GILLETTE — In the wake of two resident deaths still actively being investigated by police, the Legacy Living and Rehabilitation Center in Gillette announced Friday the facility will continue to not admit new patients until it’s fully staffed and has reduced the number of contracted staff.
The announcement comes after the beleaguered facility made international headlines when an 88-year-old female resident with dementia was found frozen outside the facility in January. Two months prior, a 66-year-old patient died of an overdose.
Both incidents are under investigation by the Gillette Police Department. And as a result of the deaths, Campbell County Health, which owns the Legacy, has fired five staff members, four of whom were contracted temporary staff, including an administrator.
This led to the hospital also terminating its contract with the unnamed agency, as announced by Campbell County Health CEO Matt Shahan.
“The recent events have shaken us all, and we are determined to take every possible step to reaffirm your confidence in our institution,” Shahan said in a statement addressing the deaths.
One way the hospital has vowed to earn back the public’s trust is to hire locals who are more invested in their jobs and training, according to hospital spokesperson Kerry Cash.
The 154,000-square-foot, 160-bed short- and long-term residential facility opened in late 2016 and cost nearly $48 million to build. It boasts a large staff of 155. Of those, 22 are travelers, or temporary contract workers, with 40 positions still open.
The goal, Cash told Cowboy State Daily on Friday, is to fill all of those positions locally.
Other efforts to improve patient care is advanced training in dementia care for staff, including teaching effective de-escalating distress behaviors without resorting to pharmacological interventions, according to a statement provided by Cash.
“We are committed to continually working with various outside resources for constant process improvement,” Shahan said in the statement. “We welcome all feedback, whether from families, residents, state or federal surveyors or outside consultants that we bring in to guide our process improvements.”
The recent deaths remain an active investigation. And while Campbell County Health has announced its staffing changes, it hasn’t publicly addressed specific questions about how a dementia patient could get outside and be out long enough to freeze to death or how a patient could get an overdose of medication.
Regaining Trust
Gillette resident Sally White was happy to provide feedback.
Speaking during the public comment period Thursday night at the Campbell County Health Board of Trustees meeting, White said she was there to speak for those whose voices could not be heard.
In particular, White was referencing Judith Duvall, the patient with dementia who froze to death after wandering outside her care ward at the Legacy and falling in the snow.
“Nine hours and 17 minutes was the amount of time Judith Duvall spent in the courtyard dressed only in a long sleeved shirt, slacks and slippers,” White said, pointing out how she not only was able to get outside, but wasn’t discovered until it was too late.
White quoted a Jan. 17 report from the Wyoming Department of Health survey conducted in the wake of Duvall’s death.
The night Duvall died Jan. 10, the temperature outside hit a low of 15 degrees.
White further referenced the overdose death of Rhonda Parker as well as a lawsuit from April 2024 that resulted in the hospital paying $660,000 after a contract traveling nurse was found guilty of abusing and neglecting a 90-year-old woman with dementia.
White, who has spent her entire career in the health care industry after serving as a medic in the Air Force during the Vietnam War at age 18, said she was pleased to hear the hospital’s plan to move away from contract staff to hiring locals.
“That’s a great first step,” White said. “But they first need to gain the trust of the community, and that’s not going to happen overnight.”
Shahan acknowledged in the statement that the community’s trust is broken, and it’s up to the hospital to rebuild that trust through corrective actions.
“We have made drastic changes to meet the needs of our residents, and above all else, we will listen and make adjustments for their betterment.”
Shahan went on to commend the Legacy staff for their willingness to make the necessary changes to improve the facility.
Not So Fast
Not all agree that the solution is as simple as swapping out temporary workers for locals.
One former longtime Legacy health care worker who worked at the facility for nearly a decade and asked to remain anonymous out of fear of retribution said that staffing has historically been a problem.
“They need to stop working with the bare minimum staff,” the worker told Cowboy State Daily. “They say it’s because there’s a staffing shortage, but that’s bullshit. There’s a staffing shortage because of the way they treat their people.”
The former worker said the traveling staff that they worked with were some of the best nurses and certified nursing assistants they’d ever met, and the problem rested in the hands of management.
The administrator position is currently open, Cash said, after the former administrator — a contract worker — was fired in the wake of Duvall’s death.
Circling The Wagons
Dawn Marie Hodges, CCH chief human resources officer, announced at the Thursday board meeting that the Legacy is already showing improvements based on two surveys completed in January.
Two inspections were conducted by the Wyoming Department of Health state surveyor as well as a voluntary independent survey brought in by the hospital.
The Wyoming Department of Health conducts inspections in its state licensing role and on behalf of the federal Centers for Medicare and Medicaid Services under the federal Health and Human Services.
Facilities are required to report alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident’s property, according to Kim Deti, public information officer for WDH.
WDH likewise determines when corrective actions are necessary based on survey results.
Hodges told the board that the state surveyor described the changes implemented thus far as “profound.”
Hodges told the board the state surveyor further complimented staff engagement and their positive interactions with residents.
“I think that’s high praise for the changes we’re making at the Legacy and the direction we’re trying to go and moving that culture there,” Hodges said.
Results of the state survey were not yet available from the Wyoming Department of Health, but Hodges said that the facility had received three complaints, two of which were unsubstantiated by the state investigator and the third may result in a minor citation.
Rankings the Medicare.gov federal website that ranks the quality of long-term residential facilities suggest that the Legacy still has a long way to go.
Long Way To Go
Currently, the Legacy (which was previously Pioneer Manor before its new facility was built) has a ranking of 1 out of 5, with five being the best, by the Medicare.gov federal website, receiving 17 health citations in a May 2004 inspection well over the national average of 9.6. among Wyoming nursing homes.
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 4 out of 5 while it received a 1 for health inspections.
Jen Kocher can be reached at jen@cowboystatedaily.com.
