Big Horn Rehabilitation and Care Center
1851 Big Horn Ave · Sheridan, WY · 82801 · 3076744416
128 certified beds For profit - Limited Liability company
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- 3 citations involved actual harm to residents.
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Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
63% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.30 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.48 | 0.55–0.75 |
| Weekend hours / resident-day | 2.95 | ≈ weekday level |
| Nursing turnover / year | 63% | median 45% |
| Fines (3-yr window) | 1 · $7,163 |
Inspection citations (46 in the current record)
-
Potential for harm · E May 7, 2026
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has no plan of correction · Resident Rights
-
Potential for harm · F May 7, 2026
Keep residents' personal and medical records private and confidential.
Deficient, Provider has no plan of correction · Resident Rights
-
Potential for harm · D May 7, 2026
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has no plan of correction · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D May 7, 2026
Respond appropriately to all alleged violations.
Deficient, Provider has no plan of correction · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D May 7, 2026
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Deficient, Provider has no plan of correction · Resident Rights
-
Potential for harm · D May 7, 2026
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Deficient, Provider has no plan of correction · Resident Rights
-
Potential for harm · D May 7, 2026
Provide activities to meet all resident's needs.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · E May 7, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · D May 7, 2026
Provide care or services that was trauma informed and/or culturally competent.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · E May 7, 2026
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Deficient, Provider has no plan of correction · Pharmacy Service
-
Potential for harm · E May 7, 2026
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Deficient, Provider has no plan of correction · Administration
-
Potential for harm · E May 7, 2026
Provide and implement an infection prevention and control program.
Deficient, Provider has no plan of correction · Infection Control
-
Potential for harm · E May 7, 2026
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has no plan of correction · Infection Control
-
No harm found · C May 7, 2026
Ensure the activities program is directed by a qualified professional.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · D February 5, 2026 · found via complaint
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected April 19, 2025 · Resident Rights
-
Potential for harm · E February 5, 2026 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected March 10, 2026 · Resident Rights
-
Potential for harm · D February 5, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 10, 2026 · Quality of Life and Care
-
Potential for harm · F February 5, 2026 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 10, 2026 · Nutrition and Dietary
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Potential for harm · D February 5, 2026 · found via complaint
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected March 10, 2026 · Administration
-
Actual harm · G October 23, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected November 21, 2025 · Resident Assessment and Care Planning
-
Actual harm · G October 23, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 21, 2025 · Quality of Life and Care
-
Potential for harm · E October 23, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected November 21, 2025 · Quality of Life and Care
-
Potential for harm · D October 23, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 21, 2025 · Quality of Life and Care
-
Potential for harm · E October 23, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected November 21, 2025 · Nursing and Physician Services
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Potential for harm · D October 23, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected November 21, 2025 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 8, 2025 | Payment Denial | 8 days |
| December 21, 2023 | Fine | $7,163 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 535026 · certified since June 1, 1978. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.