Big Horn Rehab: Notification Failures Found - WY
Big Horn Rehabilitation and Care Center failed to complete investigations into incidents involving both residents and staff, according to federal inspection records from October. The missing files contained details of verbal abuse between a resident and staff member, resident-on-resident violence, and a resident's attack on a licensed practical nurse.
The facility's policy required investigation results to be submitted within five working days. None of the four cases were completed or reported as of September 26, more than a month after some incidents occurred.
The first case involved allegations of verbal abuse between resident #7 and a staff member on July 20 at 2:30 PM. Staff reported the incident to the Social Services Designee eight days later on July 28 at noon, and the administrator learned of it an hour later. The initial incident report reached state regulators at 2:35 PM that afternoon, and an investigation began.
On September 12, state officials requested the completed investigation. The facility had produced nothing.
Three weeks later, resident #8 and resident #9 were involved in an abusive incident on August 21 at 9:45 AM. Staff witnessed it immediately, the administrator was notified 20 minutes later, and the initial report reached regulators by 12:01 PM. Again, no investigation followed.
Six days after that, resident #10 attacked LPN #1 on August 28 at 2:57 PM. Staff knew within three minutes, though the administrator wasn't notified until midnight. The initial incident report was filed at 4:21 PM. Like the others, no investigation was completed.
When inspectors arrived in October, they found empty files.
The nursing home administrator told investigators on October 1 that the investigations "were not in the facility." The regional nurse, interviewed 54 minutes later, said the reportable investigations binder had been in the building three weeks earlier but was missing when inspectors arrived. Administration had called police about the theft, the nurse said.
The Director of Nursing confirmed during her October 1 interview that investigations "should have been submitted by the former SSD but were not." She told inspectors she lacked access to submit investigations herself.
The facility's own policy, dated 2025, spelled out clear requirements. The administrator or designee must notify appropriate agencies within 24 hours of discovery, or within two hours for serious bodily injury cases. Staff statements must be obtained. Accused employees must be suspended pending investigation completion.
Most critically, the policy required reporting "sufficient information to describe the results of the investigation, and indicate any corrective actions taken" within five working days if allegations were verified.
None of that happened.
The missing investigation files represented more than administrative oversight. Each case involved potential harm to residents or staff that went unexamined by facility leadership. The July incident between resident #7 and a staff member remained uninvestigated for more than two months. The August 21 clash between residents #8 and #9 received no follow-up to determine what triggered the violence or how to prevent future incidents.
The August 28 attack on LPN #1 by resident #10 also went unexamined, leaving questions about whether the nurse received adequate support and whether the resident's behavior indicated unaddressed medical or psychological needs.
Federal regulations require nursing homes to immediately report suspected abuse, neglect, or theft to proper authorities and complete thorough investigations. The results must be shared with state agencies to ensure accountability and prevent future incidents.
The facility's failure extended beyond missing paperwork. Without completed investigations, administrators couldn't determine whether abuse actually occurred, what factors contributed to incidents, or what corrective actions were needed to protect residents and staff.
The timing of the missing files raised additional concerns. The investigations binder disappeared sometime between mid-September, when the regional nurse last saw it, and early October, when inspectors arrived for their complaint investigation.
State regulators had specifically requested the July investigation results on September 12, giving the facility two additional weeks to locate or reconstruct the missing documentation before the inspection began. The facility produced nothing.
The Social Services Designee who should have completed the investigations was no longer with the facility by October. The Director of Nursing told inspectors she couldn't access the system to submit required reports, leaving a gap in the facility's ability to meet federal reporting requirements.
Big Horn Rehabilitation and Care Center serves vulnerable residents who depend on staff for daily care and protection. When abuse allegations arise, swift investigation and reporting protect both residents and employees by establishing facts and implementing corrective measures.
The facility's policy acknowledged these responsibilities, requiring immediate notification of authorities, staff interviews, and suspension of accused employees pending investigation results. The policy also mandated reporting investigation outcomes and corrective actions within five working days.
Instead, four separate incidents went uninvestigated for weeks or months. Resident #7's alleged verbal abuse incident from July remained unresolved in October. The August incidents involving residents #8, #9, and #10 similarly lacked any investigative follow-up.
The missing investigation binder represented a systemic breakdown in the facility's abuse reporting system. Whether the files were actually stolen, misplaced, or never properly maintained, the result was the same: state regulators couldn't assess whether vulnerable residents were adequately protected.
Federal inspectors found the facility in violation of reporting requirements that exist to safeguard nursing home residents across the country. The regulations recognize that abuse can occur in institutional settings and mandate transparent investigation and reporting processes.
Without completed investigations, neither residents nor their families could know whether reported incidents constituted actual abuse, what corrective actions were taken, or whether similar problems were likely to recur. The facility's failure to maintain and submit required documentation left these critical questions unanswered.
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: August 4, 2026 · Our methodology
Big Horn Rehabilitation and Care Center in Sheridan, WY was cited for violations during a health inspection on October 8, 2025.
The facility's policy required investigation results to be submitted within five working days.
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.