Inspection Reports for
Sharmar Village Senior Care Community
1209 W ABRIENDO AVE, PUEBLO, CO, 81004-1003
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 6
Date: Aug 11, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, activities, medication administration, accident prevention, respiratory care, and nutritional services at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to promptly address resident grievances about call light response times, inadequate provision of personalized activities for residents, improper administration of pain medication, insufficient supervision to prevent resident falls, failure to ensure portable oxygen tanks were filled and proper PPE used, and failure to provide adequate food portions meeting residents' nutritional needs.
Deficiencies (6)
F 0565: The facility failed to promptly address resident council grievances related to call light response times, resulting in continued resident concerns about long wait times.
F 0679: The facility failed to provide personalized activity programs meeting the needs and interests of four residents, resulting in lack of meaningful engagement and activities.
F 0684: The facility failed to ensure nursing staff administered PRN pain medication according to physician-ordered pain parameters for one resident.
F 0689: The facility failed to provide adequate supervision to prevent falls for three residents, resulting in a fall with major injury and unsafe wheelchair transport practices.
F 0695: The facility failed to ensure two residents' portable oxygen tanks were not empty and staff used appropriate PPE when filling tanks.
F 0803: The facility failed to ensure menus met residents' nutritional needs, providing inadequate food portions and calories below recommended levels.
Report Facts
Call light wait time: 25
Calories provided: 1537
Pain medication administration: 6
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in medication error finding for Resident #8 |
| CNA #1 | Certified Nurse Aide | Checked Resident #9's empty oxygen tank |
| CNA #3 | Certified Nurse Aide | Checked Resident #16's empty oxygen tank |
| Director of Nursing | Director of Nursing | Interviewed regarding call light response, medication administration, oxygen tank protocols, and fall prevention |
| Registered Dietitian | Registered Dietitian | Interviewed regarding menu planning and nutritional adequacy |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding wheelchair foot pedal use and fall prevention |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Feb 27, 2025
Visit Reason
The inspection was conducted due to complaints and incidents involving resident accidents, falls, fractures, and skin tears at the nursing home.
Complaint Details
The investigation was complaint-driven, focusing on multiple resident falls, fractures, and a skin tear incident. The physical abuse investigations for fractures were unsubstantiated, but the facility failed to conduct root cause analyses or implement adequate interventions to prevent recurrence.
Findings
The facility failed to prevent multiple resident accidents and falls, did not perform timely root cause analyses, and delayed osteoporosis screening and treatment. The facility also failed to implement consistent fall prevention interventions and did not adequately document or investigate a resident's skin tear incident.
Deficiencies (7)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in multiple fractures and falls among residents.
The facility failed to complete timely root cause analyses and implement person-centered interventions after Resident #13 sustained fractures on 6/22/24 and 1/12/25.
The facility failed to schedule osteoporosis screening and treatment for Resident #13 until nine months after it was recommended.
The facility failed to consistently implement fall prevention interventions for Resident #17, including use of a fall mat and updating the care plan after multiple falls.
The facility failed to complete a thorough root cause analysis and implement interventions to prevent further falls and injuries for Resident #17.
The facility failed to complete a thorough root cause analysis to determine how Resident #5 obtained a skin tear and did not implement timely interventions to prevent recurrence.
The facility did not document that the interdisciplinary team reviewed the skin tear incident for Resident #5 or identified root causes and interventions.
Report Facts
Sample residents reviewed for accidents: 24
Residents affected: 3
Skin tear size: 3
Skin tear size: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #13's care and skin injury procedures |
| CNA #2 | Certified Nurse Aide | Interviewed about Resident #13's weight-bearing status and transfer assistance |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about Resident #13's transfer status and therapy |
| Director of Nursing | Director of Nursing | Interviewed about Resident #13's fracture investigations and facility procedures |
| NHA | Nursing Home Administrator | Interviewed about facility investigations, root cause analyses, and documentation |
| CNA #4 | Certified Nurse Aide | Interviewed about Resident #13's fracture and care |
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Interviewed about skin injury reporting and interventions |
| DON | Director of Nursing | Interviewed about skin injury incident reporting and IDT review process |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, medication management, and antibiotic stewardship at Sharmar Village Senior Care Community.
Findings
The facility was found deficient in multiple areas including failure to prevent resident accidents and falls, inadequate catheter care and documentation, failure to monitor and justify psychotropic medication use, improper infection control practices related to enhanced barrier precautions, and insufficient antibiotic stewardship including lack of monitoring and documentation for long-term antibiotic use.
Deficiencies (5)
F 0689: The facility failed to prevent accidents for residents #13, #17, and #5, including inadequate fall interventions and lack of root cause analysis after fractures and skin tears.
