Big Horn Rehab: Range of Motion Care Failures - WY
The facility failed to complete abuse investigations within the required five working days for four separate incidents between July and August, according to a federal inspection report. When inspectors requested the files on September 12, facility staff discovered the investigations had never been finished. By the time inspectors arrived for their October visit, the files were missing entirely.
"The administration had called the police to report it was missing," the regional nurse told inspectors on October 1.
The missing investigations involved serious incidents. On July 20 at 2:30 PM, a staff member allegedly verbally abused a resident. The facility reported the incident to state authorities eight days later but never completed the required investigation. When the state agency requested the investigation results on September 12, facility staff realized no investigation existed.
Two more cases emerged from August. On August 21 at 9:45 AM, one resident abused another resident. Staff knew about the incident immediately, and the administrator learned of it within 20 minutes. The facility sent the initial report to state authorities by noon. No investigation followed.
A week later, on August 28 at 2:57 PM, a resident abused a licensed practical nurse. Staff discovered the incident within three minutes. The administrator was notified that night at midnight, and the initial report reached state authorities by 4:21 PM. Again, no investigation was completed.
The nursing home administrator confirmed during an October 1 interview that the investigations were not in the facility. The director of nursing acknowledged that investigations should have been submitted by the former social services director but were not. She told inspectors she 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, explicitly outlines this requirement. The policy states that within five working days, staff must "report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified."
The policy also requires administrators to obtain statements from direct care staff and suspend accused employees pending completion of investigations. For serious bodily injury cases, facilities must report within two hours of discovery.
The regional nurse told inspectors that the reportable investigations binder had been in the facility three weeks earlier but was missing when she looked for it during the inspection. The timing suggests the files disappeared sometime between mid-September and early October, just as state oversight intensified.
The July incident involved the most significant delay. Staff reported the verbal abuse allegation on July 28, eight days after it occurred. The administrator learned of the incident at 1:00 PM that day, and the initial report reached state authorities at 2:35 PM. An investigation was supposed to begin immediately.
By September 12, nearly seven weeks later, state authorities requested the investigation results. That request revealed the investigation had never been completed. Another two weeks passed before inspectors arrived for their October visit, finding the files missing entirely.
The August incidents showed a pattern of prompt initial reporting but failed follow-through. In both cases, staff discovered incidents quickly and notified administrators within hours. Initial reports reached state authorities the same day. But the required investigations never materialized.
The missing files represented more than administrative oversight. Each uninvestigated incident potentially left residents at risk. Verbal abuse allegations require thorough investigation to determine whether staff training, discipline, or termination is needed. Resident-on-resident violence demands immediate assessment of safety measures and potential room reassignments.
The facility's policy requires suspended employees during investigations, but without completed investigations, it's unclear whether any disciplinary action occurred. The policy also mandates reporting to state registries when employees are found unfit for service, but incomplete investigations prevent such determinations.
The social services director position appeared central to the breakdown. The director of nursing told inspectors that the former social services director should have submitted the investigations but did not. This suggests the investigations may have been started but never completed, or that the former employee left before finishing required work.
The timing of the missing files raised additional questions. Files that existed in mid-September disappeared before the October inspection. The regional nurse's observation that the binder had been present three weeks earlier but was gone during the inspection suggests the disappearance occurred as regulatory scrutiny increased.
Police involvement in the missing files case indicates facility leadership treated the disappearance as theft rather than administrative misplacement. This characterization suggests the files contained substantial documentation that would be valuable enough to steal, contradicting earlier statements that investigations were never completed.
The four failed investigations represented a significant portion of the facility's abuse cases. Inspectors reviewed 11 sample residents for abuse allegations and found investigation failures in four cases, suggesting systemic problems with the facility's reporting and investigation procedures.
Federal oversight of nursing home abuse reporting has intensified in recent years following widespread documentation of unreported incidents. The five-day investigation deadline exists to ensure rapid response to potential ongoing threats to resident safety and to provide state agencies with timely information for their own oversight activities.
The Big Horn case illustrates how investigation failures can compound. Initial reporting delays, incomplete investigations, and missing documentation create a cascade of regulatory violations that leave both residents and oversight agencies without critical safety information.
The facility's current administrator and director of nursing inherited a system with incomplete investigations and missing documentation. Their acknowledgment of the problems during inspector interviews suggests awareness of the violations, but the missing files prevented any immediate resolution during the inspection.
State authorities now face the challenge of investigating abuse allegations without access to facility documentation that should have been completed months earlier. The missing files force regulators to reconstruct incidents from initial reports and staff interviews, potentially compromising their ability to ensure resident safety and hold appropriate parties accountable.
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 violations during a health inspection on October 8, 2025.
When inspectors requested the files on September 12, facility staff discovered the investigations had never been finished.
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.