Tobacco Root Mountains Care Center
326 Madison St · Sheridan, MT · 59749 · 4068425600
39 certified beds Government - County
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection results are getting worse cycle over cycle, not better.
- Staffing hours comfortably above national benchmarks.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
65% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 5 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 7.79 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 2.01 | 0.55–0.75 |
| Weekend hours / resident-day | 6.91 | ≈ weekday level |
| Nursing turnover / year | 65% | median 45% |
| Fines (3-yr window) | 1 · $22,205 |
Inspection citations (19 in the current record)
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Immediate jeopardy · J April 1, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 22, 2026 · Quality of Life and Care
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Actual harm · G April 1, 2026 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected April 30, 2026 · Quality of Life and Care
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Potential for harm · D April 1, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 30, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 1, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 30, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 1, 2026 · found via complaint
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected April 30, 2026 · Nursing and Physician Services
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Potential for harm · D April 9, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 10, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected May 16, 2024 · Resident Assessment and Care Planning
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Potential for harm · D April 10, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 16, 2024 · Pharmacy Service
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Potential for harm · D April 10, 2024
Provide and implement an infection prevention and control program.
Corrected May 16, 2024 · Infection Control
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Potential for harm · D March 16, 2023
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected April 26, 2023 · Resident Rights
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Potential for harm · D March 16, 2023
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected April 26, 2023 · Resident Rights
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Potential for harm · D March 16, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 26, 2023 · Resident Assessment and Care Planning
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Potential for harm · D March 16, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected April 26, 2023 · Quality of Life and Care
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Potential for harm · D March 16, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Corrected April 26, 2023 · Quality of Life and Care
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Potential for harm · D March 16, 2023
Provide care or services that was trauma informed and/or culturally competent.
Corrected April 26, 2023 · Quality of Life and Care
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Potential for harm · D March 16, 2023
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected April 26, 2023 · Quality of Life and Care
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Potential for harm · D March 16, 2023
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected April 26, 2023 · Quality of Life and Care
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Potential for harm · F March 16, 2023
Provide and implement an infection prevention and control program.
Corrected April 26, 2023 · Infection Control
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Potential for harm · D March 16, 2023
Implement a program that monitors antibiotic use.
Corrected April 26, 2023 · Infection Control
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 1, 2026 | Fine | $22,205 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 275147 · certified since June 14, 1996. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.