Cycle 1
Health 2025-04-09 · Fire 2025-04-09
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Sheridan, MT
Tobacco Root Mountains Care Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies
326 Madison St, Sheridan, MT
(406) 842-5600
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
16
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-06-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.61
Registered nurse staffing · state 0.94 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
5.11
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
7.65
All reported nurse hours · state 3.97 · national 3.89
Licensed hours
2.54
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
6.60
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
1.14
Weekend registered nurse coverage · state 0.69 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.58
CMS adjusted RN staffing hours
Adjusted total hours
7.52
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 56% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 2 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.65% |
8.2%
3.5 pts worse
|
Numerator 2 · Denominator 43 |
| Staff flu vaccination coverage | 25% |
42%
17 pts worse
|
Numerator 12 · Denominator 48 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
94.4%
2.9 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.7%
6.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.2% |
4.2%
4 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
4.7%
0.3 pts better
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.4% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.9%
1.1 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
17.4%
3.6 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
20.6%
6 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 5.5% |
0.4%
5.1 pts worse
|
0.1%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.0% |
19.7%
7.7 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.0% |
19.8%
3.8 pts better
|
14.9%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 11.0% |
2.6%
8.4 pts worse
|
1.0%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
2.9%
2.6 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
25.4%
3.3 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.4%
1.6 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-10 · Fire 2024-04-10
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-03-16 · Fire 2023-03-16
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-05-31
F · Potential for more than minimal harm
2023-03-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-04-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-16
F · Potential for more than minimal harm
2023-03-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F578 · Resident Rights Deficiencies
Health
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 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F690 · Quality of Life and Care Deficiencies
Health
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 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-04-26
Penalties and ownership
What sits behind the stars
Ownership
Madison County Finance
5% Or Greater Direct Ownership Interest · Organization
Allhands, Daniel
Corporate Officer · Individual
Allhands, Daniel
W-2 Managing Employee · Individual
Forsythe, Jayne
W-2 Managing Employee · Individual
Hart, James
Corporate Officer · Individual
Hart, James
W-2 Managing Employee · Individual
Nye, Ronald
Corporate Officer · Individual
Nye, Ronald
W-2 Managing Employee · Individual
Oneill, Bonnie
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Madison Valley Manor
Ennis, MT
4-star overall rating with 4-star inspections with 9 recent health deficiencies
#2
Pioneer Care And Rehabilitation
Dillon, MT
1-star overall rating with 1-star inspections with $158,103 in total fines with 20 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Southwest Montana Veterans Home
Butte, MT
5-star overall rating with 4-star inspections with $9,126 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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