35.5/100
Poor
1000 S Douglas Way, Gillette, WY 82716
These are findings in the public CMS record for this home. They are not our opinion — each one comes straight from a federal inspection or enforcement file.
Special Focus Facility
CMS has placed this home in its Special Focus Facility program for a persistent pattern of poor care. These homes get inspected twice as often.
8 citation(s) involving actual harm or immediate jeopardy
Inspectors found violations at scope/severity G or above, meaning residents were harmed or placed in immediate jeopardy.
$115,597 in federal fines
CMS has fined this facility across 4 penalty action(s).
Nursing staff turnover of 71%
High turnover means residents rarely see the same caregiver twice. The national average is about 50%.
Every point is shown. Nothing is weighted behind the scenes — the full formula is on How we grade.
Citations from state health inspections over the last three surveys, weighted by how much harm CMS says they caused.
Nursing hours per resident per day, adjusted for how sick the residents are, plus RN cover and weekend consistency.
How much of the nursing team leaves in a year. High turnover means a resident rarely sees the same face twice.
The CMS quality-measure rating, built from resident outcomes like falls, pressure ulcers, infections and antipsychotic use.
Fines and payment denials CMS has imposed. A denial of payment means CMS stopped paying for new admissions.
Grade ceiling applied
Hours of nursing care each resident receives per day. The marker on each bar is the national average.
RNs are the licence level most likely to catch a resident deteriorating.
The shift most families visit, and the one thinned first.
The share of nursing staff who left over the last year.
Last standard health inspection: March 13, 2026 (5 months ago).
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
No actual harm, potential for more than minimal harm
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
No actual harm, potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
No actual harm, potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, potential for more than minimal harm
| Owner | Type | Role | Since |
|---|---|---|---|
| BIGGS, ANGELA | Individual | MANAGING CONTROL - GOVERNING BODY | — |
| HARTSAW, SARA | Individual | MANAGING CONTROL - GOVERNING BODY | — |
| HITE, RANDAL | Individual | MANAGING CONTROL - GOVERNING BODY | — |
| MANSELL, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY | — |
| MURPHY, TOM | Individual | MANAGING CONTROL - GOVERNING BODY | — |
| RICE, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY | — |
| STUBER, ALAN | Individual | MANAGING CONTROL - GOVERNING BODY | — |
| POPP, DOUGLAS | Individual | CORPORATE OFFICER | — |
| SHAHAN, MATTHEW | Individual | CORPORATE OFFICER | — |
| ALEXANDER, HOLLIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — |
| PATEL, KIRTIKUMAR | Individual | OPERATIONAL/MANAGERIAL CONTROL | — |
| POPP, DOUGLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — |
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The Legacy Living And Rehabilitation Center holds an ElderGrade of F (35.5 out of 100), which we describe as "poor". The grade combines its inspection citations, nurse staffing levels, staff turnover, resident outcomes and enforcement history from the federal CMS record.
Residents receive an average of 4.59 nursing hours per day across all nursing staff, against a national average of 3.86 hours.
Yes. 8 of the 38 citations on record were scored at scope and severity G or above, meaning inspectors found actual harm to a resident or immediate jeopardy to resident safety.
Yes, The Legacy Living And Rehabilitation Center is certified to accept Medicaid, which is the programme that pays for long-term custodial care once a resident meets their state's income and asset limits.