F 0690: The facility failed to obtain physician's orders for Resident #30's urinary catheter and maintain documentation of catheter care and output.
F 0758: The facility failed to monitor and document behaviors for Resident #22 to justify psychotropic medication use and did not conduct required interdisciplinary team reviews.
F 0880: The facility failed to ensure staff followed enhanced barrier precautions for Resident #30 with an indwelling catheter, including failure to wear gowns during care.
F 0881: The facility failed to implement an effective antibiotic stewardship program, including failure to monitor and document long-term antibiotic use for Residents #22 and #37.
Report Facts
Sample residents reviewed: 24
Residents affected: 3
BIMS score: 2
BIMS score: 4
BIMS score: 3
BIMS score: 7
BIMS score: 11
Antibiotic dosage: 500
Antibiotic dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #13's care and fracture incidents |
| CNA #4 | Certified Nurse Aide | Interviewed regarding Resident #13's fracture and care |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding Resident #13's mobility and transfers |
| DON | Director of Nursing | Interviewed regarding Resident #13's fractures and medication management |
| NHA | Nursing Home Administrator | Provided facility follow-up documentation and interviews |
| IP | Infection Preventionist | Interviewed regarding infection control and antibiotic stewardship |
| CNA #1 | Certified Nurse Aide | Interviewed regarding catheter care for Resident #30 |
| CNA #3 | Certified Nurse Aide | Interviewed regarding catheter care for Resident #30 |
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Interviewed regarding catheter care and enhanced barrier precautions |
| RN #2 | Registered Nurse | Interviewed regarding catheter care and enhanced barrier precautions |
| SSD | Social Services Director | Interviewed regarding psychotropic medication monitoring and behavior management |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 1, 2024
Visit Reason
The investigation was conducted due to a fall incident involving Resident #1, a resident with advanced Huntington's disease and identified fall risk, who fell out of bed when left unattended by staff during a transfer.
Complaint Details
The complaint investigation substantiated that the resident fell due to staff leaving the resident unattended during transfer assistance. The resident sustained a head laceration requiring sutures and a sacral fracture, and passed away eight days later. Staff failed to follow facility protocol for fall precautions.
Findings
The facility failed to ensure the resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents. Resident #1 fell from a bed that was not in the low position and without a fall mat in place, resulting in injury and subsequent death eight days later.
Deficiencies (1)
F 0689: The facility failed to ensure the nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in a resident fall with injury and death.
Report Facts
Sutures required: 6
Days until resident death: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in fall incident for leaving resident unattended during transfer |
| RN #1 | Registered Nurse | Conducted initial assessment after resident fall |
| DON | Director of Nursing | Interviewed regarding fall incident and staff protocol failure |
| NHA | Nursing Home Administrator | Interviewed and confirmed termination of CNA #1 after incident |
Inspection Report
Deficiencies: 13
Date: Aug 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, environment safety, and quality assurance.
Findings
The facility had multiple deficiencies including failure to provide timely meal services, failure to knock before entering resident rooms, inadequate medication administration leading to immediate jeopardy, unsanitary food handling practices, environmental maintenance issues, lack of comprehensive care plans, insufficient activity programming, unsafe water temperatures, pest control issues, and failure to maintain residents' range of motion.
Deficiencies (13)
F0550: The facility failed to ensure timely meal service in the assisted dining room and staff failed to knock before entering resident rooms.
F0554: The facility failed to ensure Resident #13 had a physician order and interdisciplinary team documentation for self-administration of medication.
F0584: The facility failed to maintain a sanitary, orderly, and comfortable environment, including damaged walls, ceilings, doors, and missing baseboards in multiple resident rooms.
F0656: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #14, missing care plans for oxygen use, visual impairment, hospice, and activity services.
F0679: The facility failed to provide an ongoing program to support residents' choice of activities, failing to encourage Residents #23 and #38 to attend preferred activities.
F0688: The facility failed to ensure Residents #1 and #7 received services and assistance to prevent reduction in range of motion, including failure to provide occupational therapy and hand splinting as ordered.
F0689: The facility failed to ensure safe water temperatures, with multiple resident room and shower water temperatures measured between 128 and 139.9 degrees Fahrenheit.
F0695: The facility failed to ensure Resident #13 received oxygen therapy as ordered, with oxygen cannula found unused and wrapped in a ball on two observation days.
F0760: The facility failed to ensure Residents #7 and #25 were free from significant medication errors, with multiple missed doses due to medication unavailability and resident sleeping, contributing to distress and behavioral symptoms.
