Polaris Rehab: Pressure Ulcer Care Failures - WY
The wound care nurse at Polaris Rehabilitation and Care Center told inspectors she "was doing the best she could with the assessments; however, she continued to be assigned to the floor to work." She had been hired specifically as the wound care nurse in August.
One resident developed a stage 1 pressure ulcer on the buttock while receiving what inspectors determined was inadequate monitoring. When a certified nursing assistant gave the resident a bed bath the day before the pressure ulcer was identified, the CNA didn't remove the resident's socks during the bath.
The CNA confirmed to inspectors "s/he would not have been able to tell if there were wounds to the lower extremities."
Inspectors observed the resident on October 23 lying on his back with heels down on the mattress. Blue boots sat on the bed beside a heel lift cushion that wasn't being used. A wedge was positioned between the resident's legs on a ribbed mattress.
The wound care provider told inspectors the resident had developed the new pressure ulcer and recommended an air mattress. The facility called the outside agency only when they wanted a wound check, rather than following a regular assessment schedule.
A second resident's case revealed more serious problems with wound monitoring. This resident was admitted in August with moderate cognitive impairment, diabetes, and a history of repeated falls and fractures. The admission assessment showed the resident was at risk for pressure ulcer development but had no existing wounds.
The care plan called for weekly skin checks by a licensed nurse to maintain "clean and intact skin."
Instead, nursing notes from August 30 documented a discovery that suggested the weekly checks weren't happening. "This nurse assessed residents skin and observed a sacral would," the note read, with "odor is present with white appearance on wound."
The wound care nurse was notified and pictures were taken. The following day's nursing progress note confirmed the "skin issue has not been evaluated" and identified it as a pressure ulcer acquired in-house at the coccyx location.
By August 31, the resident's condition had deteriorated significantly. Nursing notes from that afternoon documented vital signs including an irregular pulse described as "new onset" and a nurse's assessment concluding "what I think is going on with the resident is: Sepsis."
The wound care nurse confirmed to inspectors that this resident "did not have a pressure ulcer upon admission."
Meanwhile, weekly skin assessment forms showed a disconnect between policy and practice. One assessment marked skin condition as "normal" with "no new wounds noted" despite the documented pressure ulcer development.
The facility's own policy, handed to inspectors during the visit, stated it was committed to "implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present." The policy specifically required staff to "inspect skin while providing care, paying close attention to bony prominences."
But inspectors found the facility failing to follow its own preventive skin care protocols. The wound care nurse's repeated assignment to floor duties left residents without the specialized assessment and monitoring they needed.
The nursing assistant's failure to remove socks during bathing meant potential wounds on lower extremities went undetected. Weekly skin checks either weren't performed as scheduled or failed to identify developing problems before they became serious.
For the resident who developed sepsis, the progression from an unnoticed wound to a life-threatening infection illustrated the consequences of inadequate monitoring. The facility's practice of calling the wound care agency only when problems were already identified, rather than for preventive assessments, left residents vulnerable during the critical early stages of pressure ulcer development.
Both residents required more intensive interventions that might have been prevented with proper wound monitoring and the wound care nurse's availability to perform her specialized duties.
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.
One resident developed a stage 1 pressure ulcer on the buttock while receiving what inspectors determined was inadequate 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.