Big Horn Rehab: Actual Harm Care Failures - WY
The fall happened on or around September 23, 2025. What followed, according to federal inspection records reviewed during a complaint survey on October 23, revealed a cascade of failures: no ambulance, a nurse practitioner who was never told the fall occurred, and an administrator who acknowledged that calling 911 was exactly what staff were supposed to do.
The nurse practitioner, interviewed by inspectors at 1:11 in the afternoon on the day of the survey, said she had not been notified of the fall. She had not been notified that the resident needed to go to the hospital. She had not been notified of anything.
A facility document told a different story. A record titled "Resident Abuse and/or Neglect," dated September 23, 2025, showed the nurse practitioner had been notified the day of the fall. The document said one thing. The nurse practitioner said another.
Someone was wrong. The inspection record does not resolve which account is accurate, but the gap between them is its own finding.
The nursing home administrator told inspectors he had been informed that the resident was found on the floor with blood coming from their head and was transported to the emergency room approximately one hour after the fall, via facility van. He confirmed, without apparent dispute, that staff were expected to call 911 when residents required a higher level of care.
A resident bleeding from the head after a fall. One hour. A van.
The inspection report was filed under F0684, the federal tag covering the standard of care residents are entitled to receive. Inspectors classified the level of harm as actual harm, meaning this was not a theoretical risk or a paperwork problem. Something happened to someone.
The resident's identity is protected under federal privacy rules, but the inspection record offers fragments of what the person's condition looked like that day. A transportation employee who drove a van for the facility recalled the resident leaning forward in their wheelchair and talking with staff. She said the resident leaned on her during the van ride and could not maintain their upper body balance.
That detail sits in the record without elaboration. A person who had just fallen and struck their head hard enough to bleed was transported across town, leaning against a driver, unable to hold themselves upright.
The facility's own fall prevention policy required staff to notify the physician and family when any resident experienced a fall. The inspection record does not say whether the family was called. It does not say what the emergency room found when the resident arrived. It does not say what treatment followed, or whether the delay in transport made any of it worse.
What it says is that the administrator knew the resident had blood coming from their head. What it says is that no ambulance was called. What it says is that the nurse practitioner, the clinician whose job includes being informed when residents are injured and need emergency care, says she heard nothing.
Big Horn Rehabilitation and Care Center sits on Big Horn Avenue in Sheridan, a small city in northern Wyoming. The complaint survey that produced these findings was completed October 23, 2025. The deficiency was one of several cited across a ten-page statement of deficiencies, though the inspection narrative provided covers the events surrounding this fall and its aftermath.
The transportation employee's account adds a layer that the facility's own documentation does not address. She was there. She watched the resident lean forward in the wheelchair before the ride. She felt the resident lean against her during it. She knew, in the way that someone physically present knows, that this person could not hold themselves up.
Whether anyone asked her before loading the resident into the van what she observed, the record does not say.
The administrator's acknowledgment is the most direct moment in the inspection record. He did not dispute that staff were expected to call 911 for residents who needed a higher level of care. He confirmed the resident had blood coming from their head. He confirmed the van. He confirmed the one-hour gap between the fall and transport.
He did not explain why 911 was not called.
The nurse practitioner's account raises a question the inspection record leaves open. If she was not notified, who made the decision to use the van? If she was notified, as the facility document suggests, why did she tell inspectors otherwise? The record captures the contradiction and moves on.
Federal inspectors classified the affected population as "few residents," the standard language indicating the problem touched more than one person or that the circumstances created risk beyond a single incident. The "actual harm" classification means inspectors concluded the failures documented here caused real injury or real degradation of a resident's condition, not merely the potential for it.
A head wound. An hour on the floor or in a wheelchair. A van ride leaning against the driver. An emergency room at the other end.
The inspection record does not follow the resident past the van doors.
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.
The fall happened on or around September 23, 2025.
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.