Big Horn Rehab: Staffing Deficiencies Found - WY
Federal inspectors cited the facility following a complaint inspection in October 2025, finding that Big Horn failed to meet its own written standards for responding to resident falls. The citation affected a few residents.
The facility's own policy laid out what was supposed to happen every time someone fell: assess the resident, complete a post-fall assessment, file an incident report, notify the physician and family, review and update the care plan, document everything, and collect witness statements when there was an injury. Inspectors found that sequence was not being followed.
The breakdown matters because the steps aren't bureaucratic formalities. A post-fall assessment can catch a slow bleed or a fracture that isn't immediately obvious. Notifying a physician and family keeps the people responsible for a resident's care in the loop. Updating the care plan is how a facility tries to prevent the next fall. When any of those steps are skipped, the gap between what happened and what anyone knows about it widens.
The violation was cited at a level of minimal harm or potential for actual harm, meaning inspectors did not find evidence that residents suffered serious injury as a direct result of the documentation failures. That is the lowest tier of harm in the federal citation system.
Big Horn Rehabilitation and Care Center is a long-term care facility in Sheridan, in northern Wyoming. The inspection was a complaint survey, meaning it was triggered by a concern brought to regulators rather than a routine visit.
The citation appeared on the final page of the inspection report.
What it doesn't say is whether anyone went back to check on the residents whose falls weren't fully documented, or whether their families were ever told.
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 28, 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 citation affected a few residents.
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.