Cycle 1
Health 2024-09-13 · Fire 2024-09-13
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Sheridan, WY
Big Horn Rehabilitation and Care Center
1-star overall rating with 1-star inspections with Special Focus status with $10,585 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1851 Big Horn Ave, Sheridan, WY
(307) 674-4416
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.90 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.48 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.62 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 53% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,113
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9941
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.97
Baseline 22.05% · Performance 18.80% · Measure score 5.97 · Achievement 5.68 · Improvement 5.97
Healthcare-associated infections
5.26
Baseline 7.59% · Performance 6.26% · Measure score 5.26 · Achievement 5.26 · Improvement 4.62
Total nurse turnover
3.64
Baseline 68.92% · Performance 50.67% · Measure score 3.64 · Achievement 3.18 · Improvement 3.64
Adjusted total nurse staffing
1.62
Baseline 2.80 hours · Performance 3.43 hours · Measure score 1.62 · Achievement 1.24 · Improvement 1.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.79% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 6.25% · Lower 95% interval 5.98% |
| Discharge to community | 47.57% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 45.07% · Lower 95% interval 36.09% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 69 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 56.25% |
53.69%
2.6 pts better
|
Numerator 27 · Denominator 48 |
| Discharge mobility score | 60.42% |
50.94%
9.5 pts better
|
Numerator 29 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 3 · Denominator 72 · Adjusted rate 5.5% |
| Healthcare-associated infections requiring hospitalization | 6.26% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 2.17% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 68.75% |
56.45%
12.3 pts better
|
Numerator 33 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 2.13% |
25.2%
23.1 pts worse
|
Numerator 1 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.2
0.7 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
94.3%
1.6 pts worse
|
93.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 92.6% · Q3 93.8% · Q4 94.2% · 4Q avg 92.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 67.9% |
94.3%
26.4 pts worse
|
95.5%
27.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 67.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
4.8%
0.8 pts better
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.9% · Q3 3.1% · Q4 4.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
6.4%
2.5 pts worse
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.7% · Q3 7.3% · Q4 8.9% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
6.5%
4 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 13.6% · Q3 8.8% · Q4 13.3% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.9% |
16.1%
3.2 pts better
|
19.6%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.5% · Q3 19.0% · Q4 13.1% · 4Q avg 12.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.0% |
24.1%
2.9 pts worse
|
16.7%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 25.0% · Q3 23.1% · Q4 25.0% · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.4% |
18.5%
5.1 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 24.8% · Q3 11.9% · Q4 5.2% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
18.7%
7.1 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 11.1% · Q3 7.0% · Q4 13.3% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.9%
0.2 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 4.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
3.0%
1.9 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.6% · Q4 1.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
23.6%
1.4 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 27.0% · Q3 17.4% · Q4 30.1% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.0%
0.7 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 10.0% · Q3 3.7% · Q4 3.1% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
75.7%
0.3 pts worse
|
81.7%
6.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 48.7% · Q2 73.1% · Q3 86.3% · Q4 86.0% · 4Q avg 75.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
13.7%
2.3 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.1% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.6%
0.6 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.3% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 52.9% |
77.0%
24.1 pts worse
|
79.7%
26.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 52.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.5% |
20.8%
14.7 pts worse
|
23.9%
11.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.5% · Observed 33.3% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-10-05 · Fire 2023-10-05
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-09-13
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-10-07
F · Potential for more than minimal harm
2024-04-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-25
F · Potential for more than minimal harm
2024-04-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-25
F · Potential for more than minimal harm
2024-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-04-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-25
F · Potential for more than minimal harm
2023-10-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-10-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-10-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-27
F · Potential for more than minimal harm
2023-10-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-27
Inspection history
Recent health citations
G · Actual harm
2025-10-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-21
G · Actual harm
2025-10-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-10-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-10-23
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-10-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-10-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-10-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-10-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-10-08
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-10-30
D · Potential for more than minimal harm
2025-01-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-24
E · Potential for more than minimal harm
2024-11-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-11-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-06
E · Potential for more than minimal harm
2024-09-13
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-09-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-09-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-09-13
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-09-13
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-09-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-04-04
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-04-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-04-04
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-10
G · Actual harm
2023-12-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-10-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-05
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-05
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-10-27
G · Actual harm
2023-05-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-13
Penalties and ownership
What sits behind the stars
$0
2025-10-08
Payment Denial
Payment Denial · denial start 2025-11-13 · 8 days
8 day denial
$7,163
2023-12-21
Fine
Fine · fine $7,163
Fine
$3,422
2023-05-12
Fine
Fine · fine $3,422
Fine
Ownership
Cheyenne Sheridan Opco Holdings LLC
Operational/Managerial Control · Organization
Connell, Eric
Operational/Managerial Control · Individual
Connell, Eric
Corporate Officer · Individual
Morrison, Robert
Operational/Managerial Control · Individual
Roberts, Ana
Operational/Managerial Control · Individual
Sheridan Opco LLC
Operational/Managerial Control · Organization
Simmons, Benjamin
Corporate Director · Individual
Simmons, Benjamin
Corporate Officer · Individual
Winterholler, David
Corporate Director · Individual
Nearby options
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1-star overall rating with 1-star inspections with Special Focus status with $103,408 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Westview Health Care Center
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5-star overall rating with 5-star inspections
#3
Amie Holt Care Center
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5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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