Big Horn Rehabilitation And Care Center

F 0658 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the foley catheter, which did help with output briefly. She revealed when she came on shift on 9/19/25, she had received a report that the resident did not have much urinary output and had been tired all night. She revealed during her shift on 9/19/25, the resident slept all day, had low urinary output, and mumbled but did not open his/her eyes when s/he was turned in bed. She revealed around 3 PM she called LPN/staff development coordinator to report the resident's change in condition and deterioration, and he told her to hold off until the night nurse came on shift to confirm her opinion because it would be an extreme transfer due to his/her size, and no large things were jumping out at the LPN/staff development coordinator. She revealed she reported to LPN/staff development coordinator she did not want to hold off on the transfer, and she was told not to contact the provider. She revealed her capacity to make a decision to send the resident to the hospital was limited by management, and decisions had to come from the provider. Further

interview revealed when the night nurse, LPN #3, came on shift, he agreed with her assessment of the resident, and in 5 minutes a non-emergent transfer was called to transport the resident to the ER. f.

Interview with the staff development coordinator on 10/22/25 at 3:26 PM revealed his opinion was that the resident was going septic because s/he had a permanent catheter and a positive UTI. Further interview revealed the resident had been at the point where s/he did not always answer questions and displayed mental changes, and did not have a temperature but did have a drop in his/her intellectual functioning.

Further interview revealed when this behavior had been seen before, the first thing the facility checked for was a UTI.g. Interview with LPN #3 on 10/23/25 at 8:23 AM revealed he had come on shift the night the resident was transferred, and RN #2 had tried all day to get the resident sent to the hospital. He revealed administration staff wanted to wait until he arrived to send resident #7 to the hospital. Further interview revealed the resident was gray and ashen, and LPN #3 could not obtain a blood pressure from the resident

before s/he was sent to the hospital.h. Interview with the NP on 10/23/25 at 1:04 PM revealed the resident had been treated for a UTI in August and she had ordered a UA on 9/9/25, which was not obtained. Further

interview revealed she had not been alerted by nursing about the resident's change in condition on 9/19/25, prior to the resident being sent to the hospital.i. Interview with the staff development coordinator on 10/23/25 at 2:22 PM revealed he noticed the resident's catheter had leaked and his/her urine didn't look too good. He revealed the night nurse gave the recommendation after he noticed the resident's change of condition, and the resident was sent to the hospital. He confirmed he waited for LPN #3's opinion before sending the resident to the hospital because he did not see the resident enough to notice a change in behavior. Further he revealed he was not sure who obtained a UA on the resident.j. Interview with the DON

on 10/23/25 at 10:48 AM confirmed the resident did not have a UA until he arrived at the hospital.k.

Interview with the NHA on 10/23/25 at 11:45 AM confirmed that RNs have the autonomy to make a clinical judgment to send a resident to the hospital.3. Review of the policy titled Fall Prevention Policy showed .9.

When any resident experiences a fall, the facility will .d. notify the physician and family .4. Review of the facility policy titled Notification of Changes showed .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complication. 3. Circumstances that require a need to alter treatment. This may include: New treatment. B. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Big Horn Rehabilitation and Care Center

1851 Big Horn Ave Sheridan, WY 82801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

Based on resident and staff interview, medical record review, and facility policy and procedure review, the facility failed to ensure bathing was performed per residents' preference for 3 of 4 sample residents (#2, #3, #4) reviewed for bathing. The findings were: 1. Review of resident #2's .ADL self-care performance . care plan last revised 10/21/25 showed the resident required 1 person assist for showers. The following concerns were identified:a. Review of the bathing record between 9/29/25 and 10/20/25 showed the resident received showers on 9/29/25 and 10/10/25 and was documented as refused on 10/6/25, 10/13/25 and 10/20/25. The record showed a shower was to be offered on an alternative day/time on 10/3/25, and 10/17/25; however, there was no evidence the bathing was offered, accepted, or refused.b. Interview with

the resident on 10/23/25 at 9:55 AM revealed the s/he received a shower every 2 weeks, because that's how they have it set up. Further interview revealed s/he would prefer more showers if there was enough help.2. Review of resident #3's .ADL self-care performance . care plan last revised 8/17/25 showed the resident required the assistance of 2 staff members for showers. The following concerns were identified:a.

