practitioner returned to Skyview Care the next day, October 22, staff informed them that no strips had been obtained. The facility could not explain why no one had contacted the NP the previous evening to report their failure to secure the monitoring supplies.
The director of nursing acknowledged during the November inspection that the facility's original order for glucose monitoring strips never arrived as expected on October 21. When staff checked with the pharmacy as their supposed backup plan, they discovered the pharmacy had no strips available either.
At that point, the facility made no additional attempts to obtain the strips from other sources. Staff also failed to reach back out to the nurse practitioner after being unable to get the supplies on the evening of October 21, as they had promised.
The breakdown left the diabetic resident without any blood glucose monitoring during critical times when their doctor had determined such checks were medically necessary. Blood sugar monitoring allows healthcare providers to detect dangerous highs or lows that can lead to serious complications in diabetic patients.
Federal regulations require nursing homes to follow physician orders for resident care and to promptly notify healthcare providers when they cannot carry out prescribed treatments. Skyview Care violated both requirements during the two-day period when they had no glucose monitoring strips.
The facility's lack of preparation was particularly striking. The director of nursing confirmed they had no backup supply of the monitoring strips in the facility when their regular stock ran out. This meant the facility was entirely dependent on a single shipment arriving on schedule to continue providing ordered medical care to their diabetic resident.
The nurse practitioner's presence in the facility on October 21 was coincidental. Had they not overheard staff discussing the supply shortage, the facility might never have informed the healthcare provider about their inability to complete the ordered blood glucose checks.
Even after making specific promises to the nurse practitioner about obtaining replacement strips, facility staff followed through on none of their commitments. They didn't contact the NP when the strips failed to arrive as promised, didn't successfully purchase strips from the pharmacy despite claiming this was their backup plan, and didn't explore other potential sources for the essential medical supplies.
The inspection found that Skyview Care's failure to monitor the resident's blood glucose created minimal harm or potential for actual harm. However, the violation affected the facility's ability to provide basic medical care as ordered by the resident's physician.
The two-day gap in blood sugar monitoring meant healthcare providers had no data about the resident's glucose levels during a period when their doctor had determined such information was medically necessary. For diabetic patients, regular monitoring helps prevent dangerous complications from blood sugar levels that are too high or too low.
Skyview Care's inability to maintain adequate supplies of basic medical equipment, combined with their failure to communicate with healthcare providers when problems arose, represented a breakdown in fundamental aspects of nursing home care coordination.
The facility had no backup plan that actually worked and no communication system that ensured healthcare providers stayed informed when ordered treatments could not be completed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyview Care and Rehab At Bridgeport from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Skyview Care and Rehab At Bridgeport
- Browse all NE nursing home inspections