Polaris Rehabilitation And Care Center

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

DON and NHA on 10/24/25 at 12:43 PM revealed the residents, which required assistance with eating, should sit at the same table and be served at the same time. 2. Review of the 9/16/25 quarterly MDS assessment for resident #5 showed a BIMS score was not determined; however, the staff assessment for mental status showed the resident to be independent with consistent/reasonable decision making. Review of the resident's care plan, initiated on 6/25/24, showed HOARDING: [resident] has a large collection of items, posing risk for falls Interventions included to Encourage [resident] to frequently declutter, Respect [resident's] right to collect items that do not pose risk, Speak respectfully and kindly when discussing [resident's] room, and Staff to help [resident] feel safe and secure. The following concerns were identified:a.

Observation and interview with resident #5 on 10/21/25 at 2:02 PM revealed s/he was upset because the [NHA] had someone come into [his/her] room and go through [his/her] things while s/he was in the hospital.

The resident stated the NHA had directed the social worker to inform him/her that his/her room was a fire hazard and needed to be cleaned up. Observation of the resident's room showed the area was cluttered and unorganized and the dresser drawers appeared to be broken. b. Review of a social services note, dated 10/6/25, showed we discussed organizing [the resident's] room, [s/he] does not have family to assist

in this as all family lives far away. [The resident] will need bins or bookshelves in order to complete this. [S/he] will look in to getting these so staff can help assist [him/her] to organize [his/her] room.c. Interview with the social services director on 10/22/25 at 9:59 AM revealed the NHA had sent her an email asking her to approach 7 different residents to inform them their rooms needed to be cleaned up. The social worker revealed she had spoken with resident #5 and offered to assist her with cleaning up her room since she did not have any family to help her.d. Review of nursing notes showed the resident was admitted to the hospital

on [DATE REDACTED] and was readmitted to the facility on [DATE REDACTED]. e. Interview with the EVS manager on 10/24/25 at 9:38 AM revealed she was instructed by the NHA to enter resident #5's room while the resident was in the hospital to retrieve any property which belonged to the facility. The EVS manager confirmed she had entered the resident's room without the resident's consent and had found and removed items such as linens and clothing protectors which belonged to the facility.f. Interview with the NHA on 10/24/25 at 12:43 PM confirmed she had authorized the EVS manager to enter the resident's room to remove any items which belonged to the facility.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Rehabilitation and Care Center

2700 E 12th Street Cheyenne, WY 82001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on medical record review, resident representative interview, staff interview, and policy and procedure review, the facility failed to ensure a notification of change of condition was given for 1 of 8 sample residents (#6) reviewed. The findings were:1. Review of the 10/9/25 admission MDS assessment for resident #6 showed the resident had a BIMS score of 12 out of 15 (moderately cognitively impaired), required partial to moderate assistance for toileting, showers, upper and lower body dressing, and putting

on and taking off footwear. The resident had diagnoses which included diabetes mellitus type 2 (DM2), transient cerebral ischemic attack, Parkinson's disease, muscle weakness, and dysphagia. Review of the care plan showed NUTRITIONAL STATUS: [resident name] is at risk for nutrition related problems r/t [related to] Parkinson's, DM2, PNA [pneumonia], dysphagia, anemia, HTN [hypertension], chronic respiratory failure, transient cerebral ischemic attack, AOC respiratory failure, falls. Resident/family decline recommended NPO diet and request regular chopped textures. They have been educated on risks associated with declining recommendations and understand risks involved with PO intake given MBSS indicating aspiration on all textures. Date Initiated: 10/04/2025 Revision on: 10/09/2025, Target Date: 01/13/2026. Explain and reinforce to the resident the importance of maintaining the diet ordered. Review of

the physician orders showed diet, regular texture, regular consistency. The following concerns were identified: a. Interview with resident #6 on 10/21/25 at 2:10 PM revealed s/he was getting enough food; however, was not sure what was being served as it was in the form of blobs. b. Interview with the residents' family on 10/23/25 at 4:25 PM revealed the resident was to be on a regular diet, not a mechanical soft diet.

The resident's representative stated the facility did not notify them of the change in diet for the resident. c.

Review of the meal card for the resident on 10/23/25 showed a mechanical soft chopped diet was specified for all 3 meals. d. Interview with the NHA on 10/24/25 at 12:50 PM revealed the resident's diet was recommended following a speech language pathology evaluation, and confirmed the family was not notified of the diet change. 2. Review of policy Change in a Resident's Condition or Status hand delivered on 10/23/25 at 5:15 PM by the NHA showed .4. Unless otherwise instructed by the resident, a nurse will notify

the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. there is a significant change in the resident's physical, mental, or psychosocial status .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Rehabilitation and Care Center

2700 E 12th Street Cheyenne, WY 82001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review, resident representative interview, and staff interview, the facility failed to ensure routine bathing was provided for 2 of 8 sample residents (#1, #5) reviewed for activities of daily living. The findings were: 1. Review of the 8/7/25 significant change assessment for resident #1 showed s/he was determined to be severely cognitively impaired and exhibited inattention and disorganized thinking

on a continuous basis and suffered from delusions. The resident was totally dependent on staff for all areas of self-care and mobility. Review of the resident's ADL care plan, last revised 9/15/25, showed the resident was a 1 to 2 person assist with bathing and preferred showers on Tuesdays and Fridays. The following concerns were identified: a. Review of the October 2025 bathing documents, provided by the facility on 10/23/25 at 5:23 PM, showed the resident was given a bed bath on 10/8/25 at 11 PM and a shower on 10/16/25 (2 baths in 22 days). Interview with LPN #1 on 10/23/25 at 5:30 PM confirmed the bathing sheets were correct. b. Interview with the resident's representative on 10/23/25 at 3:57 PM revealed the facility said

they were going to bathe [him/her] but do not do it. 2. Review of the 9/16/25 quarterly MDS assessment for resident #5 showed a BIMS score was not determined; however, the staff assessment for mental status showed the resident to be independent with consistent/reasonable decision making. Further review showed

the resident was not coded as rejecting care during the look-back period. Review of the resident's care plan, last revised 8/20/25, showed the resident preferred a shower in the morning right after breakfast twice

a week on Tuesday and Friday. Further review of the resident's care plan, initiated on 8/25/25, showed the resident was resistive to bathing/showering, at times, with interventions which included If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Document all refusals. The following concerns were identified: a. Review of the Daily Shower Sheets, dated 10/3/25 through 10/24/25, for the resident showed the resident had received a bed bath on 10/10 after refusing on 10/8 and 10/9, and was in the hospital from 10/17 to 10/19. Review of the nurse progress notes showed the resident was educated on the importance of bathing on 10/9/25 and 10/15/25. There was no documentation the resident had refused to be bathed. No further documentation was available.3. Interview with the DON and NHA on 10/24/25 at 12:40 PM revealed they had identified the need to provide a better quality of care.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Rehabilitation and Care Center

2700 E 12th Street Cheyenne, WY 82001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

(Sat and as needed). e. Observation of the resident on 10/23/25 at 12:40 PM, while CCP was finishing wound care, showed the resident was lying on his/her back, heels down on the mattress, blue boots were

on the bed, a heel lift cushion was beside the bed, a ribbed mattress, and a wedge was between the resident's legs. Interview at that time with the CCP provider revealed the resident had a new pressure ulcer to the buttock stage 1. The CCP provider stated they were going to recommend an air mattress. Further,

interview revealed the facility calls the agency when they want a wound check. f. Interview with the wound care nurse on 10/22/25 at 1 PM revealed she was hired on as the wound care nurse in August. She stated

