Big Horn Rehab: Medical Records Violations - WY
No one called 911.
Federal inspectors cited the facility on October 23, 2025, for failing to provide care that met professional standards, a violation tagged at the level of actual harm. The inspection was triggered by a complaint.
The fall happened on September 23, 2025. According to inspection records, staff found the resident on the floor with blood coming from their head. Rather than calling for an ambulance, someone loaded the resident into a facility van and drove them to the emergency room. The trip took an hour.
During that ride, a staff member observed the resident leaning forward in their wheelchair, unable to maintain their upper body balance. The resident leaned on her the entire way.
The nursing home administrator confirmed to inspectors that he had been told a resident was found on the floor with blood coming from their head and was transported to the hospital via facility van, one hour after the fall. He also confirmed, in the same conversation, that staff were expected to call 911 when a resident required a higher level of care.
He did not explain why 911 was not called.
The facility's own fall prevention policy required staff to notify the physician and family when any resident experienced a fall. Whether that notification happened is not addressed in the inspection record. What is addressed is what happened with the nurse practitioner.
A facility document titled "Resident Abuse and/or Neglect," dated September 23, 2025, showed the nurse practitioner was notified the day of the fall.
The nurse practitioner told inspectors she was not.
Interviewed at 1:11 in the afternoon on October 23, she said 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 inspection record does not reconcile the contradiction between what the document shows and what the nurse practitioner said. It simply records both, side by side.
That gap matters. A nurse practitioner notified of a head injury and a bleeding resident might have ordered an ambulance. Might have directed staff to stabilize the resident before moving them. Might have assessed whether a one-hour van ride in a wheelchair, with the resident unable to hold their own body upright, was appropriate for someone who had just hit their head hard enough to draw blood. None of that happened, because, according to the nurse practitioner, she was never given the chance.
Head injuries in elderly residents carry risks that do not always announce themselves immediately. Bleeding inside the skull can develop slowly. A resident who is conscious and talking, as this one apparently was, can still be in serious danger. The standard response to a fall with a head injury, the kind that produces visible bleeding, is to call for emergency medical services, not to wait and then drive.
The administrator knew this. He said so himself. Staff were supposed to call 911 for residents who needed a higher level of care. A resident found on the floor, bleeding from the head, unable to sit upright without support, transported over the course of an hour in a van, is not a difficult case to categorize.
The inspection record does not say who made the decision to use the van. It does not identify the staff member who rode with the resident and felt them leaning throughout the trip. It does not say what the emergency room found when the resident arrived, or what treatment was required, or what the resident's condition was in the days that followed.
What the record says is that the harm was actual, not potential. CMS uses that designation when inspectors determine that a deficiency caused real injury or harm to a resident, not just a risk of it.
The inspection covered a small number of residents. The deficiency was cited under F0684, which addresses the standard of care nursing homes are required to provide. The facility's plan of correction is not included in the inspection materials reviewed for this report.
Big Horn Rehabilitation and Care Center is located at 1851 Big Horn Avenue in Sheridan. The inspection was completed October 23, 2025.
The resident who fell, who bled, who could not sit up straight in a wheelchair, who spent an hour in a van leaning on a staff member on the way to the emergency room, is identified in the inspection record only by a number. The nurse practitioner who was supposed to be called, and says she wasn't, is identified only by her title. The administrator who confirmed his own staff's failure while explaining what his staff were supposed to do is identified only as the NHA.
The document that said the nurse practitioner was notified still exists. So does her statement that she was not.
One of those things is wrong.
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: July 30, 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 inspection was triggered by a complaint.
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.