ALBUQUERQUE, NM - Federal inspectors documented multiple serious violations at Uptown Rehabilitation Center following a February complaint investigation that revealed staff verbally confronted a quadriplegic resident who was calling for pain medication while visitors witnessed the incident.
Staff Confrontation Witnessed by Visitors
On January 8, 2025, a visitor at the facility reported witnessing disturbing treatment of a resident who was experiencing severe pain. The visitor, who was visiting her grandmother, heard a quadriplegic resident with traumatic brain injury call out for help for approximately 30 minutes around mid-morning.
According to the visitor's account, a staff member responded by yelling at the resident: "We hear you. Management is busy. The physician is aware you want to see him." The staff member continued speaking for 30 seconds to a minute while the resident continued calling for pain medications.
The resident, identified in records as having quadriplegia, traumatic brain injury, neurogenic bladder, and multiple spinal conditions including fusion surgery complications, was cognitively intact with a Brief Interview of Mental Status score of 15.
"She stated staff would not help her, and she was in pain," the resident told investigators during interviews. "She stated she yelled at the staff, because she was angry and hurting."
The incident escalated when the visitor confronted the staff member about the treatment, asking for her name after witnessing what appeared to be inappropriate responses to the resident's pain-related requests.
Medication Management Failures
Inspection records revealed systematic problems with pain medication administration for the same resident. The facility failed to provide prescribed oxycodone doses on multiple occasions between January 6-9, 2025, despite documented pain scores reaching 7-9 out of 10.
Pain assessments showed concerning patterns: - January 7: Pain levels fluctuated from 0 to 7 throughout the day - January 8: Pain scores reached 7 at 11:38 AM and 8:28 PM, with a score of 6 at 11:31 PM - January 9: Pain escalated to 9 out of 10 at 3:34 PM
The resident's care plan specifically included interventions to "request pain medication before the pain became severe" and "medicate as ordered by the physician for pain." However, medication administration records showed multiple missed doses of prescribed oxycodone.
Nursing notes revealed the facility experienced medication supply issues, with documentation stating oxycodone "was not available in the narcotic box" and required "a new script sent to the pharmacy." On January 8, staff noted they were "awaiting an order" for the medication.
Hypoglycemia Protocol Violations
The facility also failed to follow physician orders for diabetic emergency treatment. A resident with Type II diabetes, diabetic neuropathy, and blindness in one eye had specific orders for Insta-Glucose gel administration when blood glucose levels dropped below 70 mg/dL.
Blood glucose monitoring revealed three instances where levels fell below the 70 mg/dL threshold: - February 11: 66.0 mg/dL at 5:02 PM - February 4: 66.0 mg/dL at 10:22 PM - February 1: 68.0 mg/dL at 10:50 PM
Medication administration records showed staff failed to administer the prescribed Insta-Glucose gel during any of these episodes, despite clear physician orders requiring immediate treatment when glucose levels fell below 70 mg/dL.
Hypoglycemia occurs when blood glucose levels drop too low, potentially causing symptoms ranging from shakiness and confusion to seizures or loss of consciousness if untreated. The normal blood glucose range is 70-99 mg/dL, making readings in the 60s concerning and requiring immediate intervention.
Failure to Report Abuse Allegations
Perhaps most concerning was the facility's failure to report the January 8 incident to state survey authorities as required by federal regulations. The Social Services Director confirmed she conducted an investigation the same day family members reported the staff member's behavior, resulting in the suspension of the certified nursing assistant involved.
However, both the Social Services Director and the Administrator, who also serves as the Abuse Coordinator, acknowledged they did not report the incident to the State Survey Agency. The Administrator stated she was unaware of the incident because she was out of the facility when it occurred, but confirmed that "staff did not report it to the SSA."
Federal regulations require nursing homes to immediately report suspected abuse, neglect, or mistreatment to the administrator and to state authorities within 24 hours. This reporting requirement ensures proper oversight and corrective measures can be implemented to protect residents.
Medical Standards and Expectations
Pain management in nursing homes requires careful attention to individual needs and physician orders. Residents with complex medical conditions including spinal injuries, traumatic brain injuries, and surgical complications often require consistent pain control to maintain quality of life and prevent complications.
The failure to maintain adequate medication supplies and follow established protocols can result in unnecessary pain and emotional distress. Facilities are expected to have backup systems, including emergency medication supplies through automated dispensing systems, to ensure continuous care.
Similarly, diabetic emergency protocols exist because hypoglycemia can rapidly become life-threatening. Blood glucose levels below 70 mg/dL require immediate treatment with fast-acting glucose products like Insta-Glucose gel, which can raise blood sugar within 15 minutes when administered properly.
Staff Training and Communication Issues
The incident highlighted communication problems between staff and residents experiencing pain. The certified nursing assistant involved acknowledged she "had to raise her voice a little" when speaking with the resident, explaining that the resident "yelled constantly" during interactions.
However, facility policies should emphasize therapeutic communication techniques, particularly when working with residents experiencing chronic pain, cognitive communication deficits, or emotional distress. Staff training should address appropriate responses to residents' expressions of pain and frustration.
The inspection found that nursing staff were inconsistent in their understanding of emergency medication protocols. While some nurses correctly identified the need to follow physician orders for hypoglycemia treatment, others indicated they would provide juice or snacks instead of the prescribed Insta-Glucose gel.
Regulatory Response and Oversight
The Centers for Medicare & Medicaid Services inspection identified violations under multiple federal regulations governing nursing home care. The facility received citations for failing to treat residents with dignity, provide appropriate treatment according to physician orders, ensure proper pain management, and report suspected abuse.
These violations carry the classification of "minimal harm or potential for actual harm," indicating that while immediate serious injury did not occur, the practices created risk for resident safety and well-being.
The inspection demonstrates the importance of family involvement and visitor observations in maintaining care quality. The visitor's willingness to report concerns directly led to the investigation that uncovered multiple systemic issues requiring corrective action.
Uptown Rehabilitation Center must now develop and implement corrective measures addressing staff training, medication management protocols, emergency response procedures, and mandatory reporting requirements to ensure compliance with federal nursing home regulations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Uptown Rehabilitation Center from 2025-02-27 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.