Sharmar Village Senior Care Community
SHARMAR VILLAGE SENIOR CARE COMMUNITY in PUEBLO, CO — inspection on August 11, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
resolution result documented by the facility revealed the facility spoke with the resident and attempted to show the resident the call light log to go over the durations of wait times with an average of seven minutes.
The form documented Resident #9 refused to talk or sign the grievance.
The 7/10/25 grievance form documented Resident #9 expressed concern that the call lights were too long.
The resolution result documented the facility reviewed the resident's call light times.
The form further documented that the facility reviewed that a pager system was being implemented no later 8/1/25.
The form documented the facility acknowledged there were some longer call light times.-However, the grievance form failed to indicate how the facility planned to address the long call lights until the new pager system was in place or if the resident was satisfied with the resolution.
The 7/10/25 grievance form documented Resident #12 expressed concern that the call light times were too long.
The resolution result documented the facility would have a new pager system implemented by 8/1/25.-However, the grievance form failed to indicate how the facility planned to address the long call lights until the new pager system was in place or if the resident was satisfied with the resolution.V.
Staff interviewsThe DON was interviewed on 8/6/25 at 1:00 p.m.
The DON said the call light system was hooked to a computer.
She said the call lights would ring to pagers which the CNAs carried.
She said the new system had been in place for a few weeks.
The SSD, the activities director (AD) and the NHA were interviewed together on 8/11/25 at approximately 4:00 p.m.
The AD said the resident council meeting was held once a month.
The SSD said as the residents had concerns, the grievance forms were filled out and provided to the department responsible for addressing the concern.
The NHA said the grievance forms needed to have a resolution within 72 hours.
She said she wanted them to be as timely as possible.
She said the grievance forms demonstrated that the facility was paying attention to the call lights.
She said the interdisciplinary team talked about call lights everyday.
She said she wanted to make sure call lights were within reach.
She said the facility implemented walkie talkies and the pager system in August 2025 to address call lights.
She said the facility additionally had each resident assigned to a staff member for weekly rounds.-However, residents continued to voice concerns regarding long call wait times (see interview above).
The NHA said that the call light audits had shown call lights had been answered timely.
She said she had not performed audits to watch call lights and to observe to see if the lights were answered and turned off without performing the task.
The DON was interviewed again on 8/11/25 at 5:38 p.m.
The DON said the staff had been instructed to not turn off the call lights until the task was completed (during the survey).
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Sharmar Village Senior Care Community
1209 W Abriendo Ave Pueblo, CO 81004
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #2’s July 2025 and August 2025 (8/1/25 to 8/7/25) activity participation logs revealed activities including card/board games, pet visits and outdoor activities were not offered to the resident. Resident #2’s July 2025 and August 2025 (8/1/25 to 8/7/25) activity participation log revealed daily participation in independent TV time.
D.
Staff interview The AD was interviewed on 8/11 at 6:00 p.m.
She said if a resident was non-interviewable, she would interview a family member to assess family structure, religion and preferred activities.
The AD said Resident #2 had a sensory mat that should have been utilized when the resident appeared restless.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Sharmar Village Senior Care Community
1209 W Abriendo Ave Pueblo, CO 81004
SUMMARY STATEMENT OF DEFICIENCIES
According to the August 2025 computerized physician orders (CPO), diagnoses included dementia, anxiety, subsequent encounter for fracture with routine healing, abnormalities of gait and mobility, generalized muscle weakness and a history of falls.The 8/6/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15.
She was dependent on staff for partial to moderate assistance for activities of daily living (ADL). B.
Record reviewReview of Resident #8's August 2025 CPO revealed the following physician's orders:Pain Scale 1-10 or [NAME] pain scale, 1-3 mild pain, 4-6 moderate, and 7-10 severe.
Tolerable pain level is 3 out of 10, ordered 10/1/24.Acetaminophen oral tablet, give 650 mg by mouth every eight hours as needed for mild and moderate pain, ordered 7/1/25;Tramadol HCI oral tablet 50 mg, give one tablet by mouth every eight hours as needed for severe pain, ordered 7/1/25.
Review of Resident #8's August 2025 medication administration records (MAR) revealed the resident received Tramadol PRN on the following dates:-On 8/1/25 for a pain level of 5;-On 8/2/25 for a pain level of 5;-On 8/3/25 for a pain level of 5;-On 8/8/25 for a pain level of 5;-On 8/9/25 for a pain level of 5; and,-On 8/10/25 for a pain level of 6.-However, per the physician's orders for pain medication parameters, Resident #8 should have been administered acetaminophen, not tramadol, for a pain level of 5 or 6. III.
Staff interviewsRegistered nurse (RN) #3 was interviewed on 8/11/25 at 10:45 a.m. RN #3 said Resident #8 had generalized pain from arthritis.
She said after a PRN pain medication was administered she would return in an hour to check on the effectiveness.
The director of nursing (DON) and the corporate nurse consultant were interviewed together on 8/11/25 at 2:40 p.m.
The DON said the facility used the [NAME] pain scale and the faces pain scale for nonverbal residents.
The DON reviewed Resident #8's electronic medical record (EMR) and confirmed the tramadol was not administered according to the physician's orders and parameters.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Sharmar Village Senior Care Community
1209 W Abriendo Ave Pueblo, CO 81004
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #11’s care plan, initiated 8/4/25, identified Resident #11 was a fall risk.
Interventions included utilizing a fall mat while the resident was in bed, keeping the bed in the low position and keeping the call light and frequently used items in reach. -However, the fall care plan failed to include an intervention to ensure Resident #11’s foot pedals were in place when she was being transported in her wheelchair in order to prevent potential falls.