she was doing the best she could with the assessments; however, she continued to be assigned to the floor to work. g. Interview with a CNA on 10/22/25 during the afternoon revealed when s/he did the bed bath for

the resident the day before the pressure ulcer was identified the resident's socks were not removed during

the bath The CNA confirmed s/he would not have been able to tell if there were wounds to the lower extremities. 2. Review of 8/22/25 admission MDS assessment for resident #2 showed s/he was coded as being moderately cognitive impaired, The assessment showed the resident required partial/moderate assistance with eating, toileting, showers, upper body dressing, lower body dressing, and putting on footwear. The diagnoses included repeated falls, displaced fracture of upper end of left humerus, weakness, other specified disorders of bone density and structure, and diabetes mellitus. Further, review showed the resident was at risk for pressure ulcer development, had no pressure ulcers, and had a pressure reducing chair and bed. Review of the 8/17/25 care plan showed skin/connective tissue goal to maintain clean and intact skin. The interventions included weekly skin checks by a licensed nurse. The following concerns were identified: a. Review of a nursing progress notes dated 8/30/25 at 11:12 AM showed This nurse assessed residents skin and observed a sacral would (sic). Odor is present with white appearance on wound. Wound nurse notified with pictures taken on wound care phone. Review of the nursing progress note dated 8/31/25 at 10:17 AM showed .#002: Skin issue has not been evaluated. Location: Coccyx. Issue type: Pressure ulcer / injury. Wound acquired in-house. Further review of the nursing progress noted showed on 8/31/25 at 2:09 PM SBAR Summary: Vitals Signs: BP 103/60 - 8/31/2025 13:12 Position: Other , P 60 - 8/31/2025 13:12 Pulse Type: Irregular - new onset , R 20.0 - 8/31/2025 10:36, T 98.0 - 8/31/2025 10:36 Route: Forehead (non-contact), .RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: Sepsis. b. Review of the Weekly Skin assessment dated [DATE REDACTED] showed the skin turgor: good, elasticity, color: normal, temperature: warm (normal), moisture: normal, condition: normal, no new wounds noted. c. Interview with the wound care nurse on 10/23/25 at 2:50 PM revealed the resident did not have a pressure ulcer upon admission.3. Review of policy Pressure Injury Prevention Guidelines hand delivered on 10/23/25 at 4:10 PM showed To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present.Preventive Skin Care: 1 . Inspect skin while providing care, paying close attention to bony prominences.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Rehabilitation and Care Center

2700 E 12th Street Cheyenne, WY 82001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690

provide a better quality of care.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Rehabilitation and Care Center

2700 E 12th Street Cheyenne, WY 82001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

a struggle to find a second person to assist with resident care, when required, and a lot of time was wasted searching for help which frustrated both the staff members and the residents. Staff #8 further revealed the North hall had a few residents which were needy and certain CNAs would not address their needs which led to their call lights being left on for extended periods of time. Further, the facility was short of bariatric briefs and wipes and staff would have to scramble or someone from management would be sent out to shop. i. Interview with staff # 9 revealed the therapy department was unable to work efficiently due to the residents' basic cares not being addressed, the high acuity of residents, and the lack of staff impeded the ultimate goal of discharge. Staff #9 stated 35% of the residents on the North hall and 51% of the residents

on the South hall required a lift for transfers. j. Interview with staff #10 revealed s/he was unable to perform his/her responsibilities up to [his/her] own standards. Staff #10 stated s/he was overwhelmed and felt like s/he was rushing through cares; was unable to help residents with the little stuff; was not providing showers as per the schedule; was unable to round on his/her residents every two hours and oftentimes s/he would only be able to round 3 times per a 12-hour shift. k. Interview with staff #11 revealed everyday was hectic with the weekends being even worse. Staff #11 stated s/he was overwhelmed and could not give his/her best care noting showers were not being completed timely; charting was not done; meals were delivered late; and s/he admitted to transferring a resident, who required 2 staff members, without assistance because s/he could not find help. l. Interview with staff #12 revealed the day-shift staff struggled to complete resident care in a timely manner leaving residents in wet incontinence products for extended periods of time. m. Interview with staff #13 revealed s/he had observed residents which did not receive adequate pericare and timely incontinence care which made it difficult for the therapy department to provide rehabilitation services because the therapy department would have to either wait for the CNAs to perform

