The problems began around 4:15 PM on January 16 when Resident #1 complained of pain with movement in her left leg and knee. The nursing supervisor noticed no visible redness or swelling, so she asked the evening charge nurse to take vital signs and give Tylenol.
Licensed Practical Nurse #2 administered the Tylenol and checked on the resident again after 5:00 PM. The medication had worked. The resident was comfortable.
But when LPN #2 returned around 10:40 PM, everything had changed. She lifted the resident's left leg, and the woman yelled out in pain. The left knee was now swollen. The nurse immediately called the nursing supervisor, who contacted the provider.
LPN #2 later admitted she should have given another dose of Tylenol when she discovered the pain at 10:40 PM. She didn't.
The night shift nurse, LPN #3, took over at 11:00 PM knowing the resident had been in pain at the end of the previous shift. Throughout the night, she observed that the resident "appeared to be uncomfortable." But she made a critical assumption that would leave the resident suffering for hours.
LPN #3 assumed the evening nurse had already given Tylenol since the resident had "just been assessed" at shift change. She never checked the medication record to see when Tylenol was last administered. The resident remained unmedicated until 5:12 AM.
Even then, LPN #3 only gave the Tylenol because nurse aides were about to provide care. She stayed to help during the care, watching as the resident "appeared to be very uncomfortable with movement."
After 6:00 AM, the resident was still "restless and uncomfortable." LPN #3 notified the nursing supervisor but made another assumption. She figured the supervisor would call the provider about both the unrelieved pain and x-ray results.
Nobody did.
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. She said LPN #2 should have administered Tylenol when she observed the resident in pain around 10:40 PM. More critically, she said the provider should have been notified about the 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 nurses to assess acute pain every 30 to 60 minutes "until relief is obtained." It directed staff to review medication records to determine "to what extent the administered medications relieve the resident's pain."
If pain wasn't adequately controlled, the policy stated, the team including the physician "shall reconsider approaches and make adjustments as indicated." Staff were required to report "prolonged, unrelieved pain despite care plan interventions" to the physician.
None of this happened.
Instead, a resident with a swollen, painful knee was left unmedicated for over six hours during the night shift. When pain medication was finally given, nobody followed up to see if it worked. Nobody called for stronger medication when it clearly hadn't.
The cascade of assumptions and communication failures meant the resident endured a night of preventable suffering, culminating in a painful transport to the hospital without adequate pain control.
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.