Polaris Rehab: Resident Dignity Violations - WY
The assistant confirmed during an October 22 interview that socks remained on during the previous day's bath, acknowledging "s/he would not have been able to tell if there were wounds to the lower extremities."
This basic oversight occurred as the facility struggled with pressure ulcer prevention and wound care assessment. Federal inspectors found the 82-year-old resident developed a stage 1 pressure ulcer on the buttock despite being identified as high-risk for such injuries upon admission in August.
The resident required partial assistance with most daily activities and had multiple risk factors including repeated falls, a displaced fracture of the upper left arm, weakness, and diabetes. The care plan specifically called for weekly skin checks by licensed nurses to maintain "clean and intact skin."
But those assessments fell short.
On August 30, a nurse documented discovering a sacral wound with odor and "white appearance," noting pictures were taken for the wound care nurse. The next day's progress notes revealed the skin issue "has not been evaluated" and confirmed the pressure ulcer was "acquired in-house."
By August 31, nursing staff suspected sepsis, documenting irregular pulse patterns and conducting a full assessment of the resident's deteriorating condition.
The facility's wound care nurse, hired in August, told inspectors she was "doing the best she could with the assessments" but was continually pulled away to work on the floor instead of focusing on wound care duties. She confirmed the resident had no pressure ulcers upon admission.
During the October inspection, observers found the resident lying on his back with heels directly on the mattress. Blue protective boots sat unused on the bed alongside a heel lift cushion. A wedge was positioned between the resident's legs, and the person was on a ribbed mattress.
The wound care provider told inspectors about discovering a new stage 1 pressure ulcer on the resident's buttock and planned to recommend an air mattress. The provider explained the facility contacts their agency "when they want a wound check" rather than maintaining regular assessment schedules.
Weekly skin assessments painted a misleading picture of care quality. Documentation from the period showed skin described as having "good" turgor and elasticity, "normal" color and temperature, with "no new wounds noted" - contradicting the actual discovery of pressure ulcers during the same timeframe.
The facility's own pressure injury prevention policy, delivered to inspectors on October 23, emphasized implementing "evidence-based interventions for all residents who are assessed at risk." The policy specifically required staff to "inspect skin while providing care, paying close attention to bony prominences."
Yet the nursing assistant's failure to remove socks during bathing directly violated this basic inspection requirement, potentially allowing wounds to develop undetected on the resident's feet and lower legs.
The resident's case illustrated systemic problems with wound prevention protocols. Despite being classified as high-risk and having specific interventions documented in the care plan, the person developed an avoidable pressure injury within two weeks of admission.
The wound care nurse's dual responsibilities - being assigned to floor duties while trying to manage wound assessments - created gaps in specialized care. Her August hiring coincided with the resident's admission, suggesting the facility was already struggling to maintain adequate wound care staffing.
Federal inspectors classified the violations as causing minimal harm with few residents affected, but the case demonstrated how basic care failures can escalate quickly. The resident's progression from a missed skin assessment to suspected sepsis occurred within days, highlighting the serious consequences of inadequate wound monitoring.
The nursing assistant's admission about the sock oversight revealed a fundamental breakdown in bathing protocols that could affect multiple residents receiving similar 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 care plan specifically called for weekly skin checks by licensed nurses to maintain "clean and intact skin." But those assessments fell short.
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.