Big Horn Rehab: Accident Hazard Violations - WY
That is what a federal inspection completed October 23, 2025 found at Big Horn Rehabilitation and Care Center on Big Horn Avenue in Sheridan, Wyoming. The inspection was complaint-driven. Inspectors determined the harm was actual, not theoretical.
The resident could not hold themselves upright. During the van ride to the hospital, they leaned on the transport driver, unable to maintain their own upper body balance. A staff member who rode along later told inspectors she had watched the resident lean forward in the wheelchair and had confirmed, in her own words, that the resident did not maintain upper body balance during the trip.
That is who was in the van. That is how they traveled to the emergency room.
The facility's own administrator, the nursing home administrator referred to in inspection records as the NHA, told inspectors he had been informed of exactly what had happened. He knew the resident had been found on the floor. He knew there was blood coming from the head. He knew the resident was transported to the ER, and he knew the transport happened via facility van, roughly one hour after the fall. He confirmed all of this to inspectors during an interview on the morning of October 23.
He also confirmed that staff were expected to call 911 when residents required a higher level of care.
Nobody had.
The nurse practitioner assigned to this resident's care did not learn about the fall from facility staff. She learned about it some other way, or she did not learn about it at all until inspectors arrived. When she sat down with inspectors at 1:11 in the afternoon on October 23, she told them she had not been notified of the fall and had not been told there was any need to transport the resident to the hospital.
The facility's own internal document, a record titled "Resident Abuse and/or Neglect" dated September 23, 2025, stated that the nurse practitioner had been notified the day of the fall.
The nurse practitioner said she had not.
One of those two things is wrong. The inspection record does not resolve which version is true. What it establishes is that the two accounts directly contradict each other, and that a resident with a bleeding head wound was transported to an emergency room in a van while leaning on another person for support, unable to sit upright on their own.
The fall itself, and the circumstances that preceded it, are part of what inspectors examined. A review of facility records showed the resident had a documented history of not maintaining upper body balance. The staff member who accompanied the resident in the van confirmed she had observed this during the ride. Whether anyone assessed the resident's stability before loading them into a vehicle rather than calling for an ambulance is not addressed in the inspection record. What is addressed is the outcome: a resident who could not hold themselves up, traveling to the hospital without emergency medical personnel, one hour after hitting their head hard enough to bleed.
The facility's fall prevention policy required staff to notify the physician and family when any resident experienced a fall. The inspection record does not indicate whether the physician was notified before the van left for the hospital, or whether the family was called before the resident arrived at the emergency room. The nurse practitioner, who in this facility's care structure was the clinician who should have been in the loop, says she heard nothing.
Inspectors tagged this deficiency under F0684, which covers the standard that residents receive care and treatment that meets professional standards of quality. The level of harm was recorded as actual harm. The number of residents affected was listed as few.
Big Horn Rehabilitation and Care Center is a licensed nursing facility. The inspection that produced these findings was triggered by a complaint. The findings were printed April 13, 2026.
What the inspection does not contain is any account of what happened to the resident at the emergency room, what their diagnosis was, or what their condition became after that van ride. The record ends where the documentation ends. A resident leaning on a staff member in a moving vehicle, blood from a head wound, one hour already gone.
The administrator knew. The nurse practitioner says she did not. The van pulled out of the parking lot anyway.
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 2025-10-23 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 5, 2026 · Our methodology
Big Horn Rehabilitation and Care Center in Sheridan, WY was cited for violations during a health inspection on October 23, 2025.
That is what a federal inspection completed October 23, 2025 found at Big Horn Rehabilitation and Care Center on Big Horn Avenue in Sheridan, Wyoming.
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.