the task or step in and perform the task themselves. In addition, staff #13 revealed facility staff were stressed as the human resource director, maintenance director, and admissions director recently were terminated from their positions, and the director of nursing had walked out. Further, staff #13 stated it was his/her opinion staff did not work as a team to provide resident care. n. Interview with staff #14 revealed the administrator had informed the staff the facility was not short-staffed and their numbers were okay. Staff #14 stated resident care was not okay. o. Interview with staff #15 revealed it was difficult to complete his/her job due to having to either wait for a CNA to provide care prior to a rehabilitation session or having to provide

the care him/herself. Staff #15 stated if s/he provided the care it would cut into the minutes s/he could work with the resident. In addition, s/he had seen a decline in the last month with staff being overwhelmed. p.

Interview with staff #16 revealed the facility had a lot of shake-ups lately. q. Interview with staff #17 revealed treatment plans were not being followed due to resident needs not being addressed which caused the residents' rehabilitation sessions to be rushed.6. Interview with the NHA on 10/24/25 at 12:43 PM revealed

the corporation had recently developed a census tool to determine the staffing needs of the facility. The NHA stated the facility was working within the provided budget and on paper the facility was adequately staffed.7. Interview with the chief executive officer (CEO) of the corporation on 10/24/25 at 1:47 PM revealed the corporation was doing what they could and finding CNAs was challenging. The CEO stated the facility was always trying to meet the PPD established to help them to be a reliable business; however, the facility's census was currently about 20 residents short of average. In addition, the CEO stated they were doing the best they could and did not want to cut direct care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Rehabilitation and Care Center

2700 E 12th Street Cheyenne, WY 82001

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

greet [him/her] and turning [his/her] back and changing directions, 'stating, Leave me alone!g. Review of the nurses' progress notes for July 2025 failed to include when or what triggered the decline in the resident's functional status.h. Review of a 8/4/25 nurse's note showed Follow up scheduled today from previous hospital visit at neurology .Resident is unable at times to sit up in wheelchair for staff to attempt to take [him/her] .i. Review of a 8/17/25 nurse's note, showed Residents son approached this nurse and stated that

he wants resident off of Valproic Acid. This nurse educated son of mechanism of action of the medication and reason for being on this medication and the risk of seizure activity when taken off the drug. Residents son stated an understanding and is willing to take the risk of resident being tapered off medication.

Residents son requested keppa (sic) as a alternate. This nurse notified NP and awaiting orders. j. Interview with CNA #4 on 10/22/25 at 4:30 PM revealed the resident was ambulatory and had aggressive behaviors upon admission and had declined after the onset of seizures. The CNA stated the resident had improved and was now able to communicate in complete sentences. k. Interview with RN #1 on 10/21/25 at 4:39 PM revealed the resident was mobile upon admission; however, did not know what had caused the resident's decline from independent to dependent. The RN stated the resident used to be bed-bound and required repositioning every hour. In addition, the RN stated the resident had improved since s/he was taken off valproic acid. l. According to WebMD located at https://www.webmd.com/interaction-checker/default.htm and accessed on 11/4/25 showed significant interaction was possible and monitoring by a physician was required as valproic acid, olanzapine, and melatonin each cause an increase in sedation and drowsiness.

1. 2. Interview with the DON and NHA on 10/24/25 at 12:40 PM revealed neither were in the facility in July.

They stated they did not know what happened with the medications and the resident at that time. In addition, both the DON and NHA revealed they had identified the need to provide a better quality of care.

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Facility ID:

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