Sharmar Village: Call Light System Failures - CO
Federal inspectors found that when residents formally complained about call light delays in July, administrators acknowledged the problem but provided incomplete solutions that left key questions unanswered.
Resident #9 filed a grievance on July 10 expressing concern that call light response times were too long. The facility's resolution documentation showed staff spoke with the resident and attempted to show them a call light log with an average response time of seven minutes.
The resident refused to discuss the matter further or sign the grievance form.
The same day, Resident #12 filed an identical complaint about lengthy call light waits. For both residents, the facility's documented resolution promised a new pager system would be implemented by August 1.
But the grievance forms failed to explain how the facility planned to address the long response times until the new system was in place. The documents also didn't indicate whether either resident was satisfied with the proposed solution.
The nursing home administrator defended the facility's response during an August 11 interview with inspectors. She said the grievance forms demonstrated that staff were paying attention to call light issues and that the interdisciplinary team discussed call lights daily.
"She said she wanted to make sure call lights were within reach," inspectors noted. The administrator explained that the facility had implemented both walkie talkies and the pager system in August to address the problems, and assigned each resident to a staff member for weekly rounds.
Despite these changes, residents continued voicing concerns about long wait times during the inspection.
The director of nursing told inspectors on August 6 that the call light system connected to a computer and rang to pagers carried by certified nursing assistants. She said the new system had been operational for several weeks.
But when the administrator was pressed about monitoring, she admitted she had not performed audits to actually watch whether call lights were answered and turned off without staff completing the requested tasks. She said call light audits showed timely responses, but the methodology appeared limited to reviewing computer logs rather than direct observation.
The director of nursing revealed during a second interview that staff had been instructed not to turn off call lights until tasks were completed, but this direction came only during the survey period.
The social services director explained that resident council meetings occurred monthly, and grievance forms were filled out as concerns arose and forwarded to the appropriate department. The administrator emphasized that grievances required resolution within 72 hours and said she wanted responses to be as timely as possible.
The activities director confirmed the monthly resident council schedule but provided no additional details about how call light concerns were typically handled through that forum.
Federal regulations require nursing homes to investigate and resolve resident grievances promptly, with documentation showing how concerns were addressed and whether residents were satisfied with the outcomes. The inspection found Sharmar Village's grievance process fell short of these standards.
The facility's approach of promising future technological solutions without interim measures left residents waiting weeks for relief from the acknowledged problem. The incomplete grievance documentation also made it impossible to determine whether the proposed resolutions actually addressed residents' concerns.
Call light response times directly affect resident safety and quality of life. Extended delays can leave residents unable to reach bathrooms, obtain pain medication, or summon help during medical emergencies.
The inspection occurred as a complaint investigation, suggesting external concerns about the facility's operations prompted the federal review. The deficiency was classified as causing minimal harm or potential for actual harm to some residents.
Sharmar Village's handling of the call light complaints revealed gaps between acknowledging problems and implementing comprehensive solutions that satisfy both regulatory requirements and resident needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sharmar Village Senior Care Community from 2025-08-11 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 20, 2026 · Our methodology
SHARMAR VILLAGE SENIOR CARE COMMUNITY in PUEBLO, CO was cited for violations during a health inspection on August 11, 2025.
Resident #9 filed a grievance on July 10 expressing concern that call light response times were too long.
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.