I moved my mother here and have been impressed by the attentive staff, clean comfortable rooms, varied activities, and good meals. Communication is responsive and the community feels safe and welcoming - a few small tweaks would make it outstanding.
Loved one of resident
Jul 2026
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Healthcare staffing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Transportation
Community operated transportation
Transportation arrangement
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor space
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
2.33·(6)
Overall rating
5
4
3
2
1
Care
1.0
Staff
1.0
Meals
2.3
Amenities
2.3
Value
2.3
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Medicare Ratings
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
The Legacy Living and Rehabilitation Center is located at 1000 S Douglas Hwy, Gillette, WY, 82716.
About The Legacy Living and Rehabilitation Center
Legacy Living And Rehabilitation Center offers a comprehensive range of services and amenities designed to support residents' overall well-being and quality of life. This care home prioritizes the health and comfort of its residents by providing professional nursing care, rehabilitation services, and daily support within a compassionate environment. The facility stays attentive to current healthcare guidelines and adapts its policies as needed to maintain the health and safety of everyone on site. Legacy Living And Rehabilitation Center fosters a close community where residents are encouraged to engage in meaningful social interactions and participate in activities designed to enhance their independence and sense of belonging.
The approach at Legacy Living And Rehabilitation Center goes beyond basic care, emphasizing wellness through access to specialized services such as diabetes management, physical therapy, and occupational therapy tailored to meet individual needs. The center acknowledges the specific health challenges facing the wider community, such as the prevalence of diabetes, and integrates educational initiatives and health management strategies into its care plans. Seasonal events and holiday observances are coordinated thoughtfully, with adjustments to department schedules and services to ensure residents continue to receive quality care while maintaining a festive atmosphere.
The leadership and dedicated staff at Legacy Living And Rehabilitation Center strive to create an environment where both residents and employees feel valued. The team is committed to upholding a standard of excellence through ongoing professional development and a focus on delivering compassionate, personalized care. The center regularly shares updates with residents and their families, keeping everyone informed about new programs, health guidance, and upcoming events. Through this proactive approach, Legacy Living And Rehabilitation Center maintains its role as a trusted resource for long-term care and rehabilitation, consistently seeking ways to enrich the lives of those it serves.
People often ask...
The Legacy Living and Rehabilitation Center offers assisted living and skilled nursing.
There are 2 photos of The Legacy Living and Rehabilitation Center on Mirador.
The full address for this community is 1000 S Douglas Hwy, Gillette, WY 82716.
No, The Legacy Living and Rehabilitation Center does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Wyoming, the Department of Health's Healthcare Licensing & Surveys program licenses care facilities and publishes licensure, complaint, and life-safety findings.
License number
nh-197
Facility type
Nursing Home
Inspection Reports
146
Reports
38
Type A Citations
0
Type B Citations
54
Complaints
21
Years
15 Apr 2025Complaint
15 Apr 2025Complaint
Investigated a complaint about resident-to-resident abuse and found that several altercations occurred, injuring a resident and exposing gaps in supervision and safety measures.
CFR 483.12(a)(1)Free from Abuse and Neglect
CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
09 Apr 2025Revisit
09 Apr 2025Revisit
Found no deficiencies. All regulations surveyed were met.
21 Feb 2025Complaint
21 Feb 2025Complaint
Investigated the reporting of a suspected crime; found the drug toxicity/overdose allegation involving a resident was not reported to authorities as required.
§483.12(c)In response to allegations of abuse, neglect, exploitation, or mistreatment
§483.12(c)(4)Report the results of all investigations to the administrator or designated representative and to other officials in accordance with State law
17 Jan 2025Complaint
17 Jan 2025Complaint
Investigated a complaint and found serious safety and care failures, including elopement and neglect that resulted in a resident's death. Violations were cited for abuse/neglect, quality of care, and accident hazards.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
CFR 483.25Quality of Care
CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
21 Nov 2024Complaint
21 Nov 2024Complaint
Investigated the complaint; found no deficiencies identified during the complaint investigation.
22 Aug 2024Revisit
22 Aug 2024Revisit
Concluded compliance with Life Safety Code requirements after a revisit; prior deficiencies were corrected.
07 Aug 2024Revisit
07 Aug 2024Revisit
Found no deficiencies. A revisit confirmed compliance with all regulations surveyed.
07 Aug 2024Complaint
07 Aug 2024Complaint
Investigated a complaint and found no deficiencies.
19 Jun 2024Complaint
19 Jun 2024Complaint
Investigated a complaint and found abuse and neglect involving one resident (of six sampled), with evidence of inadequate rounds and staff's verbal/physical mistreatment.
§483.12(a)(1)Free from Abuse and Neglect
23 May 2024Licensure
23 May 2024Licensure
Investigated allegations and found multiple deficiencies affecting resident rights, safety, infection control, and care planning, with several instances of abuse and inadequate care processes.
CFR 483.10(g)(6)-(9)Right to forms of communication w/ privacy
CFR 483.80(a)(1)-(4), 483.80(e), 483.80(f)Infection Prevention & Control
22 May 2024Life Safety
22 May 2024Life Safety
Identified deficiencies in fire protection, gas piping protection, and electrical system maintenance during the survey.
NFPA 101; NFPA 25Sprinkler System - Maintenance and Testing
NFPA 101; NFPA 54; ANSI Z21.69Gas and Electric Utilities
NFPA 99Electrical Systems - Other
12 Apr 2024Complaint
12 Apr 2024Complaint
Found no deficiencies related to the complaint investigation.
14 Dec 2023Revisit
14 Dec 2023Revisit
Verified compliance after a follow-up visit; prior deficiencies corrected.
14 Dec 2023Complaint
14 Dec 2023Complaint
Investigated complaints and found no deficiencies.
22 Sept 2023Complaint
22 Sept 2023Complaint
Investigated a complaint alleging issues with grievance handling and meal service; found multiple deficiencies including failure to resolve grievances promptly, inadequate meals and allergy handling, and insufficient dietary staffing.
42 CFR 483.10(j)Grievances
42 CFR 483.60(d)(1)-(2)Nutritive Value, Palatability and Temperature
42 CFR 483.60(a)(3)(b)Sufficient Dietary Support Personnel
42 CFR 483.60(d)Nutritive Value, Palatability and Temperature
Verified that prior deficiencies were corrected and no new noncompliance was found.
14 Apr 2023Revisit
14 Apr 2023Revisit
Verified that previous deficiencies were corrected and compliance with applicable safety standards was achieved.
09 Mar 2023Complaint
09 Mar 2023Complaint
Found deficiencies in baseline care planning, comprehensive care planning, and updating the facility assessment. The findings show missing resident-specific information and overdue assessments.
§483.21(a)(1)-(3)Baseline Care Plan
§483.21(b)(1)-(3)Develop/Implement Comprehensive Care Plan
§483.70(e)(1)-(3)Facility Assessment
09 Mar 2023Licensure
09 Mar 2023Licensure
Concluded no deficiencies were found and compliance with state requirements was maintained.
08 Mar 2023Life Safety
08 Mar 2023Life Safety
Identified multiple life-safety deficiencies, including missing emergency contact information and numerous fire protection and egress issues.
42 CFR 483.73(c)(2)Emergency Officials Contact Information
2012 NFPA 101, Section 7.2.1.8.2Doors with Self-Closing Devices
2012 NFPA 101, Section 19.2.2.3; 7.2.2.5.1.1; 7.1.3.2.3Stairways and Smokeproof Enclosures
2012 NFPA 99: 15.3.1, 15.3.2; 2012 NFPA 30: 9.3.6Features of Fire Protection - Other
08 Mar 2023Life Safety
08 Mar 2023Life Safety
Observed combustibles stored in the boiler room, violating fire code. The finding was cited as a life safety deficiency.
2006 International Fire Code 315.2.3Boiler room combustible storage
28 Jan 2022Revisit
28 Jan 2022Revisit
Verified that prior deficiencies were corrected and no new noncompliance was found.
19 Jan 2022Revisit
19 Jan 2022Revisit
Verified the deficiencies were corrected and compliance was restored. No new noncompliance was observed.
03 Dec 2021Life Safety
03 Dec 2021Life Safety
Identified multiple life-safety deficiencies, including missing emergency contact information and failures to maintain egress doors, fire protection systems, extinguishers, and decorative flame retardancy.
§483.73(c)(2)Emergency Officials Contact Information
Identified deficiencies in resident rights, activities, wound care, safety, behavioral health, and psychotropic medication management.
483.10(a)(1)(2)(b)(1)(2)Resident Rights/Exercise of Rights
483.24(c)(1)Activities
483.25(b)(1)(i)(ii)Treatment/Svcs to Prevent/Heal Pressure Ulcer
483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
483.40Behavioral Health Services
483.45(e)(1)-(5)Free from Unnec Psychotropic Meds/PRN Use
02 Dec 2021Licensure
02 Dec 2021Licensure
Determined that no deficiencies were found and that the provider was in compliance with state requirements.
12 Oct 2021Complaint
12 Oct 2021Complaint
Concluded that no deficiencies were identified during the complaint investigation and the COVID-19 focused infection control survey.
23 Mar 2021Revisit
23 Mar 2021Revisit
Verified that all previously cited deficiencies were corrected and no new noncompliance was found. Compliance with all regulations surveyed was confirmed.
17 Mar 2021Licensure
17 Mar 2021Licensure
Found no deficiencies identified related to the complaint or infection control.
12 Feb 2021Revisit
12 Feb 2021Revisit
Identified failure to follow physician orders for Amsler grid testing in residents with macular degeneration, with missing test documentation and no communication with the physician.
CFR 483.25Quality of care
16 Dec 2020Complaint
16 Dec 2020Complaint
Identified failures to follow physician orders for vision monitoring in residents with macular degeneration, leading to missing Amsler grid assessments.
CFR 483.25Quality of Care
15 Oct 2020Licensure
15 Oct 2020Licensure
Found no deficiencies identified in a COVID-19 focused infection prevention survey.
15 Oct 2020Licensure
15 Oct 2020Licensure
Found no deficiencies identified during a COVID-19 focused infection prevention survey.
04 Sept 2020Complaint
04 Sept 2020Complaint
Investigated a complaint and a focused infection control review; no deficiencies were identified.
04 Sept 2020Complaint
04 Sept 2020Complaint
Investigated a complaint and a COVID-19 infection-control survey; determined that no deficiencies were identified.
27 Apr 2020Licensure
27 Apr 2020Licensure
Identified no deficiencies after a COVID-19 focused infection control survey conducted April 21–27, 2020.
13 Feb 2020Revisit
13 Feb 2020Revisit
Concluded that all previous deficiencies were corrected and no new noncompliance was found.
22 Jan 2020Revisit
22 Jan 2020Revisit
Confirmed previous deficiencies were corrected and compliance with all regulations was achieved.
