Big Horn Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Big Horn Rehabilitation and Care Center, in the surveyor’s own words.

• Actual harm, isolatedF658Oct 23, 2025

  Based on medical record review, facility incident review, and staff interview, the facility failed to ensure that services provided met professional standards for 2 of 4 sampled residents (#1, #7) reviewed for quality of care. This failure resulted in actual harm to resident #1 and #7. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, diabetes mellitus, hypertension, and arthritis. Review of the facility incident report dated 9/23/25 showed the resident had been found on the floor following a fall in his/her room and had been assisted to a wheelchair by staff. The resident complained of nausea and numbness to the arms. […]

• Actual harm, isolatedF684Oct 23, 2025

  Based on medical record review, staff interview, facility incident review, and policy review, the facility failed to implement interventions and treatment to prevent a decline in condition for 1 of 4 sampled residents (#1) reviewed for quality of care. This failure resulted in actual harm to residents #1. The findings were:1. Review of the admission MDS assessment dated [DATE] showed resident #1 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included cancer, diabetes mellitus, hypertension and arthritis. The following concerns were identified: a. Review of the facility incident report dated 9/23/25 showed the resident had been found on the floor following a fall in his/her room and had been assisted to a wheelchair by staff. […]

• Actual harm, isolatedF600Dec 21, 2023

  Based on medical record review, resident and staff interviews, facility performance improvement plan review, State Survey Agency incident database review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 2 of 4 sample residents (#2, #4) reviewed for abuse allegations. This failure resulted in actual harm to resident #2 who sustained injuries during a resident to resident altercation. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 11/30/23. The findings were: 1. […]

• Actual harm, isolatedF600May 12, 2023

  Based on observation, medical record review, staff interview, facility incident investigation review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 8 sample residents (#6) reviewed with resident-to-resident altercations. This failure resulted in harm to resident #6 who was struck in the face with a belt, resulting in injury to the face. The findings were: 1. Review of the 4/10/23 quarterly MDS assessment showed resident #6 had a brief interview for mental status (BIMS) score of 0 out 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. […]

• Actual harm, isolatedF684Feb 8, 2023

  Based on medical record review, staff and resident interview, and policy and procedure review, the facility failed to ensure 1 of 5 sample residents (#1) reviewed for bowel management received the appropriate care and treatment to address constipation. This failure resulted in hospitalization and actual harm to the resident. The findings were: 1. Review of the 9/20/22 quarterly MDS assessment showed resident #1 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy and had a BIMS score of 15/15 (cognitively intact). Further review showed the resident was always continent of bowel and required the extensive assistance of 2 or more staff members for toilet use and transfers. […]