The Legacy Living And Rehabilitation Center
The Legacy Living and Rehabilitation Center in Gillette, WY — inspection on March 13, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of a progress note for resident #79 dated [DATE] and timed 2:19 PM showed .This nurse was notified of resident unwitnessed fall.
Upon assessment, resident was found to be A&Ox1 [alert and oriented times 1] and slightly decreased LOC [level of consciousness], noted by increased response times.
Resident was found to have an abnormal pulse on left wrist and clammy skin.
Resident was incontinent at the time of fall, per staff report.
Provider on call aware of clinical findings and transfer to ER [emergency room] obtained .
Review of a Notice of Transfer dated [DATE] showed the resident was provided a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted.
Further review showed Return to Facility . A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan or facility policy, return to the facility to their previous room if available or immediately upon the first availability of a bed in semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services .
The following concerns were identified:a.
Review of a progress note dated [DATE] and timed 2:20 PM showed spoke with [name], POA regarding resident status.
Resident has been out of facility greater than 30 days and is no longer on bed hold for facility.
Discussed concerns with previous balance and Medicaid pending status.
Resident has not been approved for Medicaid coverage for 2025.
Being out over 30 days requires new admission per regulations.
Legacy is not currently taking admissions. [POA name] requests to return call to Legacy to further conversation with Medicaid needs.b.
Review of a progress note dated [DATE] and timed 2:46 PM showed Spoke with [name], VP care manager at [hospital name] regarding resident discharge from facility.
Explained that resident received transfer notice [DATE] with bed-hold notice and appeal rights.
Resident remained continuously inpatient beyond 30 days (current 60 days).
Bed-hold has expired; resident has lost return rights.
Facility is currently closed to admissions; readmission to facility declined at this time as resident is a new admission.c.
Review of the medical record showed no evidence the resident was issued a discharge notice following the acute care transfer on [DATE].d.
Interview with the facility administrator on [DATE] at 2:27 PM revealed the resident was not allowed to return because s/he had been gone longer than the bed hold, the facility completed a discharge, they determined the resident would be a readmission, and the facility was not accepting admissions.
She confirmed a transfer notice was provided to the resident on [DATE] when the resident required acute care services at a hospital and did not issue a discharge notice at anytime during the hospital stay.
Further interview revealed the facility had available beds when the resident was ready to return to the facility. 2.
Review of the policy titled Notice of Transfer last revised on 10/21 showed .Return to Facility . A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan or facility policy, return to the facility to their previous room if available or immediately upon the first availability of a bed in semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services .
535022 03/13/2026
The Legacy Living and Rehabilitation Center 1000 S Douglas Way Gillette, WY 82716
Review of a Notice of Transfer dated [DATE] showed the resident was provided a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted.
- Review of a progress note for resident #1 dated [DATE] and timed 9:01 PM showed Resident had
had several episodes of emesis during the evening med pass, day shift reported to cna's [sic] that the resident had not eaten very much all day.
Called to residents [sic] room as he/she had a third episode of emesis.
Took resident's vitals: BP 147/74, P124, T100, RR 68, O2 was 77% on 2 and 4 liters of oxygen, resident denies any pain.
Assessed resident as I suspected he/she may have aspirated, crackles to right lower lung.
Building charge also assessed resident and we agreed resident was in respiratory distress, tachypneic and unable to slow his/her breathing. 9:09 PM Obtained an order from on call provider W.S. to the the [sic] resident to the ER. 21: 12 [9:12 PM] Called 911 to have an ambulance dispatched to the facility. 21:20 [9:20 PM] Notified residents POA, [POA Name], that I was sending his/her [parent] to the ER. [POA] thanked us for notifying him/her, said he/she would contact the co-POA, [co-POA Name], about [their parents] situation and stated, I will probably head to the hospital. 21:31 [9:31 PM] Ambulance service left the facility with the resident. 01:44 [1:44AM] Contacted CCH for an update on the resident, spoke with [Name] R.N.
Nurse reported that the resident was awaiting a bed, and that he/she was being admitted for aspiration pneumonia, VS are stable, resident is tachypneic, and has a fever that is 100.4, down from 103.2 Resident was given lactated ringers, resident has a right sided block, and a prolonged QT interval, WBC [white blood cell] count is 20.9. 07:12 [7:12 AM] spoke with [name] R.N.
Respiratory panel is negative, CT scan shows Bilateral aspiration.
Nurse states that the resident is resting comfortably.
The following concerns were identified: a.
Review of Notice of Transfer dated [DATE] showed the resident was provided with a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted.
- Review of Notice of Transfer dated [DATE] for resident #3 showed the resident was provided with
- Interview with the facility administrator on [DATE] at 2:27 PM confirmed the transfer notices
a notice of transfer to an acute care facility due to his/her needs cannot be met in the facility currently and their welfare is impacted.
provided to the residents or representatives did not include a specific reason for the transfer to acute care.
535022 03/13/2026
The Legacy Living and Rehabilitation Center 1000 S Douglas Way Gillette, WY 82716
Review of the annual MDS assessment dated [DATE] showed resident #6 had diagnoses which included depression and psychotic disorder (other than schizophrenia).
The following concerns were identified:a.
Review of the PASARR Level I assessment completed on 3/8/21 showed the resident did not have a psychiatric diagnosis and did not present evidence of mental illness which included a possible disturbance in orientation, affect or mood that was not attributable to dementia or other medical diagnosis.b.
Review of the medical record showed the new diagnosis of psychotic disorders with hallucinations due to known physiological condition was created on 9/5/25.c.
Interview with the NHA on 3/12/26 at 4:19 PM revealed the resident had a new diagnosis of psychosis that was related to the resident's urinary tract infections that did not trigger the initial PASARR.
