The Legacy Living and Rehabilitation Center
1000 S Douglas Way, Gillette, WY 827163076887000160 certified beds · 72 residentsGovernment - Hospital districtMedicare and Medicaid
Surveys on file
9
since 2023
Deficiencies
38
● 0● 30● 8
Penalties · 3 yrs
$115,597
4 fines
Last survey
2026-03-13
Standard
CMS overall
—
stars as published by CMS
CMS overall —/5
Health —
Staffing —
Quality —
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Wyoming Healthcare Licensing and Surveys · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-03-13 | Standard | 060 | CMS-2567 (Care Compare) | — |
| 2025-09-11 | Standard | 040 | CMS-2567 (Care Compare) | — |
| 2025-04-15 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2025-02-21 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-01-17 | Complaint | 003 | CMS-2567 (Care Compare) | — |
| 2024-06-19 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2024-05-23 | Standard | 0132 | CMS-2567 (Care Compare) | — |
| 2024-02-27 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2023-09-22 | Complaint | 050 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Wyoming Healthcare Licensing and Surveys publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-09Record 535022-20260313-F627
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-09Record 535022-20260313-F628
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-13Record 535022-20260313-F644
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-13Record 535022-20260313-F679
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-30Record 535022-20260313-F689
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-04-30Record 535022-20260313-F744
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-16Record 535022-20250911-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-02Record 535022-20250911-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-16Record 535022-20250911-F610
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-01Record 535022-20250911-F744
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-04-08Record 535022-20250415-F600
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-08Record 535022-20250415-F689
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-21Record 535022-20250221-F609
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-01-13Record 535022-20250117-F600
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-02-13Record 535022-20250117-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-01-13Record 535022-20250117-F689
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-06-18Record 535022-20240619-F600
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-06-17Record 535022-20240523-F600
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-06-17Record 535022-20240523-F744
F576Ensure residents have reasonable access to and privacy in their use of communication methods.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F576
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F584
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F610
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F623
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F658
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F690
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F812
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-17Record 535022-20240523-F880
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-02-15Record 535022-20240227-F600
F585Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-06Record 535022-20230922-F585
F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-06Record 535022-20230922-F800
F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-11-06Record 535022-20230922-F802
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-06Record 535022-20230922-F804
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-06Record 535022-20230922-F806
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-04-15 | Civil money penalty | $14,505 | CMS · Penalties |
| 2025-01-17 | Civil money penalty | $14,508 | CMS · Penalties |
| 2024-05-23 | Civil money penalty | $78,566 | CMS · Penalties |
| 2024-02-27 | Civil money penalty | $8,018 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.90
Facility
Wyoming
National
Wyoming 0.94 · National 0.69
Total nurse hours per resident day4.59
Facility
Wyoming
National
Wyoming 3.87 · National 3.86
Weekend total nurse hours3.92
Facility
Wyoming
National
Wyoming 3.37 · National 3.42
Total nursing staff turnover71%
Facility
Wyoming
National
Wyoming 52% · National 46%
Registered nurse turnover48%
Facility
Wyoming
National
Wyoming 44% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Wyoming | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 0.6% | 4.6% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 9.3% | 4.7% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 14.0% | 21.8% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 3.2% | 3.1% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 15.7% | 16.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 4.2% | 5.9% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 15.3% | 15.4% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Alexander, Hollie Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Patel, Kirtikumar Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Popp, Douglas Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Shahan, Matthew Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Alexander, Hollie Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Biggs, Angela Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Hartsaw, Sara Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Hite, Randal Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Mansell, John Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Murphy, Tom Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Patel, Kirtikumar Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Popp, Douglas Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Rice, John Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Shahan, Matthew Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Stuber, Alan Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Wyoming.
No county cost figures on file for Campbell.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Crook County Medical Services District Long Term C Sundance | 55.5 mi | 2025-08-14 | 1101 |
| Powder River Manor Broadus | 80.3 mi | 2026-04-22 | 0232 |
| Amie Holt Care Center Buffalo | 60.5 mi | 2025-04-24 | 160 |
| Wyoming Veterans' Skilled Nursing Facility Buffalo | 61.9 mi | 2026-01-23 | 1141 |
| Weston County Health Services Newcastle | 71.2 mi | 2026-03-31 | 061 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |