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Nursing home report

TOBACCO ROOT MOUNTAINS CARE CENTER

SHERIDAN, MT · Medicare-certified · 39 beds

Needs attention
Government-run
4 of 5 overall

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.

Facility ratings

Health inspections

Staffing

7.7945 hrs/resident/day

Quality measures

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).

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).

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.

View the original federal record

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.

View the original federal record

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.

View the original federal record

F-Tag 552 — 42 CFR §483.10 — S/S: D

Recent history

  1. PENALTY

    A federal fine of $22,205 was recorded.

  2. STAFFING

    Reported nurse staffing met or exceeded the federal recommendation.

  3. INSPECTION

    Health inspection found 1 health deficiency.

    See what inspectors found
  4. INSPECTION

    Health inspection found 3 health deficiencies.

    See what inspectors found
  5. 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.