Further interview confirmed the PASARR II should have been completed.d.
Interview with the NHA on 3/12/26 at 5:52 PM confirmed the facility had started a full-scale audit on PASARRs last week.
535022 03/13/2026
The Legacy Living and Rehabilitation Center 1000 S Douglas Way Gillette, WY 82716
Review of the Activities care plan last revised on 2/16/26 showed the resident enjoyed listening to music while bathing, watching westerns and the news, reading mystery and action books, and playing cribbage.
The following concerns were identified:a.
Interview with the resident on 3/10/226 at 5:33 PM revealed s/he did not feel s/he was offered choices and s/he wanted to play cards; however, staff would not play with him/her.
The resident stated s/he had to wait for family to visit so s/he could play cards.
Further interview revealed the resident did not participate in other activities due to his/her decreased mobility. b.
Review of the progress notes from 3/5/26 to 3/11/26 showed the resident participated in 1 to 1 activities three times, on 3/5, 3/8, and 3/11.
Further review showed no evidence the activities included the resident's preferences, specifically, there was no evidence the facility offered or played cards with the resident.c.
Review of the progress notes from 2/10/26 to 3/4/26 showed the resident did not participate in any 1 to 1 activities. d.
Review of the progress notes from 1/28/26 to 2/9/26 showed the resident participated in 1 to 1 activities five times, on 1/28, 1/30, 2/1, 2/4, and 2/9.
Further review showed no evidence the activities included the resident's preferences, specifically, there was no evidence the facility offered or played cards with the resident.e.
Review of the medical record showed no evidence an activity assessment had been completed since 6/24/26.f.
Review of the activity calendar for March 2028, February 2028, and January 2028 showed no card game activities were scheduled or provided by the facility.g.
Review of the activity participation record from 1/13/26 through 3/12/26 showed no evidence the resident was offered, refused, or participated in any group activities during the time period.
Further review showed no evidence the resident was offered, refused, or participated in activities identified as interests on the resident's activity assessment.2.
Interview with the activity director on 3/12/26 at 5:36 PM confirmed the facility did not have card games on the activity calendar; however, she revealed there was a group of residents who played cards sometimes.
She confirmed resident #68 was not assisted to play to cards with any of the groups.
She revealed staff should document refusal of activity participation in the medical record.3.
Interview with the activity director on 3/12/26 at 6:20 PM revealed the facility identified 1 to 1 activities were not being completed as they should be and the facility had limited documentation of resident refusals. 4.
Interview with the facility administrator on 3/13/26 at 7:49 AM confirmed an activity assessment had not been completed since 6/26/24.5.
Review of the policy titled Activity Schedule last revised 5/2025 showed .1.
Activities will be designed to meet and support the participants physical, mental, intellectual, and psycho-social well-being. 2.
Activities will create opportunities for each resident to have a meaningful life by supporting their domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning) .
535022 03/13/2026
The Legacy Living and Rehabilitation Center 1000 S Douglas Way Gillette, WY 82716
Review of the MDS assessment dated [DATE] showed resident #21 had a BIMS score of 0 which indicated severe cognitive impairment and had diagnoses of Alzheimer's Disease and Non-Alzheimer's Dementia.
Review of resident #21's care plan dated 8/2025 and last revised on 4/28/25 identified that the resident was at risk for falls related to dementia, and poor safety awareness.
The following concerns were identified:a.
Interview with CNA #1 on 3/13/26 at 10 AM revealed the resident had been sitting at the end of long table in the dining room where his/her chair was pushed up to the table.
The resident tried to push the chair out, was unable to get back far enough, the resident climbed over the arm of chair and fell on the floor.
The CNA reported she was not close enough to assist.b.
Interview with LPN #1 on 3/13/26 at 8:26 AM revealed that the resident was observed trying to step over the arm of the chair that was pushed up to the table, and the resident fell.
Further interview revealed the resident could not get his/her leg up high enough to clear the chair.c.
Review of a Risk Management Review Note dated 12/18/25 and timed 9:47 AM showed Resident was in the dining room and climbed up on a dining room chair falling.
Root Cause: Poor impulse control, poor safety awareness. resident has desire to clean and tidy immediate areas.
Treatment required: Transferred to ER for evaluation.
Resulting in surgical hip repair with pinning.
Interventions put into place: Clear pathways with mobility and exit from dining tables.
Ensure that she/he is able to move chair at desire without obstacles behind her.
Requires assist with ambulation upon return.
Supervision in the dining room during meals.d.
Review of a Post Fall Evaluation note dated 1/28/26 and timed 5:45 PM showed on 1/28/26 at 4:32 PM the resident had a witnessed fall in the living room while attempting to ambulate on his/her own with an untied shoelace.
Further review showed there was no evidence of injury.e.
Review of a Post Fall Evaluation note dated 3/3/26 and timed 5:55 PM showed the resident had an unwitnessed fall in the dining room while s/he attempted to ambulate on her/his own.
Further review showed there was no evidence of injury.f.
Review of facility policy titled Fall Management last revised 6/2025 showed . 2.
Individualized care plan interventions will be implemented for those residents found to be at high risk for falls.
Resident and resident representative (if applicable) will be invited to all care plan meetings.
Interventions are to be re-evaluated when a resident falls for efficacy. 4.
Document the resident's response to interventions and revise interventions if they are not successful.
indicated staff were generally familiar with the residents' behavioral flow, and there was no wander
behavior note.
She was unaware of any specific rules of minimum staff supervision in common areas.
the locked unit was to have supervision in common areas at all possible times.
She reported if residents left the locked unit with staff, they received continuous 1 to 1 supervision.
535022 03/13/2026
The Legacy Living and Rehabilitation Center 1000 S Douglas Way Gillette, WY 82716