Sheriden Woods: Care Plan Development Failures - CT
The resident, identified in inspection records only as Resident #1, was assessed for pain and given Tylenol just before 4:15 PM on January 16. The nurse who gave it, LPN #1, checked back around 5:00 PM and found the resident comfortable. The Tylenol had worked.
What followed over the next thirteen hours was a cascade of assumptions that left the resident without adequate pain relief through the night, into the early morning hours, and ultimately onto a transport to the hospital.
Around 10:40 PM, a second nurse, LPN #2, lifted the resident's left leg during a check. The resident yelled out in pain. The knee was visibly swollen. LPN #2 notified the nursing supervisor, who called the provider. But LPN #2 did not give Tylenol at that moment. She later told inspectors she should have.
The 11PM-to-7AM charge nurse, LPN #3, was told by both LPN #2 and the overnight nursing supervisor, RN #2, that the resident had been in pain at the end of the prior shift. She checked on the resident throughout the night and found the resident appeared uncomfortable. She did not give Tylenol until 5:12 AM, nearly seven hours after LPN #2 had found the swollen knee.
Her reason: she assumed LPN #2 had already given it, since the resident had just been assessed at the end of the 3-to-11 shift. LPN #3 told inspectors she never checked the medication administration record to see when Tylenol had last been given. She said she finally administered it at 5:12 AM because nursing aides told her they were about to do morning care, and she wanted the resident to have something on board first.
The Tylenol at 5:12 AM did not fully work. LPN #3 checked again after 6:00 AM and found the resident still restless and uncomfortable. She notified RN #2. Then she assumed RN #2 would call the provider about the unrelieved pain. RN #2's actions after that notification are not described in the inspection record.
Nobody called the provider to report that the pain had not been controlled after the 5:12 AM dose.
The facility's own advanced practice registered nurse told inspectors on January 30 that if the acetaminophen was not effective after the 5:12 AM administration, the provider should have been contacted so a different medication could have been ordered. The Director of Nursing was more direct. She said LPN #2 should have given Tylenol when she found the resident in pain at 10:40 PM, and that the provider should have been notified after the morning dose failed so an alternative could be ordered, particularly given that the resident was about to be transported to a hospital.
The facility's own pain management policy, reviewed by inspectors, directed that acute pain be assessed every thirty to sixty minutes after onset and reassessed until relief is obtained. It required staff to check the medication administration record to understand how often a resident had received pain medication and how well it had worked. It required that prolonged, unrelieved pain be reported to the physician.
None of that happened in any consistent way across either shift.
The inspection was conducted January 30 as a complaint investigation. CMS rated the level of harm as minimal harm or potential for actual harm, with few residents affected. The x-ray results referenced by LPN #3, and what they showed about the swollen knee, are not detailed in the inspection narrative. What the record does show is a resident who cried out when a nurse moved their leg at 10:40 at night, and who was still restless and uncomfortable when the morning shift was already underway, heading toward a hospital transport, with no stronger medication ever ordered.
Three nurses. Two shifts. Each one waiting for someone else to act.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Civita Sheriden Woods from 2026-01-30 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: August 4, 2026 · Our methodology
CIVITA CARE SHERIDEN WOODS in BRISTOL, CT was cited for violations during a health inspection on January 30, 2026.
The resident, identified in inspection records only as Resident #1, was assessed for pain and given Tylenol just before 4:15 PM on January 16.
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.