Big Horn Rehab: Abuse Reporting Failures - WY
The nursing home administrator had called police to report the missing binder containing reportable investigations, according to staff interviews conducted during an October complaint inspection. The facility failed to complete investigations into verbal abuse between a resident and staff member, two incidents of resident-on-resident abuse, and an incident where a resident abused a licensed practical nurse.
The oldest case dated back to July 20, when verbal abuse allegedly occurred between resident #7 and a staff member at 2:30 PM. Staff reported the incident to the state survey agency eight days later on July 28 at 12:00 PM. The administrator learned about it an hour later, and the initial incident report reached state officials at 2:35 PM that same day.
An investigation should have begun immediately. Instead, nothing happened for nearly two months.
On September 12 at 10:23 AM, state officials requested the facility submit its completed investigation. The facility had none to provide. When inspectors arrived on October 1, no investigation had been completed or reported, despite the incident occurring more than two months earlier.
The pattern repeated with three additional cases in August. On August 21 at 9:45 AM, an incident of abuse occurred between resident #8 and resident #9. Staff became aware immediately. The administrator learned about it twenty minutes later at 10:05 AM. The initial incident report reached state officials at 12:01 PM.
No investigation followed. By September 26, more than a month after the incident, the facility had completed nothing and reported nothing to state authorities.
A week later, on August 28 at 2:57 PM, resident #10 abused LPN #1. Staff knew about it within three minutes. The administrator somehow wasn't notified until midnight that night, more than nine hours after the incident. The initial report reached state officials at 4:21 PM on August 28.
Again, no investigation. Again, nothing reported to the state by September 26.
When federal inspectors interviewed the nursing home administrator on October 1 at 11:36 AM, the administrator revealed the investigations were not in the facility. The regional nurse, interviewed an hour later at 12:30 PM, explained that the reportable investigations binder had been in the facility three weeks earlier but was missing when inspectors arrived. The administration had called police to report it missing.
The director of nursing, interviewed at 2:45 PM that same day, confirmed that investigations should have been submitted by the former social services director but were not. The director of nursing did not have access to submit investigations herself.
Federal regulations require nursing homes to report investigation results within five working days of an incident. The facility's own policy, dated 2025, spelled out the requirements clearly. The administrator or designee must notify appropriate agencies immediately, but no later than 24 hours after discovering an incident. Within five working days, the facility must report sufficient information describing investigation results and any corrective actions taken if allegations were verified.
The policy required administrators to obtain statements from direct care staff, suspend accused employees pending investigation completion, follow up with agencies to confirm reports were received, and report to state registries any knowledge that an employee was unfit for service.
None of this happened for any of the four cases.
The July incident involving resident #7 and a staff member remained unresolved 69 days after it occurred. The August 21 incident between resident #8 and resident #9 sat uninvestigated for 36 days. The August 28 incident where resident #10 abused LPN #1 went without investigation for 29 days.
The missing investigation binder represented more than administrative inconvenience. Each unfinished investigation meant potential abuse victims received no resolution. Staff members accused of wrongdoing faced no consequences. Residents who committed abuse faced no intervention to prevent future incidents.
The facility reported incidents to state authorities within required timeframes. Initial notifications went out the same day or within days of each incident. But reporting an incident differs fundamentally from investigating it. Reporting alerts authorities that something happened. Investigation determines what actually occurred, who was responsible, and what corrective actions are needed.
Big Horn Rehabilitation and Care Center managed the first step but failed completely at the second. State officials waited weeks for investigation results that never came. When they finally requested the completed investigations in September, the facility had nothing to provide.
The mysterious disappearance of the investigation binder raised additional questions. How does a facility lose documentation for multiple abuse cases? Who had access to the binder? When exactly did it disappear? What did police find when they investigated the missing files?
The inspection report provided no answers. Federal inspectors documented the missing investigations and the missing binder but did not detail the police response or any efforts to reconstruct the lost documentation.
The facility blamed the former social services director for failing to complete investigations. But administrative responsibility extends beyond individual staff members. The administrator knew about incidents within hours of their occurrence. The director of nursing confirmed investigations should have been completed. The regional nurse knew the investigation binder had been in the facility weeks before it vanished.
Multiple staff members knew investigations were required, knew they weren't completed, and knew the documentation had disappeared. Yet no one ensured the work got done or the files stayed secure.
The four unresolved cases represented failures at every level of the facility's abuse response system. Initial reporting worked correctly. Everything after that collapsed completely.
Residents #7, #8, #9, and #10 experienced or witnessed abuse incidents that summer. Months later, they still had no answers about what their facility planned to do about it.
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.
The oldest case dated back to July 20, when verbal abuse allegedly occurred between resident #7 and a staff member at 2:30 PM.
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.