The incident at Sheriden Woods Health Care Center began around 4:15 PM on January 16 when the nursing supervisor noticed Resident #1 had pain with movement in her left leg and knee. Though she saw no visible redness or swelling, RN #1 asked the charge nurse to give the resident Tylenol and check her vital signs.
Licensed Practical Nurse #2 administered the Tylenol and returned to check on the resident after 5:00 PM. The medication seemed to work initially — the resident appeared comfortable.
But the relief didn't last.
When LPN #2 checked on the resident again around 10:40 PM, she lifted the woman's left leg. The resident yelled out in pain. This time, the knee was visibly swollen. The nurse immediately called the nursing supervisor, who contacted the resident's doctor.
LPN #2 later admitted she should have given the resident another dose of Tylenol when she discovered the pain at 10:40 PM. She didn't.
The overnight nurse, LPN #3, took over at 11 PM knowing the resident had been in pain at the end of the previous shift. Throughout the night, she could see the resident appeared uncomfortable. Yet she waited until 5:12 AM to give Tylenol — more than six hours after the resident had been found crying out in pain.
LPN #3 explained her delay by saying she "assumed" the previous nurse had already given medication since the resident had just been assessed. She never checked the medication record to verify when Tylenol was last administered.
The 5:12 AM dose was given in preparation for morning care, with LPN #3 staying to help. The resident appeared very uncomfortable with any movement. Even after 6:00 AM, the resident remained restless and in obvious discomfort.
Only then did LPN #3 notify the nursing supervisor about the unrelieved pain.
The Advanced Practice Registered Nurse who reviewed the case was clear about what should have happened: if acetaminophen wasn't managing the resident's pain after the 5:12 AM dose, staff should have immediately reported this to the provider so additional pain relief could be ordered.
The facility's Director of Nursing agreed. She said LPN #2 should have administered Tylenol when she observed the resident in pain around 10:40 PM. More critically, the provider should have been notified about the unrelieved pain after the 5:12 AM dose so alternative pain medication could be ordered to keep the resident comfortable, especially before transport to the hospital.
The nursing home's own pain management policy required staff to assess acute pain every 30 to 60 minutes until relief is obtained. Staff were supposed to review medication records to determine how often residents request and receive pain medication, and to what extent those medications actually provide relief.
When pain isn't adequately controlled, the policy stated, the care team including the physician must reconsider approaches and make adjustments. Staff are required to report significant changes in pain levels and prolonged, unrelieved pain to the doctor or practitioner.
None of this happened.
Instead, a resident spent more than 13 hours in escalating pain while nurses made assumptions, delayed medication, and failed to follow their own protocols for pain assessment and management. The woman's cries of pain when her leg was moved, the visible swelling in her knee, and her continued restlessness throughout the night were all clear indicators that required immediate action.
The resident was eventually transported to the hospital, but only after enduring hours of preventable suffering that proper nursing care could have avoided.
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.