The Legacy Living And Rehabilitation Center
Government - Hospital district · 1000 S Douglas Hwy, Gillette, WY 82716 · See home’s Medicare page
Special Focus Facility
            Flagged by the government for having a history of serious quality issues.
          Nurse hours/resident/day
            Data unavailable
         70.9%
             Nurse turnover
            The percentage of nursing staff who stopped working at the home over a 12-month period.
            State Average: 53.3%
         160
             Certified beds
            Qualifying beds in the certified provider or supplier facility. 
         105
             Average residents/day
            Average number of residents based on daily census.
         Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
          Direct owners
               No direct owner information
               
          Indirect owners
               No indirect owner information
               
          Managerial control
               
                  No information available
               
               
          Managing employee(s)
               
                  No information available
               
               
         Inspection Reports
Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
   
         37 
         
      total deficiencies
         1 
         
               
                  
            
         
         
      
   infection-related deficiency
This home violated federal standards protecting residents from the spread of infections.
               
               Apr 15, 2025
               
               
            
            
                  2 deficiencies 
               
            
               
                  
                  to
                  G
                  
               
            
            
            
         Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 21, 2025
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
                  
                     Failure to: 
                     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jan 17, 2025
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  J
                  
               
            
            
            
         Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  Immediate jeopardy to resident health or safety
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  Immediate jeopardy to resident health or safety
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0684
                  
                     Failure to: 
                     Provide appropriate treatment and care according to orders, resident's preferences and goals.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Jun 19, 2024
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               May 23, 2024
               
               
            
            
                  15 deficiencies 
               
               
            
               
                  
                  to
                  G
                  
               
            
            
            
         Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0744
                  
                     Failure to: 
                     Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0812
                  
                     Failure to: 
                     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Many people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0576
                  
                     Failure to: 
                     Ensure residents have reasonable access to and privacy in their use of communication methods.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0804
                  
                     Failure to: 
                     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0584
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0690
                  
                     Failure to: 
                     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care,  and appropriate care  to prevent urinary tract infections.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0623
                  
                     Failure to: 
                     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Infection Control Deficiency — F0880
                  
                     Failure to: 
                     Provide and implement an infection prevention and control program.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
                  
                     Failure to: 
                     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
                  
                     Failure to: 
                     Respond appropriately to all alleged violations.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0641
                  
                     Failure to: 
                     Ensure each resident receives an accurate assessment.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0658
                  
                     Failure to: 
                     Ensure services provided by the nursing facility meet professional standards of quality.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Feb 27, 2024
               
               
            
            
                  1 deficiency 
               
            Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
                  
                     Failure to: 
                     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
                  
               
                     Severity
                  
                  Actual harm that is not immediate jeopardy
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Sep 22, 2023
               
               
            
            
                  5 deficiencies 
               
            
               
                  
                  to
                  F
                  
               
            
            
            
         Nutrition and Dietary Deficiency — F0802
                  
                     Failure to: 
                     Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Many people affected
                  
                     Seriousness
                  
                  Resident Rights Deficiency — F0585
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0800
                  
                     Failure to: 
                     Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0804
                  
                     Failure to: 
                     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Nutrition and Dietary Deficiency — F0806
                  
                     Failure to: 
                     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  
               
               Mar 9, 2023
               
               
            
            
                  3 deficiencies 
               
            
               
                  
                  to
                  D
                  
               
            
            
            
         Resident Assessment and Care Planning Deficiency — F0655
                  
                     Failure to: 
                     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Resident Assessment and Care Planning Deficiency — F0656
                  
                     Failure to: 
                     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Administration Deficiency — F0838
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with potential for minimal harm
                  
                     Scope
                  
                  Many people affected
                  
                     Seriousness
                  
                  
               
               Dec 2, 2021
               
               
            
            
                  6 deficiencies 
               
            
               
                  
                  to
                  E
                  
               
            
            
            
         Resident Rights Deficiency — F0550
                  
                     Failure to: 
                     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0679
                  
                     Failure to: 
                     Provide activities to meet all resident's needs.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Some people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0686
                  
                     Failure to: 
                     Provide appropriate pressure ulcer care and prevent new ulcers from developing.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0689
                  
                     Failure to: 
                     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Quality of Life and Care Deficiency — F0740
                  
                     Failure to: 
                     Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Pharmacy Service Deficiency — F0758
                  
                     Failure to: 
                     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.
                  
               
                     Severity
                  
                  No actual harm, with a potential for more than minimal harm
                  
                     Scope
                  
                  Few people affected
                  
                     Seriousness
                  
                  Penalties
A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
   
         $101K 
         
   total fines