Polaris Rehabilitation And Care Center
Polaris Rehabilitation and Care Center in Cheyenne, WY — inspection on January 15, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the 12/30/25 quarterly MDS assessment showed the resident was administered an antipsychotic medication during the 7-day look-back period.
The resident had diagnoses of non-traumatic brain dysfunction, cancer, hypertension, Alzheimer's disease, non-Alzheimer's dementia, unspecified pulmonary disease, respiratory failure, pain in right hip, primary thrombophilia, hearing loss, osteoarthritis, abnormalities of gait and mobility, and lack of coordination.
The following concerns were identified:a.
Review of the resident's care plan, initiated on 10/29/25, showed the resident used psychotropic medications related to dementia with behavioral disturbance.
Review of the September 2025 medication administration record showed the resident was administered 25 milligrams of Seroquel (antipsychotic medication) two times a day for dementia with behavioral disturbances with a start date of 9/9/25.
Review of the entire medical record showed no evidence the diagnosis of dementia with behavioral disturbances had been documented by a provider. b.
Interview with the DON on 1/15/26 at 10:57 AM confirmed the diagnosis of dementia with behavioral disturbances was not documented in the resident's medical record.
535025 01/15/2026
Polaris Rehabilitation and Care Center 2700 E 12th Street Cheyenne, WY 82001
Review of the
11/11/25 quarterly MDS assessment showed the resident was not receiving hospice care.
Review of the resident's medical record showed no documentation of when the resident had been discharged from hospice.
Interview with the business office manager on 1/14/26 at 2:27 PM revealed she had changed to resident's payer source on 10/24/25.
Interview with the MDS coordinator on 1/14/25 at 2:18 PM confirmed a significant change MDS assessment had not been completed on the resident following his/her discharge from hospice care. 2.
Review of the October 2023 CMS RAI manual version 3.0 version 1.18.11 showed An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care).
The ARD [assessment reference date] must be within 14 days from one of the following: 1) the effective date of the hospice CMS's RAI Version 3.0 Manual CH 2: Assessments for the RAI October 2023 Page 2-26 election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill.
535025 01/15/2026
Polaris Rehabilitation and Care Center 2700 E 12th Street Cheyenne, WY 82001
Review of the 11/6/25 comprehensive MDS assessment showed resident #62 had a memory problem with moderately impaired cognitive skills for daily decision making, and had diagnoses which included respiratory failure, hemiplegia, or hemiparesis, traumatic brain injury, and cerebral edema and edema of the larynx.
Further review showed the resident had a feeding tube.
Review of the physician orders dated 11/21/25 showed the resident received enteral feeding through the feeding tube once daily.
The following concerns were identified:a.
Observation on 1/13/26 at 6 PM showed RN # 1 administer the resident his/her enteral tube feeding; however, the RN did not check placement, residual volume, nor was the resident's head of bed elevated.b.
Review of the physician orders dated 10/31/25, showed residual and verification of the tube placement must be checked prior to administering enteral feeding. c.
Review of the care plan, last revised on 11/7/25, showed, Check for placement and gastric contents/residual volume per facility protocol, hold feed if contents/residual is over 500 cc (cubic centimeters).
Further review showed the resident's head of the bed should have been elevated 30 to 45 degrees during feeding and for 1 hour following to prevent aspiration pneumonia. d.
Review of the facility policy titled Care and Treatment of Feeding Tubes provided by the DON on 11/14/26, showed .6. In accordance with facility protocol licensed nurses will monitor and check the feeding tube is in the right location.e.
Interview with the DON on 1/14/26 at 9:44 AM confirmed staff were expected to check placement, residual of the stomach contents, and elevate the head of the bed prior to starting the feeding solution.
535025 01/15/2026
Polaris Rehabilitation and Care Center 2700 E 12th Street Cheyenne, WY 82001
receive retraining.
interview, the facility failed to obtain CNA abuse prior to resident contact for registry verification in 1
the facility had obtained CNA abuse registry verification prior to resident contact.2.
Interview with the human resource manager on 1/13/26 at 4:32 PM confirmed that he was not aware the CNA abuse registry was to be verified.
535025 01/15/2026
Polaris Rehabilitation and Care Center 2700 E 12th Street Cheyenne, WY 82001
Review of the facility's documentation showed a monthly medication review was performed on resident #1 in June, November, and December of 2025.
