Polaris Rehab: Notification Failures - WY
The oversight was part of a pattern of failed pressure ulcer prevention that left residents vulnerable to serious complications, including one case where a resident developed sepsis from an untreated wound.
Resident #2 arrived at the facility on August 17 with multiple risk factors including repeated falls, a fractured left arm, diabetes, and cognitive impairment requiring assistance with basic daily activities. The admission assessment correctly identified the resident as being at risk for pressure ulcer development and noted no existing wounds.
Thirteen days later, everything changed.
On August 30, a nurse discovered a sacral wound with a foul odor and white appearance during a routine assessment. The nurse took pictures and notified the wound care specialist. By the following day, nursing notes documented the pressure ulcer as acquired in-house at the coccyx location.
Hours later, the same resident showed signs of sepsis. Nursing notes from August 31 recorded irregular pulse, low blood pressure, and an assessment stating "What I think is going on with the resident is: Sepsis."
The facility's wound care nurse, hired just weeks earlier in August, told inspectors she was struggling to keep up with assessments because administrators kept assigning her to work regular floor shifts instead of focusing on wound care. "She stated she was doing the best she could with the assessments; however, she continued to be assigned to the floor to work," the inspection report noted.
Meanwhile, basic care protocols were failing other residents. During the October inspection, investigators observed another resident lying on their back with heels pressed against the mattress. Blue protective boots sat unused on the bed beside a heel lift cushion. A certified care provider treating a new stage-1 pressure ulcer on the resident's buttock recommended an air mattress.
The nursing assistant who had bathed the sepsis patient confirmed to inspectors that socks remained on during the bath the day before the pressure ulcer was discovered. The aide acknowledged they "would not have been able to tell if there were wounds to the lower extremities" with the socks on.
This contradicted the facility's own pressure injury prevention policy, delivered to inspectors during the visit, which required staff to "inspect skin while providing care, paying close attention to bony prominences."
Weekly skin assessments for the sepsis patient had documented normal skin condition with "no new wounds noted" just days before the serious pressure ulcer was discovered, raising questions about the thoroughness of these evaluations.
The wound care nurse told inspectors the facility operated on a call-when-needed basis for wound checks rather than systematic monitoring. She confirmed the sepsis patient "did not have a pressure ulcer upon admission," meaning the facility failed to prevent a wound that developed under their care.
Federal regulations require nursing homes to ensure residents at risk for pressure ulcers receive preventive care and that existing wounds heal properly. The inspection found the facility failed on both counts, with inadequate skin monitoring allowing preventable wounds to develop and progress to serious complications.
The case illustrates how staffing decisions can cascade into patient harm. By pulling the wound care specialist away from specialized duties to cover general floor shifts, administrators compromised the facility's ability to prevent and treat pressure ulcers systematically.
For the resident who developed sepsis, the consequences extended far beyond a missed assessment. Sepsis from pressure ulcers can be life-threatening in elderly patients with multiple health conditions, particularly those with diabetes and cognitive impairment who may not be able to communicate pain or discomfort effectively.
The inspection documented minimal harm to few residents, but the sepsis case demonstrates how quickly inadequate prevention can escalate to serious medical emergencies requiring immediate intervention.
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 assessment correctly identified the resident as being at risk for pressure ulcer development and noted no existing wounds.
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.