Polaris Rehab: Bladder Care Deficiencies - WY
The resident, admitted in August with multiple fall injuries and a fractured left arm, developed a pressure ulcer that went undetected for days. When staff finally discovered the wound, the resident showed signs of sepsis.
Federal inspectors found the facility failed to follow basic skin inspection protocols during routine care. The nursing assistant confirmed during an interview that socks remained on during the bath the day before a pressure ulcer was identified, acknowledging they "would not have been able to tell if there were wounds to the lower extremities."
The resident's condition deteriorated rapidly once the wound was discovered. A nursing progress note from August 30 documented a sacral wound with odor and "white appearance." The next day, another note indicated the resident had developed sepsis, with irregular pulse noted as a new onset symptom.
Staff had assessed the resident as high-risk for pressure ulcer development upon admission. The care plan included weekly skin checks by licensed nurses and pressure-reducing equipment for both bed and chair. Despite these precautions, the facility's wound care nurse told inspectors the resident "did not have a pressure ulcer upon admission," confirming the wound developed while under the facility's care.
The wound care nurse, hired in August, revealed systemic staffing problems that compromised patient care. She told inspectors she was "doing the best she could with the assessments" but "continued to be assigned to the floor to work" instead of focusing on wound care duties.
During an inspection visit, investigators observed another resident lying with heels directly on the mattress while protective blue boots sat unused on the bed. A heel lift cushion lay beside the bed rather than supporting the resident's feet. The certified care provider treating this resident discovered a new stage 1 pressure ulcer on the buttock and planned to recommend an air mattress.
The facility's own policy requires staff to "inspect skin while providing care, paying close attention to bony prominences." The document, delivered to inspectors during their visit, emphasizes implementing "evidence-based interventions for all residents who are assessed at risk."
Weekly skin assessments for the diabetic resident showed contradictory documentation. One assessment noted "normal" skin condition with "no new wounds noted" despite the presence of the documented sacral pressure ulcer.
The resident required moderate assistance with basic activities including eating, toileting, showering, and dressing due to cognitive impairment and physical limitations from the fall injuries. These factors increased vulnerability to pressure ulcers, particularly given the diabetes diagnosis that can impair wound healing.
Inspectors found the facility calls their contracted wound care agency only when requesting wound checks, rather than maintaining consistent oversight. This reactive approach contributed to delayed identification of the resident's deteriorating condition.
The case illustrates how seemingly minor lapses in basic care protocols can cascade into serious medical complications. Removing socks during routine bathing represents a fundamental aspect of comprehensive skin assessment, particularly for high-risk residents with diabetes and mobility limitations.
Federal regulations require nursing homes to prevent avoidable pressure ulcers through systematic skin inspection and evidence-based interventions. The facility received a citation for failing to provide adequate care to prevent pressure ulcers, with inspectors noting the violations affected few residents but carried potential for actual harm.
The resident who developed sepsis from the undetected pressure ulcer faced complications that could have been prevented through proper adherence to the facility's own skin inspection protocols during routine personal care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Polaris Rehabilitation and Care Center from 2025-10-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Polaris Rehabilitation and Care Center in Cheyenne, WY was cited for violations during a health inspection on October 24, 2025.
The resident, admitted in August with multiple fall injuries and a fractured left arm, developed a pressure ulcer that went undetected for days.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.