The facility was unable to located any further documentation. 2.
Review of the facility's documentation showed a monthly medication review was performed on resident #2 in November 2025.
The facility was unable to locate any further documentation. 3.
Review of the facility documentation showed no evidence a monthly medication review had been completed for resident #5 in December
- Further review showed a monthly medication review was performed in November 2025 with the
pharmacy recommendation of a trial dose reduction of Olanzapine from 5mg to 2.5mg at bedtime.
Review of the resident's orders showed the medication was never decreased.
Further review of physician orders dated 12/6/25 showed an increase in olanzapine dose from 5mg to 7.5mg.
Interview with the facility nurse practitioner on 1/15/26 at 10:13 AM confirmed Olanzapine dose was increased and not decreased. 4.
Review of the facility's documentation showed a monthly medication review was performed on resident #54 in November and December of 2025.
The facility was unable to locate any further documentation.5.
Review of the facility's documentation showed a monthly medication review was performed on resident #68 in November and December of 2025.
The facility was unable to locate any further documentation.6.
Interview with the DON on 1/14/26 at 4:36 PM revealed the facility had changed pharmacies in November of 2025 and she was unable to locate the documentation from the previous pharmacy.7.
Review of the Pharmacy Services Policy and Procedure, provided by the NHA on 1/15/26 at 2 PM showed .III.
Drug Regimen Review A.
The drug regimen of each resident shall be reviewed at least once a month by a licensed pharmacist .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
535025 01/15/2026
Polaris Rehabilitation and Care Center 2700 E 12th Street Cheyenne, WY 82001
Observation of the Yellowstone medication cart on 1/13/26 at 3:39 PM showed a multidose vial of Lantus insulin which was opened and not labeled. 2.
Interview with RN # 2 on 1/13/26 at 3:40 PM revealed that insulin vials should have been labeled with the date they were opened and confirmed the vial was opened and not dated.3.
Interview with the DON on 1/13/26 at 5:22 PM confirmed that staff were expected to label insulin vials with the opening date. 4.
Review of the manufacturer's instructions titled Patient Medication Information - Lantus vial last revised 12/1/21 showed opened insulin vials must be discarded after 28 days of opening. 5.
Review of the policy titled Multi-dose Vials last revised 2016, showed .2.
Multi-dose vials will be re-labeled with a beyond use date, 28 days after the vial is opened or punctured (unless otherwise specified by the manufacturer).
535025 01/15/2026
Polaris Rehabilitation and Care Center 2700 E 12th Street Cheyenne, WY 82001
Observation on 1/14/26 at 10:11 AM showed cook #1 doffed his gloves, washed his hands, donned new gloves, and then adjusted his face mask with his gloved hands. [NAME] #1 opened cooler #1 and retrieved a plastic container of shredded cheese and proceeded to make individual salads. [NAME] #1 used his gloved hands to transfer salad greens from a container into individual salad bowls; added diced celery and tomatoes in the same manner; and then reached into the cheese container to add cheese to the bowls.
After completing the first tray of 9 salad bowls cook #1 retrieved a date marking gun to date the individual salad bowls, and placed the salads into cooler #3. [NAME] #1 continued in the same manner and prepared a second tray of 12 bowls of salad. [NAME] #2 doffed his gloves at 10:21 AM and without performing hand hygiene donned new gloves and prepared a third tray of 12 salad bowls in the same manner as before. 3.
Interview with the dietary manager on 1/15/26 at 1:19 PM confirmed hand hygiene was not performed as required. 4.
According to the 2022 FDA Food Code showed 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands.
535025 01/15/2026
Polaris Rehabilitation and Care Center 2700 E 12th Street Cheyenne, WY 82001
Observation on 1/12/26 at 5:44 PM showed CNA #1 was assisting residents with eating in the
hands and handed the sandwich to the resident.
Interview with the CNA at 5:55 PM revealed she knew she had made a mistake; however, was trying to assist the resident because she did not want the resident to sit alone without assistance. 2.
Interview with the infection preventionist on 1/15/26 at 1 PM revealed it was her expectation for staff to sanitize their hands and then use gloves if they had to touch a resident's food.