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.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
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.