01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-13 | 6 | 2026-03-13 | 9 |
| Cycle 2 | 2025-09-11 | 10 | 2025-09-11 | 14 |
| Cycle 3 | 2024-05-23 | 22 | 2024-05-23 | 3 |
CMS CCN 5350222026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
The Legacy Living And Rehabilitation Center
1000 S Douglas Way · Gillette, WY 82716 · Campbell County
Certified beds160CMS provider file
Recent citation rows64current CMS citation release
Penalty rows4current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
64 rows in the current release
8 rows carry G–L scope/severity codes; 2 carry J–L. 11 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-13 · HEALTHF0627Severity D · isolated; 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.
Correction field: Deficient, Provider has date of correction · 2026-04-09 · complaint2026-03-13 · HEALTHF0628Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2026-04-09 · complaint2026-03-13 · HEALTHF0644Severity D · isolated; 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.
Correction field: Deficient, Provider has date of correction · 2026-04-132026-03-13 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2026-04-132026-03-13 · HEALTHF0689Severity D · isolated; 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.
Correction field: Deficient, Provider has date of correction · 2026-04-302026-03-13 · HEALTHF0744Severity E · pattern; 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.
Correction field: Deficient, Provider has date of correction · 2026-04-302026-03-13 · FIREK0100Severity D · isolated; potential for more than minimal harm
Construction Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-13 · FIREK0223Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-04-082026-03-13 · FIREK0271Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2026-03-122026-03-13 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-04-062026-03-13 · FIREK0325Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have properly installed hallway dispensers for alcohol-based hand rub.
Correction field: Deficient, Provider has date of correction · 2026-04-092026-03-13 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-03-182026-03-13 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2026-04-092026-03-13 · FIREK0531Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have elevators that firefighters can control in the event of a fire.
Correction field: Deficient, Provider has date of correction · 2026-03-312026-03-13 · FIREK0771Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Ensure that smoke control systems are tested and documented in accordance with established engineering principles.
Correction field: Deficient, Provider has date of correction · 2026-04-152025-09-11 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2025-09-182025-09-11 · HEALTHF0600Severity D · isolated; 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.
Correction field: Deficient, Provider has date of correction · 2025-10-16 · complaint2025-09-11 · HEALTHF0609Severity D · isolated; 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.
Correction field: Deficient, Provider has date of correction · 2025-10-022025-09-11 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-10-162025-09-11 · HEALTHF0744Severity D · isolated; 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.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-09-11 · FIREK0222Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-10-172025-09-11 · FIREK0223Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-11-262025-09-11 · FIREK0271Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2025-10-262025-09-11 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-10-0203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-04-15 | Fine | $14,505 | 0 |
| 2025-01-17 | Fine | $14,508 | 0 |
| 2024-05-23 | Fine | $78,566 | 0 |
| 2024-02-27 | Fine | $8,018 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BIGGS, ANGELAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/22/2024
- HARTSAW, SARAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/09/2022
- HITE, RANDALIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/26/2020
- MANSELL, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/29/2022
- MURPHY, TOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2020
- RICE, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/29/2022
- STUBER, ALANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2018
- POPP, DOUGLASIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/20/2023
- SHAHAN, MATTHEWIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/16/2022
- ALEXANDER, HOLLIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2025
- PATEL, KIRTIKUMARIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/13/2020
- POPP, DOUGLASIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/20/2023
- SHAHAN, MATTHEWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/16/2022
- ALEXANDER, HOLLIEIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/01/2025
- PATEL, KIRTIKUMARIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/13/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.59per resident day
RN hours0.90per resident day
Weekend nurse hours3.92per resident day
Staff turnover70.5%CMS reported field
06 / LOCAL RECORDS
Open the Wyoming ledger →Other published facilities nearby
No second facility in the same city met the directory rule.