Big Horn Rehab: Care Quality Harm Documented - WY
The resident at Big Horn Rehabilitation and Care Center told inspectors on October 23 that showers were supposed to happen on Mondays, Wednesdays, and Saturdays. The care plan confirmed the preference for three weekly showers with a female caregiver specifically because of frequent diarrhea episodes.
But bathing records showed reality fell far short. Between September 24 and October 22, the resident received just six showers over four weeks instead of the planned twelve.
"I had not received a shower for a week," the resident told inspectors during the federal complaint investigation.
Two other residents on the Chapel unit faced similar hygiene gaps. One resident requiring two-person assistance for showers went 22 consecutive days without bathing after an October 1 shower. No records showed staff even offering alternative shower times during the three-week stretch.
"I'm supposed to get 2 showers a week but so far I only get 1 shower a week," the resident said. "It could happen a little more frequently."
Another resident's care plan called for weekly showers with one-person assistance. Between September 29 and October 20, the resident received just two showers and refused three others. On two dates when alternative shower times were scheduled, no records showed staff offering bathing at all.
The resident explained the stark reality: "I received a shower every 2 weeks, because that's how they have it set up." When asked about preferences, the resident said more frequent showers would be welcome "if there was enough help."
The Chapel unit housed 17 residents within the facility's total census of 77. Nursing assistants working the unit described impossible choices during their shifts.
CNA #3 told inspectors that "showers were not getting done at night because there were often only 2 CNAs and they could not provide the necessary care to the residents and provide them with showers when there were only 2 staff who worked on the hall."
The dayshift faced similar constraints. CNA #4 explained that on normal days, staff should complete four to five showers. But staffing shortages changed everything.
"There were days where they could only give 1 resident a shower because they had to prioritize answering call lights over showers," the nursing assistant said.
Some residents had requested specific staff members for personal care, which created additional scheduling complications. When preferred caregivers weren't available, shower opportunities disappeared entirely.
The Director of Nursing acknowledged the systemic problems during interviews on October 22 and 23. She had recently hired a new scheduler and was attempting to establish consistent staff rotations instead of the "varied and chaotic schedule" that had developed.
Her stated expectation was for showers to occur on scheduled days, with missed sessions rolling over to the following day. She admitted that resident preferences for specific staff "turned into a missed opportunity to receive a shower" and said this issue had been addressed with residents.
But the inspection findings revealed a pattern extending far beyond individual preferences or scheduling glitches. Three residents on a single unit experienced weeks-long gaps in basic hygiene care, with some going nearly a month between showers.
The facility's own care plans documented residents' specific bathing needs and preferences, including medical reasons for frequent showers and requests for same-gender caregivers. Yet the actual bathing records showed these individualized care requirements going unmet for extended periods.
Federal nursing home regulations require facilities to provide sufficient staffing every day to meet resident needs and maintain a licensed nurse in charge of each shift. The inspection found Big Horn failed to ensure adequate nursing staff for the Chapel unit's 17 residents.
When nursing assistants must choose between responding to emergency call lights and providing scheduled personal care, the choice is clear. Residents' immediate safety needs take precedence over bathing schedules.
But the consequences accumulate over weeks. Residents with diarrhea episodes go days without proper cleaning. Others simply accept that showers happen "every 2 weeks, because that's how they have it set up."
The inspection narrative doesn't describe residents' medical conditions that might make extended periods without bathing particularly problematic. It doesn't detail whether skin breakdown or infections resulted from the hygiene gaps.
What it does show is a facility where basic dignity and cleanliness became casualties of chronic understaffing. Residents who preferred more frequent showers settled for whatever they could get "if there was enough help."
The Director of Nursing's efforts to establish better scheduling and staff rotations suggested recognition of the problems. But for residents who had already gone weeks without proper bathing, those improvements came too late.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. The finding affected one of four resident care units reviewed during the complaint investigation at the 77-bed facility.
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: June 20, 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 care plan confirmed the preference for three weekly showers with a female caregiver specifically because of frequent diarrhea episodes.
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.