Polaris Rehab: Daily Care Failures Cited - WY
The admission occurred during an October inspection that found multiple failures in pressure ulcer prevention and wound monitoring. The facility's own wound care nurse told inspectors she was doing "the best she could" with assessments but continued being assigned to floor work instead of wound care duties.
Federal inspectors documented the case of a resident admitted in August with diabetes, repeated falls, and a displaced fracture of the upper arm. The resident required partial assistance with eating, toileting, and dressing, and was assessed as being at risk for pressure ulcer development.
Despite having a care plan goal to "maintain clean and intact skin" with weekly skin checks by licensed nurses, the resident developed a pressure ulcer to the buttocks within two weeks of admission.
A nursing progress note from August 30 documented the discovery: "This nurse assessed residents skin and observed a sacral would. Odor is present with white appearance on wound." The next day, another note indicated the wound had not been evaluated and was classified as a pressure ulcer acquired in-house.
By August 31, nursing staff suspected sepsis. A progress note that day recorded irregular pulse as a new onset symptom and stated the nurse's assessment was "What I think is going on with the resident is: Sepsis."
The wound care nurse, hired in August, told inspectors the resident did not have a pressure ulcer upon admission. She revealed that the facility calls the contracted wound care agency only when they want a wound check, rather than following a regular schedule.
During the inspection, investigators observed another resident receiving wound care. The person was lying with heels down on the mattress, blue protective boots sitting unused on the bed, and a heel lift cushion beside the bed rather than in use. The contracted wound care provider discovered a new stage 1 pressure ulcer on the resident's buttock and recommended an air mattress.
The facility's own policy, handed to inspectors during the survey, requires staff to "inspect skin while providing care, paying close attention to bony prominences" and implement "evidence-based interventions for all residents who are assessed at risk."
Yet the CNA interviewed confirmed that during bed baths the day before pressure ulcers were identified, residents' socks remained on throughout the washing process. This practice directly contradicted the facility's stated commitment to thorough skin inspection during care.
A weekly skin assessment form showed boxes checked for normal skin condition with "no new wounds noted," despite the documented presence of pressure ulcers requiring treatment.
The inspection revealed a pattern where preventive equipment sat unused while residents developed the very injuries it was meant to prevent. Heel lifts and protective boots were observed beside beds rather than properly positioned on residents' feet.
The wound care nurse's divided attention between wound assessment duties and general floor assignments meant specialized care took a backseat to routine tasks. Her acknowledgment of doing her "best" while being pulled away from wound care responsibilities highlighted the facility's resource allocation problems.
Federal inspectors classified the violations as causing minimal harm with few residents affected, but the documentation shows a cascade of missed opportunities to prevent serious complications.
The resident who developed sepsis symptoms represents the human cost of inadequate skin monitoring. What began as missed prevention became a potentially life-threatening infection, all while weekly assessment forms continued to indicate normal skin condition.
The facility's policy promised evidence-based interventions and close attention to vulnerable areas. The reality observed by inspectors showed protective equipment unused, specialized staff reassigned to general duties, and basic hygiene practices that concealed rather than revealed developing wounds.
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 admission occurred during an October inspection that found multiple failures in pressure ulcer prevention and wound monitoring.
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.