Big Horn Rehab: Abuse Protection Failures - WY
Four residents never got the follow-up investigations they were owed after allegations of verbal abuse and physical incidents between July and August. Federal inspectors found the facility had failed to complete any of the required investigations, despite a state policy mandating results be reported within five working days.
The missing files represented months of unfinished business. A verbal abuse incident between a staff member and one resident occurred July 20 at 2:30 in the afternoon. The facility reported it to state authorities eight days later but never completed the investigation. When the state agency requested the investigation results on September 12, there was nothing to send.
Nobody had completed it.
The pattern repeated across multiple incidents. On August 21 at 9:45 in the morning, two residents were involved in what the facility classified as an abuse incident. Staff knew about it immediately, the administrator learned of it twenty minutes later, and the initial report went to state authorities by noon. But like the July incident, no investigation followed.
Three days later, another incident. A resident allegedly abused a licensed practical nurse on August 28 at 2:57 in the afternoon. Staff discovered it within three minutes, but the administrator somehow wasn't notified until midnight. The initial report reached state authorities by 4:21 that afternoon.
Again, no investigation.
When federal inspectors interviewed the nursing home administrator on October 1, the response was simple: the investigations weren't in the facility. The regional nurse, interviewed thirty minutes later, explained that the reportable investigations binder had been in the facility three weeks earlier but was missing when inspectors arrived. That's when administrators called police.
The director of nursing confirmed what inspectors suspected. The investigations should have been submitted by the former social services director but never were. The director of nursing didn't even have access to submit investigations herself.
The facility's own policy, dated 2025, spelled out exactly what should have happened. The administrator or designee was supposed to obtain statements from direct care staff, suspend any accused employee pending investigation completion, and report results to state authorities within five working days of each incident.
None of that occurred for any of the four residents.
The July 20 verbal abuse case involved a direct confrontation between staff and a resident. Eight days passed before the facility even reported the initial incident to state authorities. The administrator learned about it at 1:00 in the afternoon on July 28, and the initial report reached state officials at 2:35 that afternoon. But when the state agency specifically requested the investigation results on September 12, the facility had nothing to provide.
The August 21 incident between two residents followed a similar trajectory. The facility managed to report it to state authorities within hours, but the investigation never materialized. Staff witnessed the 9:45 morning incident, the administrator knew by 10:05, and state authorities received the initial report by noon. The quick reporting made the subsequent investigation failure more glaring.
The August 28 case presented its own complications. A resident allegedly abused a licensed practical nurse, but the administrator somehow didn't learn about it until twelve hours after it occurred. The incident happened at 2:57 in the afternoon, staff knew by 3:00, but the administrator wasn't notified until midnight. Despite this communication breakdown, the initial report still reached state authorities by 4:21 that afternoon.
The missing investigation binder represented a systematic breakdown in the facility's abuse reporting procedures. Federal regulations require nursing homes to investigate all allegations of abuse and report their findings to state authorities within five working days. The investigations must include sufficient information to describe what happened and indicate any corrective actions taken if allegations are verified.
Big Horn Rehabilitation had the policies in place. Their 2025 compliance document outlined step-by-step procedures for responding to abuse allegations. Administrators were supposed to notify appropriate agencies within 24 hours of discovery, or within two hours for cases involving serious bodily injury. They were required to obtain statements from direct care staff and suspend accused employees pending investigation completion.
The policy also mandated follow-up with appropriate agencies to confirm reports were received and required reporting any knowledge of employee actions indicating unfitness for service to the state nurse aide registry or nursing board.
But policies on paper meant nothing when the investigation files disappeared.
The four affected residents experienced different types of alleged abuse. Resident 7 faced verbal abuse from a staff member. Residents 8 and 9 were involved in an incident with each other. Resident 10 allegedly abused a licensed practical nurse. Each case required its own investigation, its own fact-finding, its own resolution.
None received it.
The facility's former social services director bore responsibility for completing the investigations but left without finishing them. The director of nursing, despite being in a supervisory role, lacked system access to submit investigations herself. The nursing home administrator couldn't produce the investigations when inspectors asked.
By September 26, more than a month after the August incidents and over two months after the July case, no investigations had been completed or reported. The state agency had specifically requested the July investigation results on September 12, but the facility had nothing to provide.
The missing binder contained more than just paperwork. It represented the facility's commitment to protecting residents from abuse and ensuring proper follow-up when incidents occurred. Without completed investigations, there was no way to determine whether abuse actually happened, whether staff members should face discipline, or whether systemic changes were needed to prevent future incidents.
The police report about the missing binder added another layer of complexity. Someone had to physically remove the investigation files from the facility, or they were misplaced during a staff transition. Either scenario suggested serious problems with the facility's record-keeping and security procedures.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. But the four residents who experienced alleged abuse never learned the results of investigations into their cases. They never knew whether their reports were taken seriously, whether staff members faced consequences, or whether the facility implemented changes to prevent similar incidents.
The facility's investigation failures violated federal regulations requiring nursing homes to report investigation results within five working days. The missing files meant Big Horn Rehabilitation couldn't demonstrate compliance with basic resident protection requirements, leaving four abuse allegations unresolved and four residents without answers about incidents that directly affected them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Big Horn Rehabilitation and Care Center from 2025-10-08 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: June 20, 2026 · Our methodology
Big Horn Rehabilitation and Care Center in Sheridan, WY was cited for abuse-related violations during a health inspection on October 8, 2025.
Four residents never got the follow-up investigations they were owed after allegations of verbal abuse and physical incidents between July and August.
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.