F0812: The facility failed to ensure appropriate hand hygiene by food service staff during food preparation and serving, increasing risk of contamination.
F0867: The facility failed to have an effective QAPI program to identify and address medication administration deficiencies that caused immediate jeopardy to Residents #7 and #25.
F0921: The facility failed to ensure backflow prevention devices were installed on all hand held showers in four shower rooms, risking contamination of the water supply.
F0925: The facility failed to ensure the main kitchen was free from flies, with flies observed on food, utensils, and surfaces, and uncovered trash cans present.
Report Facts
Missed Latuda doses: 8
Missed Lovenox doses: 10
Missed Hydrocodone doses: 38
Missed Savella doses: 9
Missed Namenda doses: 11
Missed Zyprexa doses: 4
Missed Seroquel doses: 2
Missed Depakote doses: 13
Missed Ativan doses: 21
Water temperature: 139.9
Flies observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding oxygen administration for Resident #13. |
| CNA #9 | Certified Nursing Assistant | Interviewed regarding Resident #1's hand contracture and splint. |
| Certified Occupational Therapy Assistant #1 | COTA | Interviewed regarding occupational therapy for Residents #1 and #7. |
| Director of Nursing | DON | Interviewed regarding medication administration failures and care plans. |
| Nursing Home Administrator | NHA | Interviewed regarding facility deficiencies and immediate jeopardy. |
| Dietary Manager | DM | Interviewed regarding food service hand hygiene and pest control. |
| Maintenance Supervisor | MTCE | Interviewed regarding water temperature and pest control issues. |
| Pest Control Technician | PCT | Interviewed regarding flies in kitchen and trash can lids. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: May 10, 2022
Visit Reason
The inspection was conducted following a complaint investigation related to resident-to-resident abuse and other quality of care concerns.
Complaint Details
The investigation was initiated due to a complaint of resident-to-resident abuse and concerns about quality of care including medication administration, pressure ulcer prevention, restorative care, dementia care, medication storage, hydration, and hospice services. The abuse incident involving Residents #8 and #13 was substantiated.
Findings
The facility failed to prevent resident-to-resident abuse between two residents, failed to meet professional standards in medication administration, pressure ulcer care, restorative services, dementia care, medication labeling and storage, hydration, and hospice services. Multiple residents were affected by these deficiencies.
Deficiencies (8)
F 0600: The facility failed to protect residents from resident-to-resident abuse resulting in a skin tear for Resident #13 after an altercation with Resident #8 who had dementia and verbal aggression.
F 0658: The facility failed to ensure Resident #9 was assessed for self-administration of medications, failed to document medication administration accurately, and failed to follow accepted medication administration practices.
F 0686: The facility failed to provide timely repositioning and incontinence care to Residents #5 and #22 who were at risk for pressure ulcers, resulting in prolonged periods without care.
F 0688: The facility failed to provide appropriate range of motion and restorative services to Resident #32 with left upper extremity contracture and did not assist with splint use.
F 0744: The facility failed to provide person-centered dementia care to Resident #34, including individualized behavior interventions and adequate supervision during behavioral episodes.
F 0761: The facility failed to date opened insulin and tuberculin vials and failed to discard expired insulin, risking medication efficacy.
F 0807: The facility failed to ensure Residents #5 and #22 received adequate hydration consistent with their needs, failing to offer fluids or assistance to drink throughout the day.
F 0849: The facility failed to orient hospice aides to facility policies and procedures and failed to ensure hospice aide visit notes were consistently documented in Resident #16's chart.
Report Facts
Residents affected: 2
Medication cups observed: 15
Skin tear size: 0.5
BIMS scores: 10
BIMS scores: 3
BIMS scores: 0
BIMS scores: 12
BIMS scores: 3
Fluid intake: 780
Fluid intake: 1120
Fluid intake: 240
Fluid intake: 540
Fluid intake: 600
Fluid intake: 1000
Fluid intake: 1260
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding resident behaviors, medication administration, and hydration. |
| DON | Director of Nursing | Interviewed regarding investigations, policies, and staff training. |
| SS | Social Services | Interviewed regarding resident abuse investigation and dementia care. |
| CNA #3 | Certified Nurse Aide | Interviewed regarding resident care, behaviors, and medication administration. |
| DM | Dietary Manager | Interviewed regarding nutritional assessments and hydration. |
| RTN | Restorative Therapy Nurse | Interviewed regarding restorative care program and resident #32. |
| DOR | Director of Rehabilitation | Interviewed regarding occupational therapy and restorative care for resident #32. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding hospice care and documentation. |
| CNA #2 | Certified Nurse Aide | Interviewed regarding hospice care and documentation. |
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