Cycle 1
Health 2026-01-15 · Fire 2026-01-15
21 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cheyenne, WY
Polaris Rehabilitation and Care Center
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $62,647 in total fines with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
2700 E 12th Street, Cheyenne, WY
(307) 634-7986
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-10-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing
LPN hours / resident day
0.33
Licensed practical nurse staffing
Aide hours / resident day
2.32
Nurse aide staffing
Weekend hours
2.88
Weekend nurse staffing
RN turnover
57%
Annual RN turnover
Total nurse turnover
68%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.5% |
94.3%
2.8 pts worse
|
95.5%
4 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
4.8%
0.5 pts better
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
6.4%
1.7 pts worse
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.5%
3.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.6% |
16.1%
9.5 pts better
|
19.6%
13 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
24.1%
9 pts better
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.6% |
18.5%
12.9 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
18.7%
13.4 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.9%
1.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
3.0%
0.4 pts better
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
23.6%
1 pts better
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
5.0%
4.2 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.1% |
75.7%
13.4 pts better
|
81.7%
7.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
13.7%
1.2 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.6%
0.5 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.6% |
77.0%
1.4 pts worse
|
79.7%
4.1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
20.8%
3.7 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-26 · Fire 2024-06-26
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2026-02-11
F · Potential for more than minimal harm
2026-01-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-11
F · Potential for more than minimal harm
2026-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-11
E · Potential for more than minimal harm
2026-01-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-02-11
E · Potential for more than minimal harm
2026-01-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-11
F · Potential for more than minimal harm
2024-06-26
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-06-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-06-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-22
E · Potential for more than minimal harm
2024-06-26
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-22
F · Potential for more than minimal harm
2023-06-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-06-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-22
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-22
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-07-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-02-11
E · Potential for more than minimal harm
2026-01-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-02-11
E · Potential for more than minimal harm
2026-01-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2026-02-11
D · Potential for more than minimal harm
2026-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-11
G · Actual harm
2025-11-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
G · Actual harm
2025-10-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-11-21
F · Potential for more than minimal harm
2025-10-24
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-24
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-10-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-11-21
F · Potential for more than minimal harm
2025-08-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-08-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-08-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-09-19
G · Actual harm
2025-08-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-08-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-23
F · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-24
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-08-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-19
E · Potential for more than minimal harm
2024-06-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-06-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-22
B · Minimal harm
2024-06-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-07-22
E · Potential for more than minimal harm
2024-01-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-22
D · Potential for more than minimal harm
2024-01-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-21
D · Potential for more than minimal harm
2024-01-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-06-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-22
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-13
D · Potential for more than minimal harm
2023-06-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-13
Penalties and ownership
What sits behind the stars
$62,647
2025-08-07
Fine
Fine · fine $62,647
Fine
Ownership
Cheyenne Opco LLC
Operational/Managerial Control · Organization
Connell, Eric
Operational/Managerial Control · Individual
Melvin, Eric
Operational/Managerial Control · Individual
Morrison, Robert
Operational/Managerial Control · Individual
North Big Horn Hospital District
Operational/Managerial Control · Organization
Simmons, Benjamin
Operational/Managerial Control · Individual
Winterholler, David
Operational/Managerial Control · Individual
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#3
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