Big Horn Rehab: Daily Care Failures Found - WY

It took an hour.

The resident could not hold himself upright during the ride. A staff member who accompanied him in the van told inspectors he leaned against her the entire way, unable to maintain his balance in his wheelchair. She watched him tilt forward, bracing himself against whatever was in reach. When the van arrived at the hospital, an ambulance was waiting outside.

The inspection, completed October 23, 2025, was triggered by a complaint. What inspectors found was a facility where a man with a bleeding head injury was treated as a transport problem rather than a medical emergency, where the clinician responsible for his care was never told he had fallen, and where the administrator already knew what the right answer was before anyone asked him.

The nurse practitioner on staff said she was never notified about the fall. Not when it happened. Not when staff decided to drive him to the hospital. Not at any point before inspectors sat down with her on the afternoon of October 23rd. She learned the details, it appears, around the same time the surveyors did.

The facility's own 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 nurse practitioner said that was not true. She had not been called. She had not been told there was a fall, a head wound, a hospital transport, or any need to assess the resident at all.

Someone's account of that day is wrong. The inspection report does not resolve which one. What it records is the contradiction, flat and unambiguous: the paperwork said she was notified, and she said she was not.

The facility's fall prevention policy required staff to notify the physician and family when any resident experienced a fall. Whether that notification happened, and when, and to whom, is part of what inspectors were trying to determine. The nurse practitioner's account suggests it did not happen, at least not to her.

The administrator, interviewed the same morning at 11:20, confirmed the essential facts without apparent hesitation. He told inspectors he had been informed that the resident was found on the floor with blood coming from his head. He confirmed the resident was transported to the emergency room approximately one hour after the fall. He confirmed the transport was made by facility van.

He also confirmed that staff were expected to call 911 when a resident required a higher level of care.

He said this as a statement of existing policy, not as a concession that something had gone wrong. But the implication was plain: a resident found bleeding from the head, unable to hold himself upright, being driven to a hospital in a van an hour after the fall, is exactly the situation that policy was designed to address. The administrator knew what the standard was. The question the inspection left open was why nobody applied it.

The woman who rode with the resident in the van described what she saw clearly enough. He leaned on her. He could not maintain his upper body balance. She was not a paramedic. The van was not equipped as an ambulance. Whatever condition the resident was in when he left the facility, he was not stable enough to sit upright on his own, and the people responsible for his care put him in a vehicle anyway.

Head injuries in elderly residents carry risks that do not always announce themselves immediately. A person can appear alert and communicative in the minutes after a fall and still be bleeding internally. The resident, inspectors noted, was leaning forward in his wheelchair and talking with staff when the transport van arrived at the hospital. He was observed by someone at the scene. That he was conscious and speaking did not mean the decision to skip the ambulance was sound. It meant he survived the ride.

The Centers for Medicare and Medicaid Services rated the harm in this case as actual, not potential. That designation means inspectors determined a resident was genuinely hurt or put at genuine risk by what the facility did or failed to do. It is not a finding about paperwork. It is a finding about a person.

The inspection covered a small number of residents. The deficiency citation, tagged F0684, addresses the standard of care residents are entitled to receive. That standard, as CMS applies it, requires that care be provided in a way that maintains the highest practicable physical well-being of each resident. Driving a man with a bleeding head wound to the hospital in a van, an hour after the fall, without calling 911, without notifying the clinician responsible for his care, is the conduct that citation describes.

What the record does not contain is any account of why the decision was made. No staff member is quoted explaining the choice. No supervisor is described weighing the options and concluding the van was appropriate. The decision appears to have been made, and then the van left, and then an hour passed, and then the resident arrived at the emergency room leaning against a staff member because he could not hold himself up.

The nurse practitioner found out when inspectors asked her about it.

The administrator confirmed what happened and stated, without apparent contradiction, that staff knew they were supposed to call 911.

The facility's own abuse and neglect documentation recorded a notification that the nurse practitioner says she never received.

Somewhere between what the paperwork shows and what the clinician remembers, a resident with blood coming from his head spent an hour in a van.

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

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