D.
Staff interviews The director of rehabilitation (DOR) was interviewed on 8/11/25 at 1:05 p.m.
The DOR said that not every resident utilized wheelchair foot pedals due to the facility’s goal to increase mobility. He said the residents’ feet should not dangle from the wheelchair or drag across the floor when staff were transporting the resident in order to prevent the wheelchair from tipping over.
The DOR said each resident was fit to a wheelchair for proper fit and should have foot pedals in their room.
The DON and the nurse consultant were interviewed on 8/11/25 at 2:40 p.m.
The DON said a majority of the residents without wheelchair foot pedals had the ability to self-propel in their wheelchairs.
She said there were foot pedals available for each wheelchair.
The DON and the nurse consultant were unclear as to what was best practice for utilizing foot pedals during transport.
The nurse consultant said the residents might fall trying to get out of their wheelchairs if foot pedals were attached to their wheelchairs.
E.
Facility follow-up On 8/12/25 at 4:52 p.m. (after the survey exit) the NHA provided an update regarding Resident #11’s care plan that documented the resident self-propelled safely without pedals and using them could hinder her mobility. -However, the care plan continued to fail to include an intervention for staff to ensure Resident #11’s foot pedals were in place when she was being transported by staff.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Sharmar Village Senior Care Community
1209 W Abriendo Ave Pueblo, CO 81004
SUMMARY STATEMENT OF DEFICIENCIES
new portable oxygen tank if the old one was faulty.
The DON said when the portable oxygen tanks were filled, the staff were to wear the appropriate PPE, which included an apron, gloves and a face shield.
IV.
Facility follow-up The DON provided a notebook on 8/7/25 at approximately 11:00 a.m. with an audit log.
The log included all residents who had oxygen orders.
The log indicated the facility began oxygen audits to ensure oxygen tanks were checked at the start of the shift and every two hours.
The audit log indicated if the oxygen tanks were less than a quarter full, the oxygen tank would be filled immediately.
The new process indicated if the oxygen tanks were found empty, the charge nurse should be notified.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Sharmar Village Senior Care Community
1209 W Abriendo Ave Pueblo, CO 81004
SUMMARY STATEMENT OF DEFICIENCIES
Based on observations, record review and interviews, the facility failed to ensure menus met the resident's nutritional needs.Specifically, the facility failed to ensure residents were provided adequate food to ensure they were not hungry after meals and in between meals.
Findings include:I.
Facility policy and procedure The Menu Planning and Requirements policy, dated 2020, was provided by the nursing home administrator (NHA) on 8/11/25 at 12:33 p.m. It revealed in pertinent part, Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served, (based on age, gender, physical activity, and state health), in accordance with the Dietary Reference Intakes/Recommended Dietary Allowances as issued by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, unless otherwise contraindicated by medical conditions and needs.
Menus are planned in advanced and are varied for the same day of consecutive weeks.
Cycle menus are to be planned for a minimum of one week or based upon specific state regulations.II.
Resident group interviewA group interview was conducted on 8/7/25 at 2:00 p.m. with five residents (#18, #19, #20, #21 and #22) who were identified by the facility and assessment as interviewable.
The residents said the following: -The meals did not always fill them up; and, -They were hungry when the meals were over, because they did not receive enough food at their meals. -Resident #19 said she was unable to eat any of the snacks which were provided because she did not have teeth. III.
Menu extensionsThe menu extensions for the week of 8/6/25 to 8/13/25 were provided by the NHA on 8/7/25 at 1:40 p.m The extensions revealed the following:The 8/6/25 menu extensions revealed the following menu items and portion sizes for dinner:-One breast, lemon herb chicken;-One cup garden salad;-Fresh baked roll; and,-Peanut butter cookie.-The menu extensions did not indicate the size of the chicken breast to be served.
The menu caloric needs for 8/6/25 revealed the menu provided 1537 calories for the day.The 8/7/25 menu extensions revealed the following menu items and portion sizes for dinner: showed the following:-Chicken strawberry salad; -A bread stick; and, -A slice of pie slice.-The menu extensions did not indicate how much chicken strawberry salad or pie to serve to each resident. IV.
ObservationsOn 8/6/25 at 5:15 p.m. the evening tray line was observed.
The residents were served a chicken breast which was approximately three ounces, a biscuit, eight ounce (oz) garden salad and a peanut butter cookie. -The menu extensions indicated the residents were to receive a dinner roll and not a biscuit (see extensions above).On 8/7/25 at 5:15 p.m., the evening meal was observed.
The residents were served three oz of chicken strips, iceberg garden mix salad served with tongs, a two oz scoop of strawberries, a breadstick and a slice of pie which was approximately one inch thick.V.
Staff interviewsThe registered dietitian (RD) was interviewed on 8/6/25 at 5:30 p.m.
The RD said the facility had menu extensions which were to be followed.
The RD said she has changed the menu and extensions when residents did not like an entree.
She said she reviewed the menus to ensure they met the needs of the residents.
She said that she kept their daily calorie intake for the meals between 1700 and 1800 with room for snacks. -However, the extensions revealed the total calories provided on 8/6/25 was 1537 calories, which was below what the RD recommended for daily caloric intake (see menu extensions above).
She said if a resident was losing weight then the protein pudding was utilized and also the resident was assessed for health shakes.
The RD said that snacks were always available if residents were hungry.
She said there were rice crispies, cheese crackers and various other snack items.The cook was interviewed on 8/7/25 at 5:15 p.m.
The cook said he was not aware how the pie was cut and into how many portions.
The cook agreed the pieces were small.
Facility ID: