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The Legacy Living and Rehabilitation Center

Open-data reference.

The Legacy Living and Rehabilitation Center is a government - hospital district facility in Gillette, WY with 160 certified beds and a -star overall CMS rating. The facility has 35 deficiency records on file. Total penalties: $116K.

1000 S Douglas Way, Gillette, WY 82716

Phone: 3076887000

Overall Rating

N/A

Health Inspection

N/A

Staffing

N/A

Quality Measures

N/A

Long-Stay Quality

N/A

Facility Information

Provider Number
535022
Ownership
Government - Hospital district
Provider Type
Medicare and Medicaid
Beds
160
Residents
84
In Hospital
No
County
Campbell
Last Inspection
Sep 11, 2025
Special Focus
SFF
Abuse citation on record

Staffing Data

RN Hours
0.97 (nat'l avg: 0.68)
LPN Hours
0.34
CNA Hours
2.84
Total Nursing Hours
4.15 (nat'l avg: 3.89)
PT Hours
0.02
Nursing Turnover
68.5%
RN Turnover
33.3%

What the CMS Record Reveals About The Legacy Living and Rehabilitation Center

The Legacy Living and Rehabilitation Center operates 160 certified beds in Gillette, WY with approximately 84 residents currently in care, and carries a CMS overall rating of no current rating. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (N/A★), staffing levels (N/A★), and quality measures (N/A★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 35 deficiency records from recent surveys, of which 8 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 4 penalties totaling $116K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.15 total nursing hours per resident day (national average 3.89), with RN coverage at 0.97 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.

Classified as "Government - Hospital district" ownership and operating as a "Medicare and Medicaid" provider, The Legacy Living and Rehabilitation Center falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 68.5%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (35 most recent)

D — Isolated - Minimal harm Sep 11, 2025 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Oct 16, 2025

D — Isolated - Minimal harm Sep 11, 2025 Tag: 0744

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 1, 2025

D — Isolated - Minimal harm Sep 11, 2025 Tag: 0610

Respond appropriately to all alleged violations.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Oct 16, 2025

D — Isolated - Minimal harm Sep 11, 2025 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Oct 2, 2025

D — Isolated - Minimal harm Apr 15, 2025 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Apr 8, 2025

G — Isolated - Actual harm Apr 15, 2025 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Apr 8, 2025

D — Isolated - Minimal harm Feb 21, 2025 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Feb 21, 2025

J — Isolated - Jeopardy Jan 17, 2025 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 13, 2025

G — Isolated - Actual harm Jan 17, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Feb 13, 2025

J — Isolated - Jeopardy Jan 17, 2025 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jan 13, 2025

G — Isolated - Actual harm Jun 19, 2024 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jun 18, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Jun 17, 2024

F — Widespread - Minimal harm May 23, 2024 Tag: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Category: Nutrition and Dietary Deficiencies

Corrected: Jun 17, 2024

E — Pattern - Minimal harm May 23, 2024 Tag: 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Category: Nutrition and Dietary Deficiencies

Corrected: Jun 17, 2024

G — Isolated - Actual harm May 23, 2024 Tag: 0744

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Category: Quality of Life and Care Deficiencies

Corrected: Jun 17, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Category: Quality of Life and Care Deficiencies

Corrected: Jun 17, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Jun 17, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jun 17, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jun 17, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0641

Ensure each resident receives an accurate assessment.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jun 17, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0623

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Category: Resident Rights Deficiencies

Corrected: Jun 17, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0610

Respond appropriately to all alleged violations.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jun 17, 2024

D — Isolated - Minimal harm May 23, 2024 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jun 17, 2024

G — Isolated - Actual harm May 23, 2024 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jun 17, 2024

E — Pattern - Minimal harm May 23, 2024 Tag: 0584

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Category: Resident Rights Deficiencies

Corrected: Jun 17, 2024

E — Pattern - Minimal harm May 23, 2024 Tag: 0576

Ensure residents have reasonable access to and privacy in their use of communication methods.

Category: Resident Rights Deficiencies

Corrected: Jun 17, 2024

G — Isolated - Actual harm Feb 27, 2024 Tag: 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Feb 15, 2024

D — Isolated - Minimal harm Sep 22, 2023 Tag: 0806

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Category: Nutrition and Dietary Deficiencies

Corrected: Nov 6, 2023

E — Pattern - Minimal harm Sep 22, 2023 Tag: 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Category: Nutrition and Dietary Deficiencies

Corrected: Nov 6, 2023

F — Widespread - Minimal harm Sep 22, 2023 Tag: 0802

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Category: Nutrition and Dietary Deficiencies

Corrected: Nov 6, 2023

E — Pattern - Minimal harm Sep 22, 2023 Tag: 0800

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Category: Nutrition and Dietary Deficiencies

Corrected: Nov 6, 2023

E — Pattern - Minimal harm Sep 22, 2023 Tag: 0585

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Category: Resident Rights Deficiencies

Corrected: Nov 6, 2023

C — Widespread - No harm Mar 9, 2023 Tag: 0838

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Category: Administration Deficiencies

Corrected: Apr 23, 2023

D — Isolated - Minimal harm Mar 9, 2023 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Apr 23, 2023

D — Isolated - Minimal harm Mar 9, 2023 Tag: 0655

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Apr 23, 2023

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 19.5% Yes
Percentage of long-stay residents who lose too much weight Long Stay 6.3% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 1.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 3.8% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 12.1% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 7.8% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 94.9% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 87.4% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 1.7% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 16.2% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 15.1% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 90.5% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 83.6% No
Percentage of long-stay residents with pressure ulcers Long Stay 1.9% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 27.7% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 15.3% Yes

Penalty History 4 penalties totaling $116K

Date Type Amount
Apr 15, 2025 Fine $15K
Jan 17, 2025 Fine $15K
May 23, 2024 Fine $79K
Feb 27, 2024 Fine $8K

Frequently Asked Questions

What is the overall CMS rating for The Legacy Living and Rehabilitation Center?
The Legacy Living and Rehabilitation Center has an overall CMS rating of null out of 5 stars. This rating combines health inspection results (null★), staffing levels (null★), and quality measures (null★).
What are the staffing levels at The Legacy Living and Rehabilitation Center?
The Legacy Living and Rehabilitation Center reports 4.15 total nursing hours per resident day (national average: 3.89). RN hours are 0.97 per resident day (national average: 0.68). Nursing staff turnover is 68.5%.
How many beds does The Legacy Living and Rehabilitation Center have?
The Legacy Living and Rehabilitation Center has 160 certified beds with approximately 84 residents. The facility is located at 1000 S Douglas Way, Gillette, WY 82716.
Does The Legacy Living and Rehabilitation Center have any deficiencies on record?
Yes, The Legacy Living and Rehabilitation Center has 35 deficiencies on record from recent inspections. Of these, 8 are classified as causing actual harm or jeopardy.
Has The Legacy Living and Rehabilitation Center received any fines or penalties?
Yes, The Legacy Living and Rehabilitation Center has received 4 penalties totaling $116K.
Who owns The Legacy Living and Rehabilitation Center?
The Legacy Living and Rehabilitation Center is classified as "Government - Hospital district" ownership. The facility type is "Medicare and Medicaid".
When was The Legacy Living and Rehabilitation Center last inspected?
The most recent health inspection for The Legacy Living and Rehabilitation Center was on Sep 11, 2025. The facility received a health inspection rating of null out of 5 stars.
What quality measures are tracked for The Legacy Living and Rehabilitation Center?
The Legacy Living and Rehabilitation Center is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial