The breakdown in care at Sheriden Woods Health Care Center began around 4:15 PM on January 16, when nursing supervisor RN #1 asked charge nurse LPN #2 to give Tylenol to a resident complaining of pain with movement to the left leg and knee. The supervisor had examined the resident but observed no redness or swelling.
LPN #2 administered the Tylenol and checked on the resident again after 5:00 PM. The medication appeared effective and the resident was comfortable.
But when LPN #2 returned around 10:40 PM, she lifted the resident's left leg and the resident "yelled out in pain." The left knee was now swollen. LPN #2 immediately notified the nursing supervisor, who called the provider.
LPN #2 later acknowledged to inspectors she should have administered Tylenol again when she discovered the pain at 10:40 PM. She didn't.
The night shift charge nurse, LPN #3, received reports from both LPN #2 and the nursing supervisor that the resident had been in pain at the end of the evening shift. Throughout the night, LPN #3 observed the resident appeared uncomfortable but made a critical assumption.
"She assumed LPN #2 had administered it since Resident #1 had just been assessed at the end of the 3-11PM shift," inspectors wrote. LPN #3 never checked the medication administration record to verify when Tylenol was last given.
Around 5:00 AM, nurse aides reported they were going to provide care. Only then did LPN #3 administer Tylenol at 5:12 AM "in preparation for care." She stayed to assist during the care, noting the resident "appeared to be very uncomfortable with movement."
After 6:00 AM, the resident still appeared restless and uncomfortable. LPN #3 notified the nursing supervisor but made another assumption — that the supervisor would notify the provider about both the unrelieved pain and x-ray results.
Advanced Practice Registered Nurse #1 told inspectors that if acetaminophen wasn't effective after the 5:12 AM dose, "this should have been reported to the provider so additional pain relief could have been ordered."
The facility's Director of Nursing agreed multiple failures occurred. LPN #2 should have administered Tylenol when she observed the resident in pain around 10:40 PM. The provider should have been notified about unrelieved pain after the 5:12 AM dose "so that an alternative pain medication could have been ordered and Resident #1 kept comfortable, especially with the transport to the hospital."
The facility's own pain management policy required acute pain to be assessed every 30 to 60 minutes after onset and reassessed until relief is obtained. Staff were directed to review medication records to determine how often residents request and receive pain medication, and to what extent administered medications provide relief.
When pain hasn't been adequately controlled, the policy states, the multidisciplinary team including the physician "shall reconsider approaches and make adjustments as indicated."
Most critically, staff were required to report "significant changes in the level of the resident's pain and prolonged, unrelieved pain despite care plan interventions" to the physician or practitioner.
None of this happened.
Instead, a resident endured hours of unrelieved pain while staff made assumptions about medication timing, failed to check basic records, and didn't communicate effectively with providers who could have prescribed stronger pain relief.
The resident ultimately required transport to the hospital with a swollen, painful knee — a journey that could have been made more comfortable with proper pain management protocols the facility already had in place.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sheriden Woods Health Care Center Inc from 2026-01-30 including all violations, facility responses, and corrective action plans.