The Legacy Living and Rehabilitation CenterCMS ratings, inspections and fines
- Address
- 1000 S Douglas Way, Gillette, WY 82716
- CCN
- 535022
- Ownership type
- Government, hospital district
- Certified beds
- 160
- Chain
- None in the CMS record
- Residents per day
- 72
- CMS flags
- Special Focus Facility
The watch list stays in this browser. After each CMS update, it shows the values that changed at the homes on the list.
CMS gives The Legacy Living and Rehabilitation Center no star ratings, because the home is in the Special Focus Facility program. The last standard survey was on 13 Mar 2026. The latest survey cycle has 6 health citations. The median for nursing homes in Wyoming is 6. CMS lists 4 fines with a total of $115,597 for this home in its penalties file.
Facilities may see a change in their overall rating for a number of reasons. Since the overall rating is based on three individual domains, a change in any one of the domains can affect the overall rating. Any new data for a nursing home could potentially change a star rating domain.
Centers for Medicare & Medicaid Services, Five-Star Quality Rating System: Technical Users' Guide, July 2026. CMS processed this record on .
Since the last CMS update
The site has no recorded change for this home. In each CMS update, the site compares the ratings, the penalties and the citations of each home.
Ratings
CMS gives each home 1 to 5 stars for health inspections, for staffing and for quality measures, and one overall rating.
| Rating (1 to 5 stars) | This home | Wyoming median | US average (CMS) |
|---|---|---|---|
| Overall rating | No data | 3.0 | 3.0 |
| Health inspection rating | No data | 3.0 | 2.8 |
| Staffing rating | No data | 4.0 | 2.9 |
| Quality measure rating | No data | 3.0 | 3.6 |
A median is the middle value of the homes in the group: 36 homes in the state. What the CMS star ratings measure
Citations by survey cycle
CMS keeps the last three cycles, and cycle 1 is the latest. A cycle has one standard survey. Citations from complaint and infection control inspections go into cycles of 12 months.
| Survey cycle | Standard survey | Citations | Wyoming median |
|---|---|---|---|
| Cycle 1 (latest) | 13 Mar 2026 | 6 | 6 |
| Cycle 2 | 11 Sep 2025 | 10 | 5 |
| Cycle 3 | No date | 22 | 6 |
Health citations
The record of one deficiency in an inspection. One inspection can give many citations.
Scope and severity. A letter from A to L on each citation. Scope is the number of residents that the deficiency affected. Severity is the level of harm.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy to resident health or safety | K0 | L0 | |
| Actual harm that is not immediate jeopardy | H0 | I0 | |
| No actual harm, potential for more than minimal harm | |||
| No actual harm, potential for minimal harm | A0 | B0 | C0 |
Survey cycle 1 (latest): 6 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 13 Mar 2026 | F0627 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | D | Complaint investigation | 9 Apr 2026 |
| 13 Mar 2026 | F0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | E | Complaint investigation | 9 Apr 2026 |
| 13 Mar 2026 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Standard survey | 13 Apr 2026 |
| 13 Mar 2026 | F0679 | Provide activities to meet all resident's needs. | D | Standard survey | 13 Apr 2026 |
| 13 Mar 2026 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 30 Apr 2026 |
| 13 Mar 2026 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | E | Standard survey | 30 Apr 2026 |
Survey cycle 2: 10 citations
Standard survey of this cycle: .
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 11 Sep 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint investigation | 16 Oct 2025 |
| 11 Sep 2025 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard survey | 2 Oct 2025 |
| 11 Sep 2025 | F0610 | Respond appropriately to all alleged violations. | D | Standard survey | 16 Oct 2025 |
| 11 Sep 2025 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D | Standard survey | 1 Oct 2025 |
| 15 Apr 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint investigation | 8 Apr 2025 |
| 15 Apr 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 8 Apr 2025 |
| 21 Feb 2025 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 21 Feb 2025 |
| 17 Jan 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | Complaint investigation | 13 Jan 2025 |
| 17 Jan 2025 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G | Complaint investigation | 13 Feb 2025 |
| 17 Jan 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint investigation | 13 Jan 2025 |
Survey cycle 3: 22 citations
The CMS provider file has no standard survey date for this cycle.
| Survey date | F-tag | Requirement (CMS text) | Scope and severity | Survey type | Corrected |
|---|---|---|---|---|---|
| 19 Jun 2024 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint investigation | 18 Jun 2024 |
| 23 May 2024 | F0576 | Ensure residents have reasonable access to and privacy in their use of communication methods. | E | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0584 | 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 investigation | 17 Jun 2024 |
| 23 May 2024 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0610 | Respond appropriately to all alleged violations. | D | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0641 | Ensure each resident receives an accurate assessment. | D | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0690 | 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 investigation | 17 Jun 2024 |
| 23 May 2024 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | G | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint investigation | 17 Jun 2024 |
| 23 May 2024 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 17 Jun 2024 |
| 27 Feb 2024 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint investigation | 15 Feb 2024 |
| 22 Sep 2023 | F0585 | 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 investigation | 6 Nov 2023 |
| 22 Sep 2023 | F0800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | E | Complaint investigation | 6 Nov 2023 |
| 22 Sep 2023 | F0802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | F | Complaint investigation | 6 Nov 2023 |
| 22 Sep 2023 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E | Complaint investigation | 6 Nov 2023 |
| 22 Sep 2023 | F0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D | Complaint investigation | 6 Nov 2023 |
The requirement text is the CMS summary of the F-tag. It is not the report of the surveyor. How to read an inspection report
Penalties
A fine, or a payment denial: a period in which Medicare or Medicaid does not pay for new admissions. The CMS penalties file holds three years.
| Date | Type | Fine | Days without payment |
|---|---|---|---|
| 15 Apr 2025 | Fine | $14,505 | |
| 17 Jan 2025 | Fine | $14,508 | |
| 23 May 2024 | Fine | $78,566 | |
| 27 Feb 2024 | Fine | $8,018 |
Staffing
Hours per resident per day. The nurse hours for one resident on an average day. CMS calculates the figure from the hours that the home reports for a quarter.
| Staff | This home | Wyoming median | Wyoming average (CMS) |
|---|---|---|---|
| All nurse staff | 4.59 | 3.60 | 3.87 |
| Registered nurses (RN) | 0.90 | 0.80 | 0.94 |
| Licensed practical nurses (LPN) | 0.92 | 0.50 | |
| Nurse aides | 2.76 | 2.43 | |
| All nurse staff, weekends | 3.92 | 3.20 | 3.37 |
- Nurse staff turnover in a year
- 70.5%
- Nurse staff turnover, Wyoming median
- 48.3%
- RN turnover in a year
- 47.8%
- Administrators who left in a year
- 3
Homes report the hours to CMS in the Payroll-Based Journal.
Quality measures
A figure that CMS calculates from the assessments of residents. One example is the percentage of long-stay residents with a fall and a major injury.
| Measure (CMS text) | Residents | This home | Wyoming median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 15.7% | 17.4% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.3% | 0.9% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.2% | 2.3% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 9.3% | 3.9% | 2.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 15.3% | 15.3% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 0.6% | 3.6% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 14.0% | 19.2% | 13.4% |
For each measure in this table, CMS gives more points in the quality measure rating for a lower percentage. The site calculates the medians from the CMS file. What the CMS star ratings measure
Ownership
An organisation in the CMS ownership file. CMS records its role, for example an ownership interest, operational or managerial control, or a mortgage interest.
- Ownership type
- Government, hospital district
- Legal business name
- Campbell County Hospital District
The CMS ownership record of this home lists no organisation.
The site shows organisations only. It does not show the names of persons.
Official channels
- Care Compare record of this nursing homeMedicare.gov. The official CMS record of this home.
- Wyoming Department of Health: complaintsThe complaint page of the State Survey Agency for Wyoming, from the CMS list of agencies.
- Contact information for State Survey AgenciesCMS. The web address and the telephone number of the State Survey Agency of each state. These agencies investigate complaints about nursing homes.
- Filing a complaintMedicare.gov. The page names the State Survey Agency as the place for a complaint about nursing home care or facility conditions.
- Eldercare LocatorAdministration for Community Living. A public service that connects older adults and their families to local services. Telephone: 1-800-677-1116.
Cite this page
Centers for Medicare & Medicaid Services, Care Compare. Record of The Legacy Living and Rehabilitation Center (CCN 535022). Data processed 1 Aug 2026. Elder Care Record, https://eldercarerecord.com/facility/the-legacy-living-and-rehabilitation-center-gillette-wy-535022/
Provenance
- Licence
- US government work, public domain
- CMS processed the data on
A program makes this page from the CMS files, and the same files always give the same text. How the site makes the figures. Report an error.
Questions
- When was The Legacy Living and Rehabilitation Center last inspected?
- The latest inspection with a citation in the CMS record was on 13 Mar 2026. It was a standard survey and a complaint investigation. It gave 6 citations. The standard survey before the last one was on 11 Sep 2025.
- Who operates The Legacy Living and Rehabilitation Center?
- The CMS record gives the ownership type as government, hospital district. CMS lists no chain for the home. The CMS ownership file names no organisation for this home. This site does not show the names of persons.
- What does the Special Focus status mean for The Legacy Living and Rehabilitation Center?
- CMS lists the home as a Special Focus Facility. The State Survey Agency inspects a Special Focus Facility every six months. CMS gives no star ratings to a home in the program.
- Where does the data on this page come from?
- The data comes from the CMS Care Compare files for nursing homes. CMS processed the files on 1 Aug 2026. The Care Compare record on Medicare.gov is the official record of the home.