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Nursing home report

TOBACCO ROOT MOUNTAINS CARE CENTER

SHERIDAN, MT · Medicare-certified · 39 beds

Needs attention
Abuse citationGovernment-run
Data as of September 1, 2026
1 of 5 overall

Tobacco Root Mountains Care Center in Sheridan, MT has a 1-star overall rating, with low quality measures and a recent abuse citation. Staffing is rated 4 stars and reported nurse staffing is above the federal benchmark (7.05 vs 4.1 hours per resident per day), but the facility also had $56,280 in fines in the last 24 months.

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Facility ratings

Health inspections

Staffing

7.0462 hrs/resident/day

Quality measures

Last inspection: May 21, 2026Penalties, last 24 months: $56,280recent 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).

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).

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, actual harm.

View the original federal record

F-Tag 689 — 42 CFR §483.25(d) — S/S: G

The home failed to provide safe, appropriate pain management for a resident who needed it. Cited April 2026 — isolated incident, actual harm.

View the original federal record

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.

View the original federal record

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

  1. STAFFING

    Reported nurse staffing met or exceeded the federal recommendation.

  2. INSPECTION

    Health inspection found 2 health deficiencies.

    See what inspectors found
  3. PENALTY

    A federal fine of $56,280 was recorded.

  4. PENALTY

    A federal payment denial was recorded.

  5. STAFFING

    Reported nurse staffing met or exceeded the federal recommendation.

  6. INSPECTION

    Health inspection found 5 health deficiencies.

    See what inspectors found
  7. PENALTY

    A federal fine of $22,205 was recorded.

  8. STAFFING

    Reported nurse staffing met or exceeded the federal recommendation.

  9. INSPECTION

    Health inspection found 1 health deficiency.

    See what inspectors found
  10. INSPECTION

    Health inspection found 3 health deficiencies.

    See what inspectors found
  11. INSPECTION

    Health inspection found 10 health deficiencies.

    See what inspectors found

Penalties & enforcement

On record with Medicare: 1 fine · $56,280 in total fines · 1 payment denial.

  • Medicare/Medicaid payment denial

    Apr 1, 2026

    49 days

  • Federal fine

    Apr 1, 2026

    $56,280

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.

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Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.