The Legacy Living and Rehabilitation Center
1000 S Douglas Way, Gillette, WY 82716
At or above the 2024 benchmark — review inspection history before visiting.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.97 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
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Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
38
Outstanding
6
Actual harm or worse (G–L)
8
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: Not rated
Staffing: Not rated
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NursingHomeGrade Score
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8/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
2 immediate jeopardy, 6 actual harm issues found among 38 total deficiencies. 32 corrected. — 6 still outstanding
Most recent inspection (April 15, 2025)
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies — Deficient, Provider has no plan of correction
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has no plan of correction
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Rights Deficiencies — Deficient, Provider has no plan of correction
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies — Deficient, Provider has no plan of correction
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected April 8, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected April 8, 2025
Inspection cycle 2 (February 21, 2025)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 21, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected January 13, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected June 18, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 2, 2025
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 16, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 16, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 13, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Past Non-Compliance, corrected January 13, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 1, 2025
Inspection cycle 3 (February 27, 2024)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected February 15, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2023
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2023
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2023
Ensure residents have reasonable access to and privacy in their use of communication methods.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
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.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 17, 2024
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