Review of the bathing record between 9/24/25 and 10/22/25 showed the resident received showers on 9/24/25 and 10/1/25. Showers were to be offered on alternate days/times on 10/5/25, 10/9/25, and 10/22/25; however, there was no evidence the showers were offered. Further review showed no evidence

the resident was offered, accepted, or refused bathing for 22 days following the 10/1/25 shower.b. Interview with the resident on 10/23/25 at 9:55 AM revealed I'm supposed to get 2 showers a week but so far I only get 1 shower a week. It could happen a little more frequently. 3. Review of resident #4's .ADL self-care performance . care plan last revised 4/1/24 showed .I prefer showers three days a week and prefers [sic] a female care giver . The following concerns were identified: a. Review of the bathing record between 9/24/25 and 10/22/25 showed the resident received showers one to two times per week on 9/24/25, 10/1/25, 10/3/25, 10/8/25, 10/13/25, and 10/17/25. A shower was to be offered as an alternate day/time on 10/6/25; however, there was no evidence the resident was offered, accepted, or refused bathing at that time. Further

review showed the resident refused one shower on 10/22/25.b. Interview with the resident on 10/23/25 at 10:02 AM revealed the s/he had not received a shower for a week, and s/he was supposed to have showers on Mondays, Wednesdays, and Saturdays. Further interview revealed the resident had frequent diarrhea and that was why s/he needed 3 showers per week. 4. Interview with CNA #3 on 10/22/25 at 3:10 PM revealed 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. 5. Interview with CNA #4 on 10/23/25 at 10:05 AM revealed some days there were not enough CNAs to provide showers for the residents. Further interview revealed on a normal day

the staff should be able to complete 4 to 5 showers, but there were days where they could only give 1 resident a shower because they had to prioritize answering call lights over showers. 6. Interview with the DON on 10/23/25 at 2:38 PM revealed the expectation was that showers were provided on the scheduled day, and if they were unable to be provided they would roll over to the next day. Further interview revealed some residents had staff preference which turned into a missed opportunity to receive a shower, and this had been addressed with residents. 7. Review of the policy titled Resident Showers showed .Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety .

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Big Horn Rehabilitation and Care Center

1851 Big Horn Ave Sheridan, WY 82801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

ambulance. She observed the resident leaning forward in his/her wheelchair and talking with staff. She confirmed the resident leaned on her during the van ride and did not maintain his/her upper body balance.

Level of Harm - Actual harm Residents Affected - Few

h. Review of the facility document titled Resident Abuse and/or neglect, dated 9/23/25, showed the NP was notified the date of the fall.

1. 2. Interview with the facility NP on 10/23/25 at 1:11 PM revealed she had not been notified of the fall or a

need to transport to the hospital.

2. 3. Interview with the NHA on 10/23/25 at 11:20 AM revealed he had been informed the resident was found

on the floor with blood coming from his/her head and was transported to the ER on e hour following the fall via facility van. Further interview confirmed that staff were expected to call 911 when resident's required higher level of care.

3. 4. Review of the policy titled Fall Prevention Policy showed .9. When any resident experiences a fall, the

facility will .d. notify the physician and family .

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Big Horn Rehabilitation and Care Center

1851 Big Horn Ave Sheridan, WY 82801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident representative and staff interview, medical record review, and policy review, the facility failed to ensure the environment was free of accident hazards for 1 of 3 sample residents (#5) reviewed for falls. The findings were: 1. Review of the admission MDS dated [DATE REDACTED] showed resident #5 had a BIMS score of 11/15 which indicated moderate cognitive impairment, and diagnoses which included diabetes mellitus, unspecified congestive heart failure, and morbid obesity. The resident was dependent for transfers and self cares, and was incontinent of bowel and bladder. Review of the care plan initiated on 7/30/25 showed the resident was at risk for falls, and had interventions which included If a fall occurs, alert provider and If a fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. The following concerns were identified:a. Interview with the resident's representative on 10/22/25 at 11:30 AM revealed she received a phone call from the resident's nurse on 9/9/25 at 2:03 PM and was told the resident had fallen during a mechanical lift transfer from the wheelchair to the bed. The representative was told the resident slipped through the hoyer lift sling and landed on the floor next to the bed because his/her brief was wet. The representative revealed she had asked for an incident report and had been told it could not be found.

