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Nursing HomeMedicaid Investigative

The Legacy Living and Rehabilitation Center

On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

1000 S Douglas Way, Gillette, WY 82716160 bedsLicensed & Active
Google rating
2.3/5

based on 6 Google reviews

5
4
3
2
1
The Legacy Living and Rehabilitation Center Nursing Home in Gillette, WY — Street View
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What this means for your family

Given the reports of severe safety lapses, including residents wandering outside and staff sleeping on duty, this facility currently presents significant risks. If you are considering this location, we strongly advise conducting an unannounced visit and specifically interviewing the administration about their dementia training protocols and night-shift supervision policies.

Google Reviews

Google Reviews

6 reviews analyzed
Families report significant concerns regarding the quality of care and safety at The Legacy Living and Rehabilitation Center. Reviewers consistently highlight critical issues with understaffing, inadequate supervision of patients, and a lack of specialized training for residents with dementia.

Quality Themes

Tap a score for details
FoodN/AStaff1.0CleanN/AActivities1.0MedsN/AMemory0.0Comms1.0ValueN/A

Strengths

  • Nurses described as nice by some
  • Facility is accessible for short-term stays

Concerns

  • Chronic understaffing (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02020(1)1.02023(1)3.02024(2)1.02025(3)

Distribution

5
0
4
0
3
0
2
0
1
3

How They Respond to Reviews

50%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1Since we noticed you are very active in responding to feedback from families, how do you typically communicate updates regarding a resident's daily care or health changes to us?
  • 2What kind of daily activities or social events are planned to keep residents engaged and connected with one another?
  • 3How does the nursing team manage resident care during the night shifts to ensure everyone stays safe and comfortable?
  • 4What specific programming or specialized support do you have in place for residents who may need extra help with memory care?
  • 5With the facility being so accessible for short-term stays, how do you help new residents transition into the community during their first few days?
  • 6In the event of a medical emergency after hours, what is the specific protocol for notifying the family and coordinating with doctors?

Personalized based on this facility's data


Key Review Excerpts

My dad was at Legacy and we were not happy at all, he has dementia and they did not have people there that were trained in dementia, my dad wondered outside and couldn’t get back in because he has dementia and could not remember the code

Memory care family member · 2025☆☆☆☆

They are very short staff half the cnas sleep on noc shift and most of the nurses don’t care

General visitor/family · 2025☆☆☆☆

My husband was left unattended by a therapist nam of Page on an exercise machine .the therapist left him unattended snd the machine pulled on him so hard.

Rehab patient's spouse · 2024☆☆☆☆
Source: 6 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.97hrs
OK
Registered nurses for medical care
Total Nursing
4.15hrs
OK
All nurses + aides combined
Staff Turnover
69%
Lower is better (< 30% = good)
RN Turnover
33%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Better Than Avg

5

measures

Worse Than Avg

4

measures

Mixed Results

8

measures

Long-Stay Residents
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility15.3%
Better than Avg
Here
15.3%
US
19.5%
WY
15.8%
Campbell
26.6%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility28.4%
Worse than Avg
Here
28.4%
US
19.4%
WY
23.0%
Campbell
18.1%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility13.6%
Better than Avg
Here
13.6%
US
15.4%
WY
22.8%
Campbell
19.1%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility90.5%
Worse than Avg
Here
90.5%
US
95.5%
WY
94.3%
Campbell
98.5%
😔

Residents with depression symptoms

↓ Lower is better
This Facility11.9%
Mixed vs Avgs
Here
11.9%
US
12.1%
WY
6.3%
Campbell
16.9%
⚠️

Residents who fell and were seriously hurt

↓ Lower is better
This Facility8.6%
Worse than Avg
Here
8.6%
US
3.2%
WY
4.5%
Campbell
3.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility90.4%
Mixed vs Avgs
Here
90.4%
US
81.8%
WY
76.5%
Campbell
95.9%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility83.6%
Mixed vs Avgs
Here
83.6%
US
79.7%
WY
77.0%
Campbell
92.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.8%
Mixed vs Avgs
Here
1.8%
US
1.6%
WY
1.4%
Campbell
1.9%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

6deficiencies
4penalties
31 complaint-triggered
$115,597 in fines

This facility has serious recurring problems with protecting residents from abuse and neglect, with families filing 29 complaints triggering federal investigations. The most persistent issues involve resident protection, accident prevention, and care planning, with abuse/neglect violations appearing across multiple surveys from 2024-2025. While the facility corrects deficiencies when cited, the pattern of repeated violations in critical care areas suggests ongoing systemic problems that families should carefully consider.

Mar 13, 2026Routine
15
0771ModerateCorrected

Miscellaneous Deficiencies

Ensure that smoke control systems are tested and documented in accordance with established engineering principles.

0628ModerateCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0744ModerateCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

0223ModerateCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0531ModerateCorrected

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

0627MinorCorrected

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

0644MinorCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0679MinorCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0689MinorCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0100MinorCorrected

Construction Deficiencies

Meet other general requirements.

0271MinorCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0321MinorCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0325MinorCorrected

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

0353MinorCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0511MinorCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Sep 11, 2025Routine
17
0041ModerateCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0345ModerateCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0927ModerateCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

0222ModerateCorrected

Egress Deficiencies

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.

0223ModerateCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0271ModerateCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0511ModerateCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0923ModerateCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0609MinorCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610MinorCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0744MinorCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

0321MinorCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0351MinorCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0353MinorCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0781MinorCorrected

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

0918MinorCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0920MinorCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Sep 11, 2025Complaint
1
0600MinorCorrected

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.

Apr 15, 2025Complaint
4
0600Moderate

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.

0600Moderate

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.

0689Minor

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0689Minor

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Feb 21, 2025Complaint
1
0609MinorCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Jan 17, 2025Complaint
3
0600Severe

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.

0689Severe

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0684ModerateCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Federal Penalties

Fine

Apr 15, 2025

$14,505

Fine

Jan 17, 2025

$14,508

Fine

May 23, 2024

$78,566

Fine

Feb 27, 2024

$8,018

Ownership & Operations

Who Operates This Facility

Owner / Operator

The Legacy Living and Rehabilitation Center

Organization Type

government

Ownership & Management

Key personnel

Klein, GerardW-2 Managing EmployeeKlein, GerardOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

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