Tobacco Root Mountains Care Center in Sheridan, MT has a 4-star overall rating, with strong health inspection and staffing scores but a very low 1-star quality measures rating. It has a recent federal penalty and $22,205 in fines, while reported nurse staffing is 7.79 hours per resident per day, above the 4.1-hour federal benchmark.
Last inspection: April 9, 2025Penalties, last 24 months: $22,205recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 7.7945.
Staffing detail
Registered nurses
2.01
Licensed practical nurses
0.77
Nurse aides
5.02
Weekend nursing
6.91
Hours per resident per day.
Total staff turnover: 65%
Registered nurse turnover: 29%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Last yrNowTrend
Long-stay residents on antipsychotic medication
—12.5%—
Residents with a fall causing major injury
—11.6%—
Residents with pressure ulcers (bedsores)
—7%—
Residents with a urinary tract infection
—2.9%—
Residents who lost too much weight
—7.4%—
Residents who were physically restrained
—5.8%—
Residents needing more help with daily activities
—19.6%—
Residents whose ability to walk got worse
—18.8%—
Long-stay residents on antianxiety or sleep medication
—14.5%—
Residents with a long-term catheter
—11.2%—
Residents with new or worsening incontinence
—32.8%—
Residents with depressive symptoms
—8.1%—
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Last yrNowTrend
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
—98.6%—
What the inspectors found
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited March 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: F
The nursing home failed to protect residents from abuse and neglect by others. Cited April 2025 — isolated incident, potential for harm.
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F-Tag 600 — 42 CFR §483.12 — S/S: D
The home failed to complete and keep the resident’s care plan properly prepared, reviewed, and updated by the right health professionals. Cited April 2024 — isolated incident, potential for harm.
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F-Tag 657 — 42 CFR §483.21(b)(2) — S/S: D
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited April 2024 — isolated incident, potential for harm.
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F-Tag 755 — 42 CFR §483.45 — S/S: D
The home failed to make sure residents fully understood their health status, care, and treatments. Cited March 2023 — isolated incident, potential for harm.
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F-Tag 552 — 42 CFR §483.10 — S/S: D
Recent history
PENALTY
A federal fine of $22,205 was recorded.
STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
INSPECTION
Health inspection found 10 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $22,205 in total fines.
Federal fine
Apr 1, 2026
$22,205
Operator & ownership
Ownership
Government - County
Occupancy
13.2 residents on an average day (34% of 39 beds)
Resident voice
Resident council
Medicare history
Certified for 30 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.