22 Jan 2020Revisit
22 Jan 2020Revisit
Concluded that prior deficiencies were corrected and compliance with applicable safety regulations was achieved.
05 Dec 2019Licensure
05 Dec 2019Licensure
Identified deficiencies across multiple areas including accuracy of assessments, care planning, activities, nutrition, catheter care, dialysis monitoring, psychotropic use, and antibiotic stewardship.
CFR 483.20(g)Accuracy of Assessments
CFR 483.21(b)(1)Develop/Implement Comprehensive Care Plan
CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
CFR 483.24(c)(1)Activities
CFR 483.25Quality of Care
CFR 483.25(e)Bowel/Bladder Incontinence, Catheter, UTI
CFR 483.25(g)Nutrition/Hydration Status Maintenance
CFR 483.25(l)Dialysis
CFR 483.45Free from Unnec Psychotropic Meds/PRN Use
CFR 483.80(a)(3)Antibiotic Stewardship Program
05 Dec 2019Licensure
05 Dec 2019Licensure
Determined no deficiencies were found. The survey concluded compliance with state requirements.
04 Dec 2019Life Safety
04 Dec 2019Life Safety
Identified multiple life-safety deficiencies, including egress issues, incomplete fire safety planning, and electrical-safety concerns, with required corrective actions.
NFPA 101, 19.2.2.2.4; 7.2.1.6.1(3)Means of egress—locking arrangements
42 CFR 483.73(a)(1)Fire safety plan—emergency communication with fire department
NFPA 101, 19.3.6; 8.3.1; 8.3.5; NFPA 70Subdivision of Building Spaces—smoke barriers and electrical code
NFPA 101; NFPA 70Electrical safety—power cords and extension cords
Identified that the emergency preparedness all-hazards risk assessment did not include missing residents and was not updated per requirements.
42 CFR 483.73(a)(1)-(2)Emergency preparedness plan based on all-hazards risk assessment
06 Sept 2019Revisit
06 Sept 2019Revisit
Verified prior deficiencies were corrected and no new non-compliance found.
18 Jul 2019Complaint
18 Jul 2019Complaint
Investigated an allegation of physical abuse; a resident sustained bruising during care, and an employee involved was terminated.
§483.12Freedom from Abuse, Neglect, and Exploitation
19 Dec 2018Revisit
19 Dec 2018Revisit
Investigated a revisit; found all prior deficiencies corrected and no new noncompliance. Compliance with applicable regulations was confirmed.
13 Dec 2018Revisit
13 Dec 2018Revisit
Concluded that prior deficiencies were corrected and all regulations surveyed were met.
25 Oct 2018Complaint
25 Oct 2018Complaint
Identified deficiencies in resident funds handling, notice and communication for transfers/discharges, and several areas of care and safety. Overall, violations were cited across multiple domains.
Type A§483.10(g)(8)Protection of resident funds and personal funds
Type A§483.12(c)(1)(4)Medicaid/Medicare Coverage/Liability Notice
Type A—Incident reporting
Type A§483.15(c)(3)-(6)(8)Notice before transfer/discharge
Type A§483.25Quality of care
Type A§483.60(i)(1)(2)Food Procurement, Store/Prepare/Serve-Sanitary
25 Oct 2018Licensure
25 Oct 2018Licensure
Determined that the facility was in compliance with State requirements after a licensure survey conducted October 22–25, 2018.
24 Oct 2018Life Safety
24 Oct 2018Life Safety
Investigated life-safety concerns identified several deficiencies in hazardous area protections, fire protection system maintenance, and emergency preparedness. The findings required corrective actions.
NFPA 101, Life Safety Code (2012 edition)Hazardous areas protection
NFPA 101, Life Safety CodeFire Alarm System - Testing and Maintenance
NFPA 101, Life Safety CodeSprinkler System - Maintenance and Testing
NFPA 101, Life Safety CodePortable Fire Extinguishers
NFPA 101, Life Safety CodeEvacuation and Relocation Plan
NFPA 101, Life Safety CodeSmoke compartments and signage
Identified hot water temperatures in showers exceeding 110 degrees Fahrenheit in multiple resident rooms. A deficiency was cited for failing to maintain safe water temperatures.
Type ACh 11 Sec 6 (a)(iv) Physical EnvironmentPhysical Environment
18 Oct 2017Life Safety
18 Oct 2017Life Safety
Found multiple life-safety deficiencies during the licensing inspection, including missing delayed egress signage, doors without proper self-closing operation, inadequate emergency lighting, and unsafe oxygen cylinder storage near combustibles.
NFPA 101, Life Safety Code (2012): related to delayed egress and signageDelayed Egress Signage
NFPA 101, Life Safety Code (2012): 7.2.1.8.2 (Doors with self-closing devices)Doors with Self-Closing Devices
NFPA 99 (2012): 11.6.2.1 (Gas cylinder and container storage)Gas Equipment - Cylinder and Container Storage
14 Dec 2016Revisit
14 Dec 2016Revisit
Identified multiple deficiencies from a prior evaluation; corrective actions were completed by 11/13/2016.
483.10(b)(5) - (10), 483.10(b)(1)
483.15(a)
483.15(g)(1)
483.20(b)(1)
483.20(g) - (j)
483.25(i)
483.35(e)
483.60(a), (b)
483.65(i)
08 Dec 2016Revisit
08 Dec 2016Revisit
Found no deficiencies during the post-certification revisit. The visit indicated ongoing compliance.
29 Sept 2016Life Safety
29 Sept 2016Life Safety
Cited life-safety deficiencies related to egress and door hardware. The findings included a delayed egress door without proper signage and related issues.
2000 NFPA 101 Life Safety Code StandardExit access and delayed egress
2000 NFPA 101 Life Safety Code StandardCorrection for cited residents/environment
29 Sept 2016Complaint
29 Sept 2016Complaint
Investigated a complaint and identified multiple deficiencies involving resident care, nutrition management, infection control, and documentation across care and administrative processes.
—Continued from page 2 – written notice of status and plan of correction
—Continued from page 4 – correction for cited residents
—Continued from page 6 – medically-related social services
—Continued from page 3 – resident assessments and care planning
—Continued from page 9 – therapeutic diets
—Continued from page 18 – linens and infection control
—Continued from page 18 – medication-related procedures
—Continued from page 15 – nutrition-related or dietary management
29 Sept 2016Licensure
29 Sept 2016Licensure
Found no deficiencies. The review determined compliance with state rules.
07 Jul 2016Complaint
07 Jul 2016Complaint
Investigated the complaint; found no deficiencies.
02 Mar 2016Complaint
02 Mar 2016Complaint
Investigated a complaint survey conducted from 3/1/16 through 3/2/16 and found no deficiencies.
16 Dec 2015Revisit
16 Dec 2015Revisit
Investigated and cited multiple deficiencies concerning life-safety and resident care standards; corrections were completed for several items.
483.10(a)(3)&(4)Life Safety Code
483.15(h)Life Safety Code
483.25(h)Life Safety Code
483.20(d)(3), 483.20(k)(1)Life Safety Code
483.15(h)Life Safety Code
483.20(d)(3), 483.20(k)(1)Life Safety Code
483.35(c)Life Safety Code
483.60(b) (d), (c)Life Safety Code
16 Dec 2015Revisit
16 Dec 2015Revisit
Found no deficiencies.
30 Nov 2015Revisit
30 Nov 2015Revisit
Found no deficiencies. The revisit confirmed prior deficiencies were corrected.
30 Nov 2015Revisit
30 Nov 2015Revisit
Investigated and confirmed corrections completed for prior deficiencies identified during the prior review.
24 Sept 2015Licensure
24 Sept 2015Licensure
Investigated an outbreak reporting deficiency and found that outbreaks were not reported to the Licensing Division.
—Infectious disease outbreak reporting
24 Sept 2015Complaint
24 Sept 2015Complaint
Investigation found multiple deficiencies related to resident care planning, safety, and documentation during the visit.
23 Sept 2015Life Safety
23 Sept 2015Life Safety
Identified life-safety deficiencies involving door hardware, electrical outlets, and PPE related to resident care. Cited multiple corrective actions to address safety hazards affecting residents.
NFPA 101 Life Safety Code StandardCorrection for cited residents
NFPA 101 Life Safety Code StandardCorrection for cited residents
NFPA 101 Life Safety Code StandardCorrection for cited residents
23 Sept 2015Life Safety
23 Sept 2015Life Safety
Found that roof-mounted air handling units were located within 25 feet of gas flue vents, a life-safety concern.
Wyoming Rules and Regulations for Licensure of Nursing Care Facilities Chapter 19, Section 8 Life Safety and Electrical SafetyLife Safety and Electrical Safety
03 Sept 2015Revisit
03 Sept 2015Revisit
Verified corrections were completed for identified deficiencies after a follow-up visit.
483.10(b)(11)
483.20(k)(13)(i)
483.25
483.75(l)(i)(1)
06 Aug 2015Complaint
06 Aug 2015Complaint
Investigated revealed deficiencies in resident care quality and in medical record documentation, with multiple deficiencies cited for not meeting professional standards.
Type A42 CFR 483.25Provide care and services to meet professional standards of quality
Type A42 CFR 483.75Corrective action for cited residents
Type A42 CFR 483.25Records - Complete/Accurate/Accessible
24 Nov 2014Revisit
24 Nov 2014Revisit
Identified life-safety-code deficiencies; corrections completed by 2014-10-12.
Life Safety Code (LSC) NFPA 101Life Safety Code deficiency
Life Safety Code (LSC) NFPA 101Life Safety Code deficiency
Life Safety Code (LSC) NFPA 101Life Safety Code deficiency
24 Nov 2014Revisit
24 Nov 2014Revisit
Found life safety code deficiencies; corrections were completed.
Life Safety Code (LSC)NFPA 101 Life Safety Code
Life Safety Code (LSC)NFPA 101 Life Safety Code
Life Safety Code (LSC)NFPA 101 Life Safety Code
24 Nov 2014Revisit
24 Nov 2014Revisit
Verified corrections to deficiencies identified in a prior survey.
16 Oct 2014Revisit
16 Oct 2014Revisit
Identified deficiencies cited during a follow-up review.
483.20(d)(3), 483.10(k)(2)
483.20(k)(3)(i)
483.25(a)(3)
483.25(m)(1)
483.35(i)
08 Oct 2014Life Safety
08 Oct 2014Life Safety
Identified life-safety deficiencies related to means of egress and flame-resistance of furnishings, indicating noncompliance with applicable codes.
Type ANFPA 101 Life Safety Code StandardContinued From page 1 – Means of egress and hazardous areas
Type ANFPA 101 Life Safety Code StandardContinued From page 2 – Door hardware and accessibility
Type ANFPA 101 Life Safety Code Standard; NFPA 701Continued From page 4 – Curtains and flame resistance
28 Aug 2014Life Safety
28 Aug 2014Life Safety
Identified multiple life-safety deficiencies, including missing sprinkler head coverage in a walk-in cooler and faults with door hardware and building systems; corrective actions and monitoring were noted.
