The Legacy Living and Rehabilitation Center, Gillette, WY

The Essentials

Summary

Across 8 inspections from February 2024 to March 2026, state surveyors documented 33 findings at The Legacy Living and Rehabilitation Center; 33 have a recorded correction; CMS lists 4 enforcement actions in the window.

Inspections: 8; 2024–2026, standard and complaint
Findings: 33; Deficiencies cited by state inspectors
Corrected: 33; Of 33 findings, with a recorded correction date
Penalties: 4; 4 fines; payment not published

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2024	3	17	4
2025	4	10	4
2026	1	6	0

What the Record Shows

33 of 33 findings have a recorded correction date.
CMS lists 4 enforcement actions in the window: 4 fines totaling $115,597, their payment not published.
8 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, March 13, 2026, recorded 6 findings (most serious: Level E).

What to Ask About

Protection From Abuse and Neglect, Cited in Six Inspections
Accident Hazards and Supervision, Cited in Four Inspections
Reporting Suspected Abuse, Cited in Three Inspections
Citation F744, Cited in Three Inspections
Investigating Alleged Violations, Cited in Two Inspections

Report at a Glance

Facility: The Legacy Living and Rehabilitation Center
Address: 1000 S Douglas Way, Gillette, WY 82716
CMS Certification Number: 535022
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 160
Ownership: Government - Hospital district
Record Window: February 27, 2024 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Mar 132026
Standard health inspection
6 findings
The same visit included a complaint investigation.
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected Apr 9, 2026
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level ENo actual harm, potential for moreCorrected Apr 30, 2026
- F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Level DNo actual harm, potential for moreCorrected Apr 9, 2026
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Apr 13, 2026
- F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Apr 13, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 30, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Sep 112025
Standard health inspection
4 findings
The same visit included a complaint investigation.
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Oct 16, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 2, 2025
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Oct 16, 2025
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Oct 1, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Apr 152025
Complaint investigation
2 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Apr 8, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 8, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Feb 212025
Complaint investigation
1 finding
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 21, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jan 172025
Complaint investigation
3 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Jan 13, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jan 13, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Feb 13, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jun 192024
Complaint investigation
1 finding
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Jun 18, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
May 232024
Standard health inspection
15 findings
The same visit included a complaint investigation.
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Jun 17, 2024
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level GActual harmCorrected Jun 17, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jun 17, 2024
- F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level ENo actual harm, potential for moreCorrected Jun 17, 2024
- F584Honor 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.Level ENo actual harm, potential for moreCorrected Jun 17, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jun 17, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 17, 2024
Enforcement Action
Civil money penalty, $78,566 imposed May 23, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 23, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $14,508 imposed January 17, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 23, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $14,505 imposed April 15, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of May 23, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Feb 272024
Complaint investigation
1 finding
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Feb 15, 2024
Enforcement Action
Civil money penalty, $8,018 imposed February 27, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of February 27, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Protection From Abuse and Neglect, Cited in Six Inspections
Inspectors cited F600 in February 2024, May 2024, June 2024, January 2025, April 2025 and September 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2424242525252526F600 across all 8 inspections, oldest to newest
2
Accident Hazards and Supervision, Cited in Four Inspections
Inspectors cited F689 in May 2024, January 2025, April 2025 and March 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2424242525252526F689 across all 8 inspections, oldest to newest
3
Reporting Suspected Abuse, Cited in Three Inspections
Inspectors cited F609 in May 2024, February 2025 and September 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2424242525252526F609 across all 8 inspections, oldest to newest
4
Citation F744, Cited in Three Inspections
Inspectors cited F744 in May 2024, September 2025 and March 2026. The agency describes it this way: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2424242525252526F744 across all 8 inspections, oldest to newest
5
Investigating Alleged Violations, Cited in Two Inspections
Inspectors cited F610 in May 2024 and September 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2424242525252526F610 across all 8 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in six inspections, most seriously at level J.
02
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level J.
03
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in three inspections, most seriously at level D.
04
What changed after F744 was cited, and how do you check it now?
Citation F744: cited in three inspections, most seriously at level G.
05
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in two inspections, most seriously at level D.
06
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
07
What led to the 2025 fine, and has it been paid?
A $14,505 civil money penalty was imposed April 15, 2025. CMS publishes the fine, not whether it has been paid. The record holds four enforcement actions in the window.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Wyoming state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wyoming state survey agency
Inspection Feb 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wyoming state survey agency
Inspection May 23, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wyoming state survey agency
Inspection Jun 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wyoming state survey agency
Inspection Jan 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wyoming state survey agency
Inspection Feb 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wyoming state survey agency
Inspection Apr 15, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wyoming state survey agency
Inspection Sep 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Wyoming state survey agency
Inspection Mar 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 535022
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowFebruary 27, 2024 – October 1, 2026

CMS publishes about three inspection cycles; inspections before February 2024 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.