Nursing homes › Wyoming › The Legacy Living and Rehabilitation Center
1000 S Douglas Way, Gillette, WY 82716 · 3076887000 · 160 certified beds
CMS lists no chain affiliation for this facility. Ownership type on record: Government - Hospital district.
Total nurse staffing: 4.59 (Wyoming median: 3.56). RN hours: 0.90. Weekend total: 3.92. Nursing staff turnover: 70%.
All-time on record: 38 deficiency citations, including 2 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-03-13 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E | complaint | corrected 2026-04-09 |
| 2026-03-13 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E | Health | corrected 2026-04-30 |
| 2026-03-13 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | D | complaint | corrected 2026-04-09 |
| 2026-03-13 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Health | corrected 2026-04-13 |
| 2026-03-13 | Provide activities to meet all resident's needs. | D | Health | corrected 2026-04-13 |
| 2026-03-13 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2026-04-30 |
| 2025-09-11 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2025-10-16 |
| 2025-09-11 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Health | corrected 2025-10-02 |
| 2025-09-11 | Respond appropriately to all alleged violations. | D | Health | corrected 2025-10-16 |
| 2025-09-11 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D | Health | corrected 2025-10-01 |
| 2025-04-15 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | complaint | corrected 2025-04-08 |
| 2025-04-15 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2025-04-08 |
| 2025-02-21 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2025-02-21 |
| 2025-01-17 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | complaint | corrected 2025-01-13 |
| 2025-01-17 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | complaint | corrected 2025-01-13 |
| 2025-01-17 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | complaint | corrected 2025-02-13 |
| 2024-06-19 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | complaint | corrected 2024-06-18 |
| 2024-05-23 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | complaint | corrected 2024-06-17 |
| 2024-05-23 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | G | complaint | corrected 2024-06-17 |
| 2024-05-23 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | complaint | corrected 2024-06-17 |
| 2024-05-23 | Ensure residents have reasonable access to and privacy in their use of communication methods. | E | complaint | corrected 2024-06-17 |
| 2024-05-23 | 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. | E | complaint | corrected 2024-06-17 |
| 2024-05-23 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | complaint | corrected 2024-06-17 |
| 2024-05-23 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2024-06-17 |
| 2024-05-23 | Respond appropriately to all alleged violations. | D | complaint | corrected 2024-06-17 |
| 2024-05-23 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | complaint | corrected 2024-06-17 |
| 2024-05-23 | Ensure each resident receives an accurate assessment. | D | complaint | corrected 2024-06-17 |
| 2024-05-23 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | complaint | corrected 2024-06-17 |
| 2024-05-23 | Ensure services provided by the nursing facility meet professional standards of quality. | D | complaint | corrected 2024-06-17 |
| 2024-05-23 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2024-06-17 |
| 2024-05-23 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | complaint | corrected 2024-06-17 |
| 2024-05-23 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2024-06-17 |
| 2024-02-27 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | complaint | corrected 2024-02-15 |
| 2023-09-22 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | F | complaint | corrected 2023-11-06 |
| 2023-09-22 | 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. | E | complaint | corrected 2023-11-06 |
| 2023-09-22 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | E | complaint | corrected 2023-11-06 |
| 2023-09-22 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | complaint | corrected 2023-11-06 |
| 2023-09-22 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | complaint | corrected 2023-11-06 |
| Date | Type | Amount |
|---|---|---|
| 2025-04-15 | Fine | $14,505 |
| 2025-01-17 | Fine | $14,508 |
| 2024-05-23 | Fine | $78,566 |
| 2024-02-27 | Fine | $8,018 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| BIGGS, ANGELA | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 11/22/2024 |
| HARTSAW, SARA | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 12/09/2022 |
| HITE, RANDAL | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 10/26/2020 |
| MANSELL, JOHN | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 10/29/2022 |
| MURPHY, TOM | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 11/01/2020 |
| RICE, JOHN | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 10/29/2022 |
| STUBER, ALAN | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 11/01/2018 |
| POPP, DOUGLAS | Corporate Officer | Individual | NOT APPLICABLE | since 03/20/2023 |
| SHAHAN, MATTHEW | Corporate Officer | Individual | NOT APPLICABLE | since 05/16/2022 |
| ALEXANDER, HOLLIE | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/01/2025 |
| PATEL, KIRTIKUMAR | Operational/Managerial Control | Individual | NOT APPLICABLE | since 10/13/2020 |
| POPP, DOUGLAS | Operational/Managerial Control | Individual | NOT APPLICABLE | since 03/20/2023 |
| SHAHAN, MATTHEW | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/16/2022 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 535022. Corrections: data@carerecords.org.