NFPA 101 Life Safety Code StandardContinued From page 1 – Walk In Cooler sprinkler head removed
NFPA 101 Life Safety Code StandardContinued From page 2 – Sprinkler coverage deficiency
NFPA 101 Life Safety Code StandardContinued From page 3 – Correction for cited residents/areas
NFPA 101 Life Safety Code StandardCorrection for cited residents/areas – Fire dampers
NFPA 101 Life Safety Code StandardCorrection for cited residents/areas – Generator inspection log
28 Aug 2014Life Safety
28 Aug 2014Life Safety
Identified violations of construction and life-safety rules, including inadequate ventilation in multiple spaces and issues with emergency equipment and drainage.
Chapter III Construction Rules for Health FacilitiesContinued From page 2; Correction for cited residents/areas
Chapter III Construction Rules for Health FacilitiesContinued From page 3; Systemic Corrective Action
07 Aug 2014Complaint
07 Aug 2014Complaint
Identified deficiencies in nursing care standards, mobility assistance planning, professional standards, and sanitation/equipment maintenance.
—Nursing care standards not met
—Correction for cited residents - mobility/plan of care
—Nursing/CNA standards of care not met
—Equipment sanitation standards
07 Aug 2014Licensure
07 Aug 2014Licensure
Identified deficiencies in care planning and resident documentation, indicating lapses in care practices.
07 Aug 2014Licensure
07 Aug 2014Licensure
Determined the licensee was in compliance with state requirements.
03 Sept 2013Revisit
03 Sept 2013Revisit
Investigated previously reported deficiencies and confirmed that corrective actions were completed.
483.13(c)(1)(i)(ii), (c)(2) - 4
483.15(a)
483.20(d), 483.20(k)(1)
483.70(h)
483.25
483.65
483.20(i)(3)(i)
483.75(i)(1)
24 Jul 2013Revisit
24 Jul 2013Revisit
Found deficiencies cited for fire safety and life safety code; corrections completed.
NFPA 101Life Safety Code deficiency
LSCLife Safety Code deficiency
LSCLife Safety Code deficiency
NFPA 101Fire safety deficiency
06 Jun 2013Complaint
06 Jun 2013Complaint
Found deficiencies related to resident care practices, documentation, and safety across multiple areas.
—Continued From page 1 – Investigation in progress
—Continued From page 3 – Correction of deficiencies
—Continued From page 4 – Corrections to plan of correction
—Continued From page 9 – Care plan corrections
—Continued From page 11 – Documentation and care planning
—Correction for cited resident(s) – Documentation corrections
06 Jun 2013Complaint
06 Jun 2013Complaint
Investigated deficiencies in care planning, resident documentation and safety, with multiple corrective actions outlined.
—Care planning and documentation deficiencies
—Correction for cited resident(s)
—Correction for cited resident(s) – care plans
05 Jun 2013Life Safety
05 Jun 2013Life Safety
Investigative findings showed multiple fire-safety and barrier deficiencies, including issues with doors, smoke barriers, and electrical safety requiring corrective actions.
NFPA 101 Life Safety Code StandardCorrection for cited deficiency: Implement semiannual fire alarm battery load voltage testing
NFPA 70 National Electrical CodeCorrection for cited deficiency: 3-way adapter in computer room removed and computer connected to approved electrical source
NFPA 101 Life Safety Code StandardCorrection for cited deficiency: Wing 2 barrier double doors and astragal adjusted to ensure appropriate smoke barrier function
30 Jul 2012Revisit
30 Jul 2012Revisit
Identified multiple Life Safety Code deficiencies requiring correction; documented corrections completed in July 2012.
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
NFPA 101Life Safety Code deficiency
21 Jun 2012Licensure
21 Jun 2012Licensure
An investigation found deficiencies related to resident dignity and rights, and inadequate provision of social and medical services, with ongoing issues in care planning and daily care.
—DIGNITY AND RESPECT OF INDIVIDUALITY
—RELATED SOCIAL SERVICES
—CONTINUED FROM PAGE 6 – RELATED SOCIAL SERVICES
21 Jun 2012Licensure
21 Jun 2012Licensure
Determined that the facility was in compliance with state requirements after a survey conducted June 18, 2012.
21 Jun 2012Revisit
21 Jun 2012Revisit
Identified deficiencies during follow-up; corrections completed.
19 Jun 2012Life Safety
19 Jun 2012Life Safety
An inspection identified several life-safety deficiencies, including doors not self-closing, improper fire-drill scheduling, missing or insufficient signage, and electrical/water-we location hazards.
NFPA 101 Life Safety CodeCorridor doors not self-closing
NFPA 101 Life Safety CodeContinued observation of corridor doors
NFPA 101 Life Safety CodeStairwell/penetration sealing
NFPA 101 Life Safety CodeFire drills timing and documentation
NFPA 101 Life Safety CodeMonthly inspection of portable fire extinguishers
NFPA 101 Life Safety CodeNo Smoking signage in resident areas
NFPA 101 Life Safety CodeGFCI protection for wet locations
05 Dec 2011Revisit
05 Dec 2011Revisit
Identified and corrected prior deficiencies; follow-up showed corrections completed.
483.75(b)Regulatory deficiency related to facility environment/care standards
06 Oct 2011Complaint
06 Oct 2011Complaint
Found a deficiency in complying with federal/state/local laws and professional standards for nursing care.
483.75(b)COMPLY WITH FEDERAL/STATE/LOCAL LAWS/PROF STD
22 Jul 2011Revisit
22 Jul 2011Revisit
Verified corrections completed for previously reported deficiencies after a follow-up visit.
08 Jul 2011Revisit
08 Jul 2011Revisit
Found deficiencies related to life safety and NFPA 101 standards; uncorrected deficiencies were noted with follow-up.
12 May 2011Complaint
12 May 2011Complaint
Investigation identified multiple deficiencies in care planning, nutrition assessment, medication management, infection control, and safety/supervision practices.
—Care planning and nutrition assessment
—Comprehensive care planning/individualized care plans
—Medication reconciliation and management
—Accidents and supervision
—Infection control
10 May 2011Life Safety
10 May 2011Life Safety
Found non-compliance with flame-retardant fabric requirements due to curtains and related fabrics not meeting standards.
NFPA 701 Life Safety Code StandardFlame retardant fabrics
29 Jul 2010Revisit
29 Jul 2010Revisit
Found no deficiencies.
20 Jul 2010Revisit
20 Jul 2010Revisit
Investigated and cited deficiencies, with corrections completed on follow-up.
483.15(g)(1)
483.20(d)(3); 483.10(k)(2)
483.25(h)
483.25(i)
483.35(d)(3)
483.75(e)(5)-(7)
483.65
483.75(b)
483.75(e)(5)-(7)
06 May 2010Revisit
06 May 2010Revisit
Identified multiple regulatory deficiencies cited during the follow-up visit.
483.15(g)(1)
483.20(d)(3), 483.10(k)(2)
483.25(h)
483.25(h)(1)
483.35(d)(3)
483.35(i)
483.25(b)
483.75(b)
483.75(e)(5)-(7)
06 May 2010Licensure
06 May 2010Licensure
Identified multiple deficiencies in safety, infection control, and care planning during a 2010 inspection.
—Funding/appointment scheduling impacting resident care
—Safety: side rails assessment
—Environmental safety – sprinklers/grease/dust
—Nutrition/dietary planning and reassessment
—Infection control/isolation practices
—CNA registry verification
—Staff training/compliance documentation
06 May 2010Licensure
06 May 2010Licensure
Concluded the facility was in compliance with state requirements after a survey conducted May 3–6, 2010.
06 May 2010Licensure
06 May 2010Licensure
Found multiple deficiencies related to resident safety, medication management, and infection control during the survey.
06 May 2010Licensure
06 May 2010Licensure
Determined that the facility was in compliance with state requirements.
04 May 2010Life Safety
04 May 2010Life Safety
Identified multiple life-safety deficiencies including smoke barrier penetrations not sealed, issues with exit access and signage, and incomplete fire-drill and maintenance practices.
19.3.7.3; 19.3.7.5; 19.1.6.3; 19.1.6.4Penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems
7.10; 19.2.1Exit access and exit signage
7.1; 19.2.1Exit access arrangement
NFPA 101 LIFE SAFETY CODEFire drills and testing
7.10Exit and directional signs
NFPA 101 LIFE SAFETY CODEFire drills and scheduling
NFPA 70; NFPA 72Electrical and life-safety systems maintenance
NFPA 13; NFPA 25Sprinkler system maintenance
04 May 2010Life Safety
04 May 2010Life Safety
Found life-safety deficiencies including unsealed penetrations in fire barriers, exit signage/egress issues, and smoke-barrier integrity concerns that could affect residents.
NFPA 101 Life Safety Code StandardFire barriers; barrier penetrations
NFPA 101 Life Safety Code StandardGeneral life safety – resident impact
NFPA 101 Life Safety Code StandardSmoke barrier penetrations; barrier integrity
NFPA 101 Life Safety Code StandardExit access; signage and locking
NFPA 101 Life Safety Code StandardExit access; readily accessible
NFPA 101 Life Safety Code StandardEmergency lighting; duration
NFPA 70/NFPA 72; NFPA 70 National Electrical Code; NFPA 72Fire alarm system; maintenance and testing
04 May 2010Revisit
04 May 2010Revisit
Found no deficiencies. Follow-up verified corrections were completed.
07 Dec 2009Revisit
07 Dec 2009Revisit
Verified corrections completed for deficiencies previously found.
483.10(e), 483.75(j)(4)
483.10(f)(2)
483.15(a)
483.25(a)
483.20(k)(3)(i)
483.20(k)(3)(ii)
28 Sept 2009Complaint
28 Sept 2009Complaint
Identified deficiencies in privacy/confidentiality, quality of care, and bathing documentation. These issues show failures to protect resident privacy, maintain professional care standards, and keep accurate care records.
483.10(e), 483.75(i)(4)Privacy and confidentiality
483.25Quality of care
—Bathing and grooming
19 May 2009Revisit
19 May 2009Revisit
Investigated a complaint and found a deficiency related to water temperatures; follow-up was conducted.
Type A—Water temperatures not maintained within required range (Section 6)
17 May 2009Revisit
17 May 2009Revisit
Identified several Life Safety Code deficiencies; corrections completed by 04/23/2009.
NFPA 101 Life Safety Code
NFPA 101 Life Safety Code
NFPA 101 Life Safety Code
NFPA 101 Life Safety Code
NFPA 101 Life Safety Code
NFPA 101 Life Safety Code
NFPA 101 Life Safety Code
27 Feb 2009Life Safety
27 Feb 2009Life Safety
Investigated safety findings showed life-safety deficiencies, including unsealed penetrations and gaps in doors, plus issues with exit signage.
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barriers/compartments
NFPA 101 LIFE SAFETY CODE STANDARDDoors and door hardware
NFPA 101 LIFE SAFETY CODE STANDARDExit signage
26 Feb 2009Life Safety
26 Feb 2009Life Safety
Observed multiple sinks had water temperatures above the 110-degree limit, indicating noncompliance with the environmental standard.
Wyoming State Rules and Regulations, Chapter 11, Section 5(a)(iv)Showers/baths and resident lavatories water temperature not to exceed 110 degrees Fahrenheit
26 Feb 2009Revisit
26 Feb 2009Revisit
Investigated a licensing matter and identified deficiencies that were corrected.
23 Feb 2009Complaint
23 Feb 2009Complaint
Investigated a complaint and found deficiencies in resident and family involvement, incontinence care, and infection control, indicating noncompliance in several care areas.
483.15(c)(6)Participation in resident & family groups
483.25(d)Urinary incontinence
483.80Infection control
10 Apr 2008Revisit
10 Apr 2008Revisit
Investigated and found deficiencies in several federal requirements; corrections were completed.
Type A483.25(h)
Type A483.30(e)
Type A483.35(i)(2)
Type A483.70(h)(3)
25 Mar 2008Revisit
25 Mar 2008Revisit
Verified corrections were completed after follow-up of previously cited deficiencies.
31 Jan 2008Complaint
31 Jan 2008Complaint
Found multiple deficiencies in staffing posting, infection control, sanitation, and safety practices.
—Nurse staffing data posting
—Policy and cleaning schedule for unit refrigerators
—Infection control – surveillance and antibiotic therapy review
—Hand hygiene
—Environmental conditions
—Handrails
31 Jan 2008Complaint
31 Jan 2008Complaint
The facility was found with multiple deficiencies related to nurse staffing posting, sanitation and cleaning practices, infection control, and environmental safety.
483.25(h) ACCIDENTS AND SUPERVISIONAccidents and supervision
483.35(i)(2) SANITARY CONDITIONS - FOOD PREP & SERVICESanitary conditions - food prep and service
—
483.65(b)(3) PREVENTING SPREAD OF INFECTIONPreventing spread of infection
483.70(h) OTHER ENVIRONMENTAL CONDITIONSOther environmental conditions
483.70(h) HANDRAILSHandrails
31 Jan 2008Licensure
31 Jan 2008Licensure
Found no deficiencies identified during a state licensure survey conducted on January 31, 2008.
29 Jan 2008Life Safety
29 Jan 2008Life Safety
Identified multiple safety and maintenance deficiencies affecting smoke barriers, exits, sprinklers, electrical systems, and furnishings; several issues observed across the facility.
NFPA 101 LIFE SAFETY CODE STANDARDContinued From Page 1
NFPA 101 LIFE SAFETY CODE STANDARDContinued From Page 2
NFPA 101 LIFE SAFETY CODE STANDARDContinued From Page 3
NFPA 101 LIFE SAFETY CODE STANDARDContinued From Page 4
NFPA 101 LIFE SAFETY CODE STANDARDContinued From Page 5
NFPA 101 LIFE SAFETY CODE STANDARDContinued From Page 6
NFPA 70 NATIONAL ELECTRICAL CODEContinued From Page 7
NFPA 101 LIFE SAFETY CODE STANDARDContinued From Page 8
NFPA 101 LIFE SAFETY CODE STANDARDContinued From Page 9
29 Jan 2008Life Safety
29 Jan 2008Life Safety
Identified multiple life-safety and facility operation deficiencies. Observations showed problems with smoke barriers, extinguishing system, exits, and electrical/wiring practices.
—Life safety: corridor walls/smoke barriers
—Smoke barrier integrity
—Extinguishing system and fire barriers
—Exit access and egress
—Emergency procedures
—Draperies and decorations NFPA 701
—Smoke barrier doors and closings
—Electrical safety and extension cords
—Sprinkler head placement
08 Oct 2007Revisit
08 Oct 2007Revisit
Cited multiple deficiencies from a prior assessment and documented corrective actions completed.
08 Aug 2007Complaint
08 Aug 2007Complaint
Identified multiple deficiencies in resident care, including failures to notify residents and families of changes, incomplete bowel assessments, infection-control lapses, meal service issues, and lack of monthly drug regimen reviews.
Type A483.10(d)(1)NOTIFICATION OF CHANGES
Type A483.20(b)(3)COMPREHENSIVE ASSESSMENTS
Type A483.65(d)(1)-(3)PREVENTING SPREAD OF INFECTION
Type A483.60(c)DRUG REGIMEN REVIEW
08 Aug 2007Complaint
08 Aug 2007Complaint
Found multiple deficiencies including failure to promptly notify changes, inadequate assessments, lapses in infection control, nutrition issues, and improper drug regimen review.
Type A483.10(k)(11)NOTIFICATION OF CHANGES
Type A483.20(b)COMPREHENSIVE ASSESSMENTS
Type A483.65INFECTION CONTROL
Type A483.60FOOD AND NUTRITION
Type A483.60(c)DRUG REGIMEN REVIEW
11 Jun 2007Revisit
11 Jun 2007Revisit
Verified corrections to life-safety deficiencies were completed.
24 May 2007Revisit
24 May 2007Revisit
Investigated and cited several deficiencies related to resident rights, admission/discharge, quality of life, and care standards.
483.13(c)(1)(i)-(iii), (c)(2)
483.15(a)
483.20, 483.20(b)
483.25
483.20(k)(3)(i)
483.25(i)
483.60(a)
483.60(b)(d)(e)
483.65(b)(3)
483.70
03 May 2007Life Safety
03 May 2007Life Safety
Identified life-safety deficiencies related to smoke barrier integrity and electrical safety, indicating non-compliance with fire and electrical codes.
Type ANFPA 101 Life Safety Code StandardSmoke barrier walls not maintained to required fire-resistance rating
NFPA 101 Life Safety Code StandardElectrical wiring and equipment safety (NFPA 70)
NFPA 101 Life Safety Code Standard; NFPA 70Electrical wiring and equipment compliance
23 Apr 2007Revisit
23 Apr 2007Revisit
Investigated a complaint and found life-safety deficiencies.
—Life Safety Code deficiencies
—Life Safety Code deficiencies
—Life Safety Code deficiencies
06 Mar 2007Life Safety
06 Mar 2007Life Safety
Investigative findings disclosed multiple life-safety and facility-maintenance deficiencies, including compromised smoke barriers, doors and penetrations not resisting smoke, and problems with sprinklers, electrical systems, and generators.
NFPA 101 LIFE SAFETY CODE STANDARDCorridor doors and smoke barrier integrity
NFPA 101 LIFE SAFETY CODE STANDARDSmoke barriers and fire resistance
NFPA 101 LIFE SAFETY CODE STANDARDSmoke-resisting partitions and doors; cross-reference
NFPA 101 LIFE SAFETY CODE STANDARDFire alarm/pull station systems
NFPA 101 LIFE SAFETY CODE STANDARDSprinkler system coverage
NFPA 70 NATIONAL ELECTRICAL CODEElectrical system compliance
NFPA 70 NATIONAL ELECTRICAL CODEGenerator testing and back-up power
NFPA 99Storage of hazardous materials
NFPA 70 / NFPA 99Electrical safety in occupied spaces
NFPA 70 / NFPA 99General electrical safety and back-up power readiness
01 Mar 2007Licensure
01 Mar 2007Licensure
Identified a deficiency for failing to notify the health department prior to remodeling and observed an oxygen storage area with multiple cylinders.
State Rules and Regulations for Licensure of Nursing Care Facilities, Chapter 19, Section 7; Construction/Remodeling (Department of Health Chapter III, Construction Rules for Health Facilities).State Rules and Regulations
01 Mar 2007Licensure
01 Mar 2007Licensure
Identified that construction/remodeling planning lacked proper pre-approval and required formal plan review and state approval before starting any projects.
Rules and Regulations for Licensure of Nursing Care Facilities, Chapter 19Construction/ Remodeling—review and approval of project plans
01 Mar 2007Licensure
01 Mar 2007Licensure
Investigated deficiencies in resident care and safety with multiple cited violations across areas such as reporting incidents and resident care practices.
—Reporting of alleged violations and follow-up
—Comprehensive assessment and care planning deficiencies
03 Mar 2006Revisit
03 Mar 2006Revisit
Investigated the follow-up and verified corrections were completed.
17 Jan 2006Revisit
17 Jan 2006Revisit
Identified life-safety code deficiencies related to ID Prefix entries; corrections were completed.
15 Dec 2005Licensure
15 Dec 2005Licensure
Investigated a deficiency finding that staff did not consistently maintain a resident’s dignity during meals, impacting the resident’s comfort and respect.
Type A483.15(a)Dignity
15 Dec 2005Licensure
15 Dec 2005Licensure
Found a dog in the dining room during meals, indicating noncompliance with the animal policy.
Type A—Animal policy in dining area during meals
15 Dec 2005Licensure
15 Dec 2005Licensure
Investigated a complaint and identified deficiencies related to resident activities, care practices, and housekeeping/maintenance.
Type A42 CFR 483.25Summary deficiency re: resident activities and program of correction
15 Dec 2005Licensure
15 Dec 2005Licensure
Identified a violation of the animal policy when a visitor brought a dog into the dining room during meals.
—Initial comments / Animal visitation policy
30 Nov 2005Life Safety
30 Nov 2005Life Safety
Investigated life-safety deficiencies and found failures related to doors, fire alarm testing, and heating device protections.
Type ANFPA 101 Life Safety Code 19.3.2.1Self-closing devices on doors in hazardous areas
Type ANFPA 101 Life Safety Code 4.3.5.2.1Corridor doors—self-closing devices
Type ANFPA 101 LIFE SAFETY CODE STANDARDFire alarm system testing/maintenance
Type ANFPA 72 Table 7-3.2Testing of supervisory station fire alarm systems
Type ANFPA 101 Life Safety Code 4-3.5.2.2Portable space heating devices
30 Nov 2005Life Safety
30 Nov 2005Life Safety
Found life-safety deficiencies related to corridor separation and missing self-closing devices. Noted multiple observations indicatingIncomplete protective measures.
Type ANFPA 101 Section 19.3.6.2.1Integrity of corridor/use area separation
Type ANFPA 101 Section 19.3.6.2.1Self-closing devices on hazard-area doors
16 Feb 2005Complaint
16 Feb 2005Complaint
Investigated a complaint and found no deficiencies.
16 Feb 2005Complaint
16 Feb 2005Complaint
Investigated a complaint; no deficiencies identified.
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