The Legacy Living and Rehabilitation Center
1000 S Douglas Way, Gillette, WY 82716 · Campbell County · 160 certified beds · avg 72 residents/day · certified since Jun 16, 1984
SFF
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: —/5 · CMS overall rating: —/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jan 17, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 13, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Jan 17, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 13, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Apr 15, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 8, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Jan 17, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 13, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 19, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 18, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · May 23, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 23, 2024 · F-0744 · triggered by a complaint
The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 27, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 15, 2024 (Past Non-Compliance)
All citations in the current public record (38)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 13, 2026 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Mar 13, 2026 | E · Potential for harm, repeated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Sep 11, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Apr 15, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 15, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 21, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 17, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 17, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 17, 2025 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 19, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 23, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 23, 2024 | ▲ G · Actual harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| May 23, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · from a complaint |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| May 23, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| May 23, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 27, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 22, 2023 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. · from a complaint |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. · from a complaint |
| Sep 22, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Sep 22, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | F |
| 2024 | 17 | 4 | G ▲ |
| 2025 | 10 | 4 | J ▲ |
| 2026 | 6 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $115,597.
| Date | Type | Amount / length |
|---|---|---|
| Apr 15, 2025 | Fine | $14,505 |
| Jan 17, 2025 | Fine | $14,508 |
| May 23, 2024 | Fine | $78,566 |
| Feb 27, 2024 | Fine | $8,018 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wyoming avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.98 | 4.47 | 3.95 | top 31% in Wyoming; top 14% in the U.S. |
| Registered Nurse hours | 0.98 | 1.09 | 0.69 | top 46% in Wyoming; top 17% in the U.S. |
| Weekend total nurse staffing | 4.25 | 3.89 | 3.50 | top 31% in Wyoming; top 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.48 | 0.65 | 0.48 | bottom 40% in Wyoming; top 36% in the U.S. |
| Total nursing staff turnover (%) | 70.5 | 51.8 | 45.8 | bottom 17% in Wyoming; bottom 5% in the U.S. |
| RN turnover (%) | 47.8 | 44.1 | 42.9 | bottom 41% in Wyoming; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.59, RN 0.90, weekend 3.92. Staffing rating: —/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: —/5 · long-stay residents: —/5 · short-stay residents: —/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Alexander, Hollie | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2025 |
| Alexander, Hollie | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2025 |
| Biggs, Angela | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/22/2024 |
| Hartsaw, Sara | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/09/2022 |
| Hite, Randal | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/26/2020 |
| Mansell, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/29/2022 |
| Murphy, Tom | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2020 |
| Patel, Kirtikumar | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/13/2020 |
| Patel, Kirtikumar | Individual | ADP of the SNF | NOT APPLICABLE | 10/13/2020 |
| Popp, Douglas | Individual | Corporate Officer | NOT APPLICABLE | 03/20/2023 |
| Popp, Douglas | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/20/2023 |
| Rice, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/29/2022 |
| Shahan, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 05/16/2022 |
| Shahan, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/16/2022 |
| Stuber, Alan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
No other Medicare-certified nursing homes within 20 miles in the current records.
Facility data as of CMS processing date 2026-08-01. CCN 535022.