The Legacy Living and Rehabilitation Center
1000 S Douglas Way · Gillette, WY · 82716 · 3076887000
160 certified beds Government - Hospital district
Why this verdict
- On the federal Special Focus list of the most persistently poor performers.
- Federal penalties on record: $29,013 in fines in the last 24 months.
- 6 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
Red flags
Special Focus Facility
CMS has designated this facility one of the most persistently poor performers in the country — it is under increased inspection and enforcement.
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
5 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
69% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: not rated Inspections: not rated Staffing: not rated Quality measures: not rated
| Total nurse hours / resident-day | 4.63 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.94 | 0.55–0.75 |
| Weekend hours / resident-day | 4.06 | ≈ weekday level |
| Nursing turnover / year | 69% | median 45% |
| Fines (3-yr window) | 4 · $115,597 |
Inspection citations (38 in the current record)
-
Potential for harm · D March 13, 2026
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected April 13, 2026 · Resident Assessment and Care Planning
-
Potential for harm · D March 13, 2026
Provide activities to meet all resident's needs.
Corrected April 13, 2026 · Quality of Life and Care
-
Potential for harm · D March 13, 2026
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 30, 2026 · Quality of Life and Care
-
Potential for harm · E March 13, 2026
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected April 30, 2026 · Quality of Life and Care
-
Potential for harm · D March 13, 2026 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected April 9, 2026 · Resident Rights
-
Potential for harm · E March 13, 2026 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected April 9, 2026 · Resident Rights
-
Potential for harm · D September 11, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected October 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D September 11, 2025
Respond appropriately to all alleged violations.
Corrected October 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D September 11, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected October 1, 2025 · Quality of Life and Care
-
Potential for harm · D September 11, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Actual harm · G April 15, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 8, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D April 15, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 8, 2025 · Quality of Life and Care
-
Potential for harm · D February 21, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J January 17, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 13, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J January 17, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 13, 2025 · Quality of Life and Care
-
Actual harm · G January 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 13, 2025 · Quality of Life and Care
-
Actual harm · G June 19, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected June 18, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Actual harm · G May 23, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected June 17, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Actual harm · G May 23, 2024 · found via complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected June 17, 2024 · Quality of Life and Care
-
Potential for harm · E May 23, 2024 · found via complaint
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected June 17, 2024 · Resident Rights
-
Potential for harm · E May 23, 2024 · found via complaint
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.
Corrected June 17, 2024 · Resident Rights
-
Potential for harm · D May 23, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 17, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D May 23, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected June 17, 2024 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D May 23, 2024 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected June 17, 2024 · Resident Rights
-
Potential for harm · D May 23, 2024 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected June 17, 2024 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 15, 2025 | Fine | $14,505 |
| January 17, 2025 | Fine | $14,508 |
| May 23, 2024 | Fine | $78,566 |
| February 27, 2024 | Fine | $8,018 |
Better-scoring options nearby
No better-scoring facility within 25 miles in the current data. See the whole state.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 535022 · certified since June 16, 1984. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.