About The Legacy Living and Rehabilitation Center
The Legacy Living And Rehabilitation Center, located in Gillette, WY, is a government owned organization that accepts Medicare and Medicaid.
Why Families Choose The Legacy Living and Rehabilitation Center
- More Nursing Time: Staff spends 4.63 hours per resident daily (National Avg: 3.87).
Key Performance Indicators
- CMS Overall Rating Stars
- Nursing Hours 4.63 hrs
- Safety Record Clean
Chain Affiliations & Network
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Nursing Staff Analysis
Staffing levels are a critical indicator of quality care. We analyze the daily hours of care provided by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs).
Above Average Staffing
The Legacy Living and Rehabilitation Center provides more care hours than the state average and more than the national average.
Registered Nurses (RN)
Licensed Practical Nurses
Certified Assistants
CMS Quality Ratings
| Category | Rating | Stars |
|---|---|---|
| Overall Rating | Not Rated | |
| Health Inspection | Not Rated | |
| Quality Measures | Not Rated | |
| Staffing | Not Rated |
Health Inspection History
| Inspection Cycle | Score | Date |
|---|---|---|
| Cycle 1 (Most Recent) | 32 | Mar 13, 2026 |
| Weighted Average | 100 | Combined Score |
Detailed Quality Measures
Rates are from CMS quality measures (claims-based and MDS-based) for the reporting period ending Jun 01, 2026. Some measures may be omitted when CMS does not report a numeric rate for this facility.
Medicare claims-based measures
Typically includes short-stay outcomes, hospitalizations, and ED use from Medicare claims.
| Measure | Rate |
|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursi... (QM521) | 21.0% |
| Percentage of short-stay residents who had an outpatient emergency depar... (QM522) | 31.8% |
| Number of hospitalizations per 1000 long-stay resident days (QM551) | 1.5% |
| Number of outpatient emergency department visits per 1000 long-stay resi... (QM552) | 3.8% |
MDS-based measures
Resident assessment data; often used for long-stay care quality.
| Measure | Rate |
|---|---|
| Percentage of long-stay residents whose need for help with daily activit... (QM401) | 16.0% |
| Percentage of long-stay residents who lose too much weight (QM404) | 5.8% |
| Percentage of long-stay residents with a catheter inserted and left in t... (QM406) | 0.9% |
| Percentage of long-stay residents with a urinary tract infection (QM407) | 4.9% |
| Percentage of long-stay residents who have depressive symptoms (QM408) | 11.9% |
| Percentage of long-stay residents who were physically restrained (QM409) | 0.0% |
| Percentage of long-stay residents experiencing one or more falls with ma... (QM410) | 8.6% |
| Percentage of long-stay residents assessed and appropriately given the p... (QM415) | 96.0% |
| Percentage of short-stay residents assessed and appropriately given the... (QM430) | 90.4% |
| Percentage of short-stay residents who newly received an antipsychotic m... (QM434) | 1.8% |
| Percentage of long-stay residents whose ability to walk independently wo... (QM451) | 11.6% |
| Percentage of long-stay residents who received an antianxiety or hypnoti... (QM452) | 15.3% |
| Percentage of long-stay residents assessed and appropriately given the s... (QM454) | 90.5% |
| Percentage of short-stay residents who were assessed and appropriately g... (QM472) | 83.6% |
| Percentage of long-stay residents with pressure ulcers (QM479) | 1.1% |
| Percentage of long-stay residents with new or worsened bowel or bladder... (QM480) | 28.4% |
| Percentage of long-stay residents who received an antipsychotic medicati... (QM481) | 13.6% |
Complaints & Deficiencies
Complaint History by Year
This chart shows the number of complaints filed each year.
Summary:
- 2023: 5 complaints
- 2024: 17 complaints
- 2025: 7 complaints
- 2026: 2 complaints
- Total: 31 complaints on record
Recent Complaints (Since Jan 2023)
| Date | Description |
|---|---|
| Apr 09, 2026 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. |
| Apr 09, 2026 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. |
| Oct 16, 2025 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Apr 08, 2025 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Apr 08, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Feb 21, 2025 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Feb 13, 2025 | Provide appropriate treatment and care according to orders, resident?s preferences and goals. |
| Jan 13, 2025 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Jan 13, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Jun 18, 2024 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Jun 17, 2024 | Respond appropriately to all alleged violations. |
| Jun 17, 2024 | Provide and implement an infection prevention and control program. |
| Jun 17, 2024 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. |
| Jun 17, 2024 | Ensure each resident receives an accurate assessment. |
| Jun 17, 2024 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. |
| Jun 17, 2024 | Ensure services provided by the nursing facility meet professional standards of quality. |
| Jun 17, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Jun 17, 2024 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. |
| Jun 17, 2024 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. |
| Jun 17, 2024 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. |
| Jun 17, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. |
| Jun 17, 2024 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Jun 17, 2024 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Jun 17, 2024 | 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. |
| Jun 17, 2024 | Ensure residents have reasonable access to and privacy in their use of communication methods. |
| Feb 15, 2024 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Nov 06, 2023 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. |
| Nov 06, 2023 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. |
| Nov 06, 2023 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. |
| Nov 06, 2023 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. |
| Nov 06, 2023 | 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. |
Nearby Hospitals
CAMPBELL COUNTY HEALTH
GILLETTE, WY
Owner & Operator Information
Business Entity
CAMPBELL COUNTY HOSPITAL DISTRICT
Ownership Structure
Management & Direction
- HOLLIE ALEXANDER OPERATIONAL/MANAGERIAL CONTROL
- HOLLIE ALEXANDER ADP OF THE SNF
- ANGELA BIGGS MANAGING CONTROL - GOVERNING BODY
- SARA HARTSAW MANAGING CONTROL - GOVERNING BODY
- RANDAL HITE MANAGING CONTROL - GOVERNING BODY
- JOHN MANSELL MANAGING CONTROL - GOVERNING BODY
- TOM MURPHY MANAGING CONTROL - GOVERNING BODY
- KIRTIKUMAR PATEL OPERATIONAL/MANAGERIAL CONTROL
- KIRTIKUMAR PATEL ADP OF THE SNF
- DOUGLAS POPP CORPORATE OFFICER
- DOUGLAS POPP OPERATIONAL/MANAGERIAL CONTROL
- JOHN RICE MANAGING CONTROL - GOVERNING BODY
- MATTHEW SHAHAN CORPORATE OFFICER
- MATTHEW SHAHAN OPERATIONAL/MANAGERIAL CONTROL
- ALAN STUBER MANAGING CONTROL - GOVERNING BODY
Associated Doctors
Local Comparison
| Facility | Distance | Rating |
|---|---|---|
| The Legacy Living and Rehabilitation Center | N/A | N/A |
Related Analysis
Best Nursing Homes in Gillette, WY
Compare The Legacy Living and Rehabilitation Center to the top-rated facilities in the area.
Ownership Details
Complete list of registered owners, including direct and indirect ownership.
Noted Deficiencies
Detailed history of deficiencies with descriptions and correction dates.
Nursing Hours Analysis
Detailed breakdown of staffing hours per resident by role.
Frequently Asked Questions
- Skilled Nursing Care: 24/7 medical supervision and complex medical treatments
- Long-term Residential Care: Assistance with daily living activities for extended stays
- Short-term Rehabilitation: Recovery services after hospital stays or surgeries
- Memory Care: Specialized programs for residents with dementia and Alzheimer's disease
- Level of care needed (skilled nursing vs. long-term care)
- Room type (private vs. semi-private)
- Insurance coverage (Medicare, Medicaid, private insurance)
- Length of stay and specific services required
For current rates and to discuss payment options, contact The Legacy Living and Rehabilitation Center directly at 3076887000. Their admissions team can help determine coverage and out-of-pocket expenses.
Environment & Cleanliness
- Overall cleanliness and odors
- Resident room conditions
- Common area maintenance
- Safety features and accessibility
Staff & Care Quality
- Staff-to-resident ratios
- How staff interact with residents
- Response time to resident needs
- Staff knowledge and professionalism
Ask to speak with current residents and their families, tour at different times of day, and review the facility's most recent inspection reports.