Further interview revealed the resident had been discharged to a different facility.b. Interview with RN #2 on 10/22/25 at 2:08 PM revealed she had been the nurse on duty with resident #5 the day after the fall, and was not aware of the fall until the resident's representative called and asked how the resident was doing, because there had not been any notes about the fall in the record. She revealed she documented on the resident's behavior after the incident because the resident had been upset, and her documentation had been deleted.c. Interview with the current DON on 10/22/25 at 2:59 PM revealed on 9/9/25 a CNA reported to her when she was RN on duty that resident #5 had fallen from the mechanical lift to the floor while being transferred from his/her wheelchair to the bed for a check and change. She revealed the resident had slipped out of the bottom of the sling and it was determined the sling had been placed appropriately; however, the resident's wet brief had caused the resident to slip out of the sling and onto the floor. She revealed she had completed a risk management note, progress note, and notified the family; however, she was unable to find the documentation in the medical record. Further interview confirmed there was no documentation in the resident's medical record about the fall, and there had been no follow up with risk management.d. Interview with RA #1 on 10/23/25 at 10:31 AM revealed he controlled the mechanical lift

during resident #5's transfer after a CNA placed the sling. He revealed the resident fell to the floor, and he immediately alerted RN #1 about the fall. Further interview revealed he did not position the sling under the resident, he ran the controls of the lift. e. Interview with the NP on 10/23/25 at 1:04 PM revealed she had not been notified about the resident's fall.f. Review of the resident's medical record showed there was no documentation on the fall and the care plan had not been updated after the fall.2. Review of facility policy titled Fall Prevention Policy showed .9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g.

Obtain witness statements in the case of injury.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Big Horn Rehabilitation and Care Center

1851 Big Horn Ave Sheridan, WY 82801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Based on resident and staff interview and medical record review, the facility failed to ensure there was sufficient nursing staff for 1 of 4 resident care units (Chapel) reviewed for sufficient staffing. The facility census was 77 and the Chapel unit census was 17. The findings were: 1. Review of resident #2's .ADL self-care performance . care plan last revised 10/21/25 showed the resident required 1 person assist for showers. The following concerns were identified:a. Review of the bathing record between 9/29/25 and 10/20/25 showed the resident received showers on 9/29/25 and 10/10/25 and was documented as refused

on 10/6/25, 10/13/25 and 10/20/25. The record showed a shower was to be offered on an alternative day/time on 10/3/25, and 10/17/25; however, there was no evidence the bathing was offered, accepted, or refused.b. Interview with the resident on 10/23/25 at 9:55 AM revealed the s/he received a shower every 2 weeks, because that's how they have it set up. Further interview revealed s/he would prefer more showers if there was enough help.2. Review of resident #3's .ADL self-care performance . care plan last revised 8/17/25 showed the resident required the assistance of 2 staff members for showers. The following concerns were identified:a. Review of the bathing record between 9/24/25 and 10/22/25 showed the resident received showers on 9/24/25 and 10/1/25. Showers were to be offered on alternate days/times on 10/5/25, 10/9/25, and 10/22/25; however, there was no evidence the showers were offered, accepted, or refused. Further review showed no evidence the resident was offered, accepted, or refused bathing for 22 days following the 10/1/25 shower.b. Interview with the resident on 10/23/25 at 9:55 AM revealed I'm supposed to get 2 showers a week but so far I only get 1 shower a week. It could happen a little more frequently. 3. Review of resident #4's .ADL self-care performance . care plan last revised 4/1/24 showed .I prefer showers three days a week and prefers [sic] a female care giver . The following concerns were identified: a. Review of the bathing record between 9/24/25 and 10/22/25 showed the resident received showers one to two times per week on 9/24/25, 10/1/25, 10/3/25, 10/8/25, 10/13/25, and 10/17/25. A shower was to be offered on as an alternate days/time on 10/6/25; however, there was no evidence the resident was offered, accepted, or refused bathing at that time. Further review showed the resident refused one shower on 10/22/25.b. Interview with the resident on 10/23/25 at 10:02 AM revealed the s/he had not received a shower for a week, and s/he was supposed to have showers on Mondays, Wednesdays, and Saturdays. Further interview revealed the resident had frequent diarrhea and that was why s/he needed 3 showers per week. 4. Interview with CNA #3 on 10/22/25 at 3:10 PM revealed 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. 5. Interview with CNA #4 on 10/23/25 at 10:05 AM revealed some days there were not enough CNAs to provide showers for the residents. Further interview revealed on a normal day the staff should be able to complete 4 to 5 showers, but there were days where they could only give 1 resident a shower because they had to prioritize answering call lights over showers. 6. Interview with the DON on 10/22/25 at 2:59 PM revealed

she had brought someone new into the position of scheduler, and was trying to get staff on a set rotation because she did not want a varied and chaotic schedule, but wanted a routine schedule for the staff. 7.

Interview with the DON on 10/23/25 at 2:38 PM revealed her expectation was for showers to be provided on

the scheduled day, and if they were unable to be provided, they would roll over to the next day. Further

interview revealed some residents had staff preference which turned into a missed opportunity to receive a shower, and this had been addressed with residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Big Horn Rehabilitation and Care Center

1851 Big Horn Ave Sheridan, WY 82801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm

.9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet