The Legacy Living and Rehabilitation Center
Nursing Home · Gillette, WY
CMS certification number535022
CMS lists this nursing home as a Special Focus Facility – a facility with a persistent record of serious quality problems that is inspected more often.
Contact & location
1000 S Douglas WayGillette, WY 82716
Campbell County
- Phone
- (307) 688-7000
- ZIP code
- 82716 – all care providers
Facility details
- Certified beds
- 160
- Residents per day
- 71.5 (45% occupied)
- Ownership
- Government - Hospital district
- Legal name
- Campbell County Hospital District
- Medicare certified since
- June 16, 1984
- Participates in
- Medicare and Medicaid
- Council
- Resident council
CMS star ratings
Staffing
Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.
- Total nurse staffing
- 4.59 (state 3.87 · U.S. 3.86)
- Registered nurses (RN)
- 0.90 (state 0.94 · U.S. 0.69)
- Licensed practical nurses
- 0.92 (state 0.50 · U.S. 0.86)
- Nurse aides
- 2.76 (state 2.43 · U.S. 2.32)
- Weekend total
- 3.92 (state 3.37 · U.S. 3.42)
- Nursing staff turnover
- 70.5 (state 51.8 · U.S. 45.8)%
- RN turnover
- 47.8 (state 44.1 · U.S. 42.9)%
- Administrators who left
- 3 in the last year
Inspections
- Last standard inspection
- March 13, 2026
- Health deficiencies (last cycle)
- 6.0 (state 7.6 · U.S. 9.3)
- From complaints
- 2
- Citations on record (3 years)
- 38 health · 26 fire safety · includes immediate jeopardy
| Date | Citation | Severity | Status |
|---|---|---|---|
| 2026-03-13 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. F0628 · Resident Rights Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2026-04-09 |
| 2026-03-13 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. F0744 · Quality of Life and Care Deficiencies |
E No actual harm, potential for more than minimal harm |
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. F0627 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-04-09 |
| 2026-03-13 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. F0644 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2026-04-13 |
| 2026-03-13 | Provide activities to meet all resident's needs. F0679 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
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. F0689 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
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. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-10-16 |
| 2025-09-11 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-10-02 |
| 2025-09-11 | Respond appropriately to all alleged violations. F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-10-16 |
| 2025-09-11 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. F0744 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
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. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
G Actual harm |
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. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-04-08 |
| 2025-02-21 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
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. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
J Immediate jeopardy to resident health or safety |
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. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
J Immediate jeopardy to resident health or safety |
Corrected 2025-01-13 |
| 2025-01-17 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies · complaint inspection |
G Actual harm |
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. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
G Actual harm |
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. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
G Actual harm |
Corrected 2024-06-17 |
| 2024-05-23 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. F0744 · Quality of Life and Care Deficiencies · complaint inspection |
G Actual harm |
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. F0812 · Nutrition and Dietary Deficiencies · complaint inspection |
F No actual harm, potential for more than minimal harm |
Corrected 2024-06-17 |
| 2024-05-23 | Ensure residents have reasonable access to and privacy in their use of communication methods. F0576 · Resident Rights Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
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. F0584 · Resident Rights Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-06-17 |
| 2024-05-23 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. F0804 · Nutrition and Dietary Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-06-17 |
| 2024-05-23 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-06-17 |
| 2024-05-23 | Respond appropriately to all alleged violations. F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
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. F0623 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-06-17 |
| 2024-05-23 | Ensure each resident receives an accurate assessment. F0641 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
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. F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-06-17 |
| 2024-05-23 | Ensure services provided by the nursing facility meet professional standards of quality. F0658 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
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. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
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. F0690 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-06-17 |
| 2024-05-23 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
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. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
G Actual harm |
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. F0802 · Nutrition and Dietary Deficiencies · complaint inspection |
F No actual harm, potential for more than minimal harm |
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. F0585 · Resident Rights Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
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. F0800 · Nutrition and Dietary Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2023-11-06 |
| 2023-09-22 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. F0804 · Nutrition and Dietary Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
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. F0806 · Nutrition and Dietary Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2023-11-06 |
Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results
Fines & penalties
4 penalties in the last three years, including $115,597 in fines.
| 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 |
Ownership & management
| Name | Role | Since |
|---|---|---|
| Alexander, Hollie (individual) | Administrator · NOT APPLICABLE | |
| Patel, Kirtikumar (individual) | Administrator · NOT APPLICABLE | |
| Popp, Douglas (individual) | Corporate Officer · NOT APPLICABLE | |
| Shahan, Matthew (individual) | Corporate Officer · NOT APPLICABLE | |
| Biggs, Angela (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Hartsaw, Sara (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Hite, Randal (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Mansell, John (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Murphy, Tom (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Rice, John (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Stuber, Alan (individual) | Managing Control - Governing Body · NOT APPLICABLE | |
| Alexander, Hollie (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Patel, Kirtikumar (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Popp, Douglas (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Shahan, Matthew (individual) | Operational/managerial Control · NOT APPLICABLE |
Frequently asked questions
How many beds does The Legacy Living and Rehabilitation Center have?
It has 160 certified beds and cares for about 72 residents per day.
Has The Legacy Living and Rehabilitation Center been fined?
Yes. CMS lists 4 penalties totaling $115,597 in the last three years.
What is the phone number of The Legacy Living and Rehabilitation Center?
(307) 688-7000. The facility is located at 1000 S Douglas Way, Gillette, WY 82716.
Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.