Polaris Rehab: Pressure Ulcer Care Failures - WY
The answer was in the medication record.
Federal inspectors cited the facility for actual harm after finding that the resident had been prescribed valproic acid, olanzapine, and melatonin at the same time. All three drugs increase sedation. Inspectors flagged a significant interaction risk requiring physician monitoring. That monitoring didn't happen.
The resident's decline tracked directly to the onset of seizures. A certified nursing assistant told inspectors on October 22 that the resident had been ambulatory and showed aggressive behaviors on admission, then deteriorated after the seizures began. Nurses' progress notes from July 2025 failed to record when the decline started or what triggered it.
The resident's son pushed back. A nurse's note from August 17 documented him requesting that his parent be taken off valproic acid entirely and switched to Keppra. The nurse documented educating him about seizure risk. He said he understood and was willing to accept that risk. The request went to the nurse practitioner. The note ends there.
After the medication change finally happened, the resident improved. RN #1 told inspectors the resident had previously been bed-bound and needed hourly repositioning. By the time of the interview, the resident could communicate in complete sentences again.
The director of nursing and the nursing home administrator were interviewed together on October 24. Neither had been at the facility in July. Both said they didn't know what had happened with the medications or the resident during that period. Both acknowledged they had identified a need to provide better quality of care.
The nurses' notes from July, the months of unexplained decline, the three sedating drugs given together without documented oversight — none of it was investigated by the people now running the building. They had not been there. Nobody who had been there left a record that explained it.
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: August 6, 2026 · Our methodology
Polaris Rehabilitation and Care Center in Cheyenne, WY was cited for violations during a health inspection on October 24, 2025.
The answer was in the medication record.
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.