Federal inspectors found that Resident 6 displayed clear signs of pain including facial grimacing, furrowed brows, tense and rigid body posturing, and restless legs. Staff documented the patient's non-verbal pain indicators at 6 out of 10 on November 12, yet the facility had not properly addressed the resident's inability to take oral medications.
The resident had been refusing medications for days. On November 11 at 9:15 PM, staff documented that the patient's anti-anxiety medication buspirone was "not given" with the reason listed as "resident refused." Hours later at 12:37 AM on November 12, the pain medication hydrocodone was also marked as "not given" because the "resident refused."
But the resident wasn't actually refusing the medications. The patient would only take a few bites of crushed medication mixed in pudding, then stop eating entirely.
Registered Nurse A told inspectors they had "difficulty administering Resident 6's medications, including their pain medications as the resident would only accept a few bites of the crushed medication." The nurse documented in progress notes that the resident "would only take a few bites of their medication that had been crushed and put in pudding."
Despite the obvious medication administration problem, no one had informed the resident's doctor.
When inspectors interviewed the Nurse Practitioner on November 13, the doctor revealed they "had been unaware until informed by this surveyor now that Resident 6 had not been taking their oral medications."
The medical consequences were severe. The Nurse Practitioner identified the resident's restless legs as "being uncomfortable from withdrawals from the fluvoxamine and methocarbamol, as the resident needs these medications due to their tight spasticity in their legs."
The resident had been displaying baseline behaviors of mumbling, but the loud groaning represented a significant change. The Nurse Practitioner told inspectors that "being able to hear the resident from down the hallway would be outside their normal and would identify this as a non-verbal indication of pain."
Meanwhile, the Director of Nursing had been discussing comfort care measures but made no changes to help the resident actually receive medications. The DON told inspectors they were "unaware if the resident not swallowing their medications had been reported to the Nurse Practitioner" and stated that "comfort cares had been discussed, but no changes to the resident's regimen had been made due to an issue with the Power of Attorney."
On November 11 at 1:45 AM, a writer had asked the Director of Nursing "if it would be possible to obtain comfort medication for day as the resident is not taking any medication, so the resident could remain comfortable." But the facility failed to act on this request for days.
The DON finally documented speaking to the Power of Attorney about medication changes on November 12 at 11:34 AM, noting they had "followed up with the NP about comfort care medication being approved by the family." This was more than 24 hours after the resident had been observed in obvious distress.
When inspectors observed the resident on November 12 at 9:45 AM, they found Resident 6 "laying in bed" and "displaying non-verbal indications of pain, including facial grimacing and groaning." The resident's "posturing appeared to be rigid."
An hour and a half later, the situation had worsened. At 11:10 AM, inspectors noted that "Resident 6 could be heard groaning from down the hallway." The patient "continued to be displaying non-verbal indication of pain including facial grimacing, furrowed brows, tense/rigid body posturing, restless legs, and loud/constant groaning."
The facility's medication administration records painted a picture of systematic failure. Rather than addressing the underlying problem that the resident could not effectively swallow crushed medications, staff simply documented refusals and left the patient to suffer.
Federal inspectors determined the facility had caused actual harm to the resident by failing to ensure proper pain management and medication administration. The inspection was conducted in response to a complaint on November 17, 2025.
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.
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