Tobacco Root Mountains Care Center in Sheridan, MT has a 1-star overall rating, with 2 stars for health inspections, 4 stars for staffing, and 1 star for quality measures. It reports 7.05 nurse hours per resident per day versus the 4.1 federal benchmark, and has had $22,205 in fines in the last 24 months plus a recent abuse citation.
Last inspection: May 21, 2026Penalties, last 24 months: $22,205recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 7.0462.
Staffing detail
Registered nurses
1.74
Licensed practical nurses
0.66
Nurse aides
4.66
Weekend nursing
6.37
Hours per resident per day.
Total staff turnover: 73%
Registered nurse turnover: 43%
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
—18.9%—
Residents with a fall causing major injury
—12.7%—
Residents with pressure ulcers (bedsores)
—7.7%—
Residents with a urinary tract infection
—0%—
Residents who lost too much weight
—8%—
Residents who were physically restrained
—7.9%—
Residents needing more help with daily activities
—17.1%—
Residents whose ability to walk got worse
—23.2%—
Long-stay residents on antianxiety or sleep medication
—11.8%—
Residents with a long-term catheter
—9.9%—
Residents with new or worsening incontinence
—33.6%—
Residents with depressive symptoms
—14.3%—
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
—100%—
Short-stay residents given the pneumonia vaccine
—95.5%—
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited April 2026 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: J
The home failed to provide safe, appropriate pain management for a resident who needed it. Cited April 2026 — isolated incident, actual harm.
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F-Tag 697 — 42 CFR §483.25(k) — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited May 2026 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to prevent unnecessary mind-altering medications or ensure medicines did not limit a resident’s ability to function. Cited May 2026 — isolated incident, potential for harm.
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F-Tag 605 — 42 CFR §483.12 — S/S: D
The nursing home failed to protect residents from abuse and neglect by others. Cited April 2026 — isolated incident, potential for harm.
View the original federal record
F-Tag 600 — 42 CFR §483.12 — S/S: D
Recent history
STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
INSPECTION
Health inspection found 5 health deficiencies.
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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.
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INSPECTION
Health inspection found 3 health deficiencies.
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INSPECTION
Health inspection found 10 health deficiencies.
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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
14.9 residents on an average day (38% 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.