Sharmar Village: Wrong Pain Medication Given - CO
The 65-year-old woman at Sharmar Village Senior Care Community received tramadol instead of acetaminophen every time she reported pain levels of 5 or 6 on a 10-point scale during the first ten days of August. Her physician's orders were explicit: acetaminophen for mild to moderate pain levels of 1 through 6, tramadol only for severe pain of 7 through 10.
Federal inspectors found the medication errors during an August 11 complaint investigation. The resident, identified only as Resident #8, was severely cognitively impaired with a mental status score of just 4 out of 15. She required partial to moderate assistance with daily activities and had diagnoses including dementia, anxiety, muscle weakness and a history of falls.
Her doctor had established clear pain management parameters in October 2024. The orders specified her tolerable pain level was 3 out of 10. For pain levels 1 through 3, she needed no medication. For levels 4 through 6, she should receive 650 mg of acetaminophen every eight hours as needed. Only for severe pain levels of 7 through 10 should staff administer 50 mg tramadol tablets.
The medication administration records showed a pattern of ignoring these guidelines. On August 1, staff gave her tramadol for a pain level of 5. They repeated this on August 2, August 3, August 8, August 9, and August 10. The highest pain level recorded was 6 on the final day, still within the moderate range that called for acetaminophen.
Registered Nurse #3 told inspectors during an interview that the resident had generalized arthritis pain. The nurse said she would return an hour after giving pain medication to check its effectiveness, but made no mention of following the physician's specific medication parameters.
When confronted with the medication records, the director of nursing confirmed the errors. During a joint interview with a corporate nurse consultant on August 11, the director of nursing reviewed the resident's electronic medical record and acknowledged that tramadol was not administered according to the physician's orders.
The facility's own pain management policy, dated 2025, emphasized the importance of following physician orders. The policy stated that the facility would "develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission." It required collaboration between the interdisciplinary team, attending physician, and resident or representative to establish "pertinent, realistic and measurable goals for treatment."
Tramadol is a synthetic opioid pain medication that affects the central nervous system and carries risks of dependence, drowsiness, and dangerous interactions with other medications. Acetaminophen is a non-opioid pain reliever with fewer side effects and no addiction potential. For elderly patients with dementia, the distinction becomes particularly important as opioids can increase confusion and fall risk.
The facility used both a numbered pain scale and a faces pain scale for nonverbal residents to assess pain levels. Despite having these assessment tools and clear physician guidelines, nursing staff consistently chose the stronger medication when the weaker one was prescribed.
The inspection found that few residents were affected by medication administration problems, suggesting this was an isolated case rather than a systemic issue. However, the repeated nature of the errors over ten consecutive days raised questions about staff training and oversight of pain management protocols.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The facility failed to ensure residents received treatment and care according to professional standards and their comprehensive care plans, specifically regarding following physician-ordered pain medication parameters.
The case illustrates broader challenges in nursing home pain management, particularly for residents with cognitive impairment who may struggle to communicate their needs effectively. When staff ignore physician guidelines designed to provide appropriate pain relief while minimizing medication risks, vulnerable residents face unnecessary exposure to stronger drugs they don't need.
For this resident with severe dementia, the medication errors meant receiving an opioid six times when her doctor had determined acetaminophen would adequately address her moderate pain levels.
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.
Her physician's orders were explicit: acetaminophen for mild to moderate pain levels of 1 through 6, tramadol only for severe pain of 7 through 10.
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.