The Legacy Living and Rehabilitation Center
1000 S Douglas Way, Gillette, WY 82716
The Legacy Living and Rehabilitation Center is a nursing home in Gillette, Wyoming. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star ratingnot rated by CMS
- Last standard health inspectionMarch 13, 2026 (7 months ago)
- Health citations since February 27, 202433 (Wyoming average 21)
- Fines in the past three years4, $115,597 in total
- CMS flagsSpecial Focus Facility
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CMS flags
Special Focus Facility
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of May 27, 2026
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on March 13, 2026
6 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 6 citations
Citation F0628. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on April 9, 2026.
Citation F0744. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on April 30, 2026.
CMS has cited this home for F0744 3 times since 2024.
Citation F0627. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
CMS lists it as corrected on April 9, 2026.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on April 13, 2026.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on April 13, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 30, 2026.
CMS has cited this home for F0689 4 times since 2024.
Fire safety inspection on March 13, 2026
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation K0771. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
CMS lists it as corrected on April 15, 2026.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on April 8, 2026.
CMS has cited this home for K0223 2 times since 2025.
Citation K0531. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have elevators that firefighters can control in the event of a fire.
CMS lists it as corrected on March 31, 2026.
Citation K0100. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet other general requirements.
CMS lists it as corrected on April 8, 2026.
Citation K0271. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on March 12, 2026.
CMS has cited this home for K0271 2 times since 2025.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 6, 2026.
CMS has cited this home for K0321 2 times since 2025.
Citation K0325. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on April 9, 2026.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 18, 2026.
CMS has cited this home for K0353 3 times since 2024.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 9, 2026.
CMS has cited this home for K0511 3 times since 2024.
Health inspection on September 11, 2025
4 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 4 citations
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0600 6 times since 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0609 3 times since 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on October 16, 2025.
CMS has cited this home for F0610 2 times since 2024.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on October 1, 2025.
Fire safety inspection on September 11, 2025
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on September 18, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on October 15, 2025.
Citation K0927. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
CMS lists it as corrected on October 6, 2025.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on October 17, 2025.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on November 26, 2025.
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on October 26, 2025.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on October 9, 2025.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on October 6, 2025.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on October 2, 2025.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on October 26, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 26, 2025.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on October 26, 2025.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 18, 2025.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on October 16, 2025.
CMS update of June 25, 2025
Fine
CMS changed the fine from May 23, 2024 from $120,870 to $78,566.
CMS update of May 28, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to not rated by CMS.
Star rating
The CMS health inspection star rating changed from 1 of 5 to not rated by CMS.
Star rating
The CMS staffing star rating changed from 3 of 5 to not rated by CMS.
Star rating
The CMS quality measures star rating changed from 4 of 5 to not rated by CMS.
Special Focus Facility
CMS now lists this home as a Special Focus Facility.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Fine
CMS changed the fine from February 27, 2024 from $12,335 to $8,018.
Health inspection on April 15, 2025
2 citationsCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
14 of 36 Wyoming homes (39%) got a citation at the actual harm level in 2025.
CMS fine of $14,505 on April 15, 2025.
Show the 2 citations
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 8, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 8, 2025.
CMS update of February 26, 2025
Staffing
Total nurse staffing reported to CMS went from 5.0 to 4.2 hours per resident per day.
Health inspection on February 21, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on February 21, 2025.
Health inspection on January 17, 2025
3 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
1 of 36 Wyoming homes (3%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $14,508 on January 17, 2025.
Show the 3 citations
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on January 13, 2025.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 13, 2025.
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 13, 2025.
CMS update of August 29, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
Health citation
CMS removed citation F0578 from the health inspection on May 23, 2024.
Health citation
CMS removed citation F0644 from the health inspection on May 23, 2024.
CMS update of July 31, 2024
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Health inspection on June 19, 2024
1 citationCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
12 of 36 Wyoming homes (33%) got a citation at the actual harm level in 2024.
Show the 1 citation
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 18, 2024.
CMS update of May 29, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on May 23, 2024
15 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
12 of 36 Wyoming homes (33%) got a citation at the actual harm level in 2024.
CMS fine of $78,566 on May 23, 2024.
Show the 15 citations
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 17, 2024.
Citation F0744. Severity G: actual harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on June 17, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 17, 2024.
Citation F0576. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on June 17, 2024.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on June 17, 2024.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on June 17, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on June 17, 2024.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on June 17, 2024.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on June 17, 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on June 17, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 17, 2024.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on June 17, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 17, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on June 17, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 17, 2024.
Fire safety inspection on May 23, 2024
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0911. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on August 7, 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 17, 2024.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 17, 2024.
Health inspection on February 27, 2024
1 citationCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
12 of 36 Wyoming homes (33%) got a citation at the actual harm level in 2024.
CMS fine of $8,018 on February 27, 2024.
Show the 1 citation
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on February 15, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5.
CMS star ratings
- not rated by CMS CMS overall star rating
- not rated by CMS CMS health inspection star rating
- not rated by CMS CMS staffing star rating
- not rated by CMS CMS quality measures star rating
CMS does not give star ratings to homes in its Special Focus Facility program.
Facts from CMS
- Phone
- (307) 688-7000
- Last standard health inspection
- March 13, 2026 (7 months ago)
- Certified beds
- 160
- Residents per day, on average
- 71.8
- Ownership type
- Government - Hospital district
- Legal business name
- Campbell County Hospital District
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the Wyoming average (33 vs 21).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- ALEXANDER, HOLLIEOperational/managerial control · not applicable · since 04/01/2025
- PATEL, KIRTIKUMAROperational/managerial control · not applicable · since 10/13/2020
- POPP, DOUGLASOperational/managerial control · not applicable · since 03/20/2023
- SHAHAN, MATTHEWOperational/managerial control · not applicable · since 05/16/2022
Questions
When was The Legacy Living and Rehabilitation Center last inspected?
CMS lists March 13, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does The Legacy Living and Rehabilitation Center have?
CMS lists 33 health citations since February 27, 2024. CMS also calls these deficiencies.
Has The Legacy Living and Rehabilitation Center been fined?
CMS lists 4 fines in the past three years, $115,597 in total.
What is the CMS star rating of The Legacy Living and Rehabilitation Center?
CMS does not give star ratings to homes in its Special Focus Facility program.
Is The Legacy Living and Rehabilitation Center a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility.