A coroner’s report reveals significant problems at a Gillette, Wyoming, assisted living center where an 88-year-old resident died of hypothermia in January and another resident died of an overdose last fall. The center terminated four emploees due to investigations.
The 88-year-old resident found deceased outdoors at a Gillette assisted living center in January died of hypothermia, according to a coroner’s investigatory report released this week that also revealed a second death at the center last year and the terminations of multiple employees.
Judith Duvall, of Rozet, Wyoming, had been a patient in the memory care wing at The Legacy Living and Rehabilitation Center when she was found dead in the early morning hours on Jan. 10 in an outside courtyard on the facility grounds. Temperatures that morning were between 10 and 35 degrees with 2 inches of snow falling the day prior.
Duvall’s death was caused by exposure and hypothermia, according to Campbell County Coroner Paul Wallem, who declined to provide additional information, citing an active investigation by the Gillette Police Department.
In the same coroner’s report, Wallem said, police are also investigating the overdose death of a 66-year-old female resident at The Legacy that occurred on Nov. 29, 2024.
Brent Wasson, deputy chief of police, told Cowboy State Daily on Wednesday that both investigations are ongoing, and he had no information to release at this time.
In response, the Campbell County Health Department, which oversees The Legacy, acknowledged its participation in the investigations and steps it has taken to ensure patient safety, according to a statement from Bree Richardson, a CCH spokeswoman.
Duvall’s death prompted the firing of one full-time employee and the termination of three contracted employees, including an administrator.
Richardson further stated that as a result of an investigation into the overdose death, another contract employee was terminated and that person's nursing license was reported to the state.
"We at Campbell County Health express our deepest sorrow to the families affected. We are committed not only to addressing what happened but also to learning from the incidents and emerging from these experiences as a safer, stronger institution, continually striving to improve the care and services we provide to the community,” Tom Murphy, Campbell County Health’s Board of Trustees chairman, said in the statement.
Following Duvall’s death, the hospital said they had beefed up staffing and taken other safety measures and were not accepting further admissions pending the results of an investigation by the state licensing board.
Low Ranking
The 160-bed Legacy facility currently has a ranking of one out of five by Medicare.gov, with five being the highest. The facility has been cited before for abuse, according to the federal website.
Medicare’s ratings are based on three categories, along with an overall rating. The three categories include health inspections, staffing and quality measures. For staffing and quality measures the facility ranks four out of five while it received a one for health inspections.
During its most recent health inspection on May 23, 2024, The Legacy received 17 health citations compared to a national average of 9.6. or an average of six among Wyoming nursing homes.
It also was cited with 16 complaints over the past three years with 10 of those resulting in a citation.
The Legacy had zero citations for infection control inspections between November 2023 and October 2024.
Complaints in the most recent inspection from June 19, 2024, included an allegation of physical and verbal abuse of a patient by a certified nursing assistant in which a certified nursing assistant physically pushed a resident in bed while pulling that person up by one arm while telling that patient she hated entering their room while asking what they needed among other complaints.
In response, the nursing assistant was suspended during the investigation with the incident reported to all the relevant agencies, including the adult protection agency, state survey agency and state board of nursing.
Additionally, The Legacy implemented system changes that included “coaching and education, monitoring of nursing assistants, training on rounding requirements and expectations, staff reassignment and staff education on abuse and neglect,” according to the report.
Jen Kocher can be reached at jen@cowboystatedaily.com.
