Sharmar Village: Fall Safety Plan Failures - CO
Federal inspectors found the facility's fall prevention plan for Resident #11 included keeping a fall mat by her bed and maintaining the bed in a low position. The plan also required keeping her call light and frequently used items within reach.
But the care plan failed to address a basic safety measure: ensuring foot pedals were in place when staff wheeled the resident around the facility.
The omission became more troubling when inspectors interviewed facility staff on August 11. Nobody seemed to know the rules.
The director of rehabilitation told inspectors that not every resident used wheelchair foot pedals because the facility wanted to "increase mobility." He acknowledged that residents' feet shouldn't dangle from wheelchairs or drag on the floor during transport, which could cause the wheelchair to tip over. Each resident was supposed to be fitted to a wheelchair for proper use, he said, and should have foot pedals available in their room.
Two hours later, the director of nursing and a nurse consultant offered different explanations. The director of nursing said most residents without foot pedals could propel their own wheelchairs. She confirmed foot pedals were available for each wheelchair but admitted uncertainty about best practices for using them during transport.
The nurse consultant suggested foot pedals might actually create safety problems, saying residents could fall trying to get out of their wheelchairs if the pedals were attached.
The contradictory explanations revealed confusion about basic wheelchair safety at the facility. While staff debated whether foot pedals helped or hindered residents, Resident #11 continued to be transported without clear safety protocols.
The day after inspectors completed their survey, the nursing home administrator tried to address the deficiency. At 4:52 p.m. on August 12, she provided an updated care plan stating that Resident #11 could self-propel safely without pedals and that using them might hinder her mobility.
The update still missed the point. Federal inspectors hadn't questioned whether Resident #11 needed foot pedals when moving herself around the facility. The violation concerned what happened when staff transported her.
The revised care plan continued to omit any intervention requiring staff to ensure foot pedals were in place during transport.
The failure highlighted a broader safety gap at Sharmar Village. Staff members responsible for preventing falls couldn't agree on fundamental wheelchair safety measures. The director of rehabilitation worried about wheelchairs tipping over when residents' feet dragged on the floor. The nurse consultant worried about residents falling when getting out of wheelchairs with foot pedals.
Both concerns were valid. Neither addressed the specific safety need identified by inspectors.
Resident #11's case illustrated how facilities can create detailed care plans while missing essential safety elements. Her fall prevention plan covered multiple interventions for bedroom safety but overlooked transportation risks that occurred every time staff moved her between rooms.
The August 11 inspection revealed actual harm to a few residents from the facility's inadequate fall prevention measures. Federal regulations require nursing homes to assess each resident's fall risk and implement appropriate interventions to prevent injuries.
For wheelchair-bound residents like Resident #11, proper foot positioning during transport represents a basic safety requirement. When feet dangle or drag during wheelchair transport, the risk of tipping increases significantly. When staff transport residents without ensuring proper foot support, they create unnecessary fall hazards.
The facility's response after the inspection suggested administrators still didn't understand the core violation. Rather than developing clear protocols for staff transport of wheelchair-bound residents, they focused on Resident #11's ability to move independently.
The distinction mattered. Self-propelling residents control their own foot positioning and movement speed. When staff transport residents, they assume responsibility for ensuring proper safety measures, including foot pedal placement.
Sharmar Village's confusion about wheelchair foot pedals reflected deeper problems with fall prevention training and protocols. Three different staff members offered three different explanations for the same safety equipment, none of which addressed the specific transportation risks identified by federal inspectors.
Resident #11's care plan remained incomplete more than 24 hours after inspectors identified the deficiency. Each time staff transported her without proper foot support, they potentially exposed her to the same fall risks the care plan was designed to prevent.
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.
Federal inspectors found the facility's fall prevention plan for Resident #11 included keeping a fall mat by her bed and maintaining the bed in a low position.
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.