Big Horn Rehab: Care Quality Harm Documented - WY
That is what federal inspectors found when they visited Big Horn Rehabilitation and Care Center on October 23, 2025, following a complaint. The inspection produced a citation for actual harm, the level CMS assigns when inspectors determine a deficiency has already hurt someone, not just created a risk of hurting them.
The resident, whose name and gender are not identified in the inspection report, had been transported to the hospital roughly an hour after the fall. The vehicle was a facility van. The driver was not a paramedic. The resident had been found on the floor with blood coming from their head.
The facility's own fall prevention policy required staff to notify the physician when any resident experienced a fall. That notification did not happen. The nurse practitioner, interviewed by inspectors at 1:11 in the afternoon on the day of the inspection, said she had not been told about the fall. She had not been told the resident needed to go to the hospital. She learned nothing.
The nursing home administrator told a different story, though not a reassuring one. He confirmed to inspectors that he had known the resident was found on the floor bleeding from the head. He confirmed the resident had been put in a facility van and driven to the emergency room about an hour after the fall. He also confirmed, in the same interview, that staff were expected to call 911 when a resident needed a higher level of care.
He did not explain why that did not happen here.
What the inspection report documents is a gap between what the administrator said staff were supposed to do and what staff actually did. A resident with a head wound, unable to maintain their own upper body balance, was loaded into a van. The person sitting beside them during the ride held them up. The resident leaned on a staff member for the duration of the trip because they could not hold themselves upright.
That detail came from the staff member who made the van ride. She told inspectors she had observed the resident leaning forward in the wheelchair before they left, talking with staff but unable to keep their balance. She confirmed the resident leaned on her the entire way to the hospital.
A facility document, titled "Resident Abuse and/or Neglect" and dated September 23, 2025, showed that the nurse practitioner had been notified the day of the fall. The nurse practitioner said that was not true. Inspectors interviewed her directly. She said she had not been notified of the fall. She had not been notified of the transport. She found out none of it from the facility.
The inspection report does not say what condition the resident was in when they arrived at the hospital. It does not say what treatment they received. It does not say whether the hour that passed between the fall and the van ride made any difference to what happened next. Those details are not in the record inspectors produced.
What is in the record is a citation at the actual harm level, which means inspectors concluded that what happened to this resident was not a near miss. The deficiency tag is F0684, which covers the standard requiring facilities to provide care and services that attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Inspectors marked it as affecting few residents. They marked it as causing actual harm.
The facility's fall prevention policy, reviewed by inspectors, listed specific steps staff were required to follow after any fall. Notifying the physician was among them. The policy did not say "notify the physician unless it's inconvenient" or "notify the physician when you have time." It said notify the physician. The nurse practitioner, who was the relevant clinician in this case, was not notified.
The administrator, when inspectors interviewed him, did not dispute the basic facts. He knew the resident had been found bleeding. He knew the resident had been driven to the ER in a van. He acknowledged that 911 was supposed to be called in situations requiring a higher level of care. The inspection report does not record him offering an explanation for why none of those protocols were followed in this case.
The document that claimed the nurse practitioner had been notified the day of the fall exists in the facility's own records. The nurse practitioner says it is wrong. Inspectors appear to have credited her account. The citation stands.
Big Horn Rehabilitation and Care Center sits on Big Horn Avenue in Sheridan, a small city in the northeastern corner of Wyoming. The facility is a long-term care and rehabilitation center. The inspection was a complaint survey, meaning someone contacted regulators with a concern before inspectors arrived.
The resident at the center of this citation cannot maintain their upper body balance without support. They lean. They needed someone to hold them upright in a vehicle that was not equipped to transport a person in medical distress, driven by staff who were not paramedics, on a ride that lasted long enough for inspectors to note it as a detail worth recording.
The nurse practitioner who should have been called sat elsewhere, unaware, while that ride happened.
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 federal inspectors found when they visited Big Horn Rehabilitation and Care Center on October 23, 2025, following 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.