Federal inspection record · CMS data as of October 1, 2026
Tobacco Root Mountains Care Center
326 Madison St, Sheridan, MT · (406) 842-5600
- Cited for abuse (CMS abuse icon)
- Certified beds
- 39
- Residents per day
- 15
- Ownership
- Government
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 14, 1996
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Montana.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★−1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Montana homes
Tobacco Root Mountains Care Center carries 55 inspection points. That is fewer than 59% of Montana's 59 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Montana: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–31.5 pts
- 4★ 31.5–49.25 pts
- 3★ 49.25–84.75 pts
- 2★ 84.75–135.38 pts
- 1★ over 135.38 pts
Bars show every rated home in Montana by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
11 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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G
Provide safe, appropriate pain management for a resident who requires such services.
Everything else, by area of care
Freedom from Abuse, Neglect, and Exploitation4D
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Nutrition and Dietary1F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nursing and Physician Services1D
- D
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.
Resident Assessment and Care Planning1D
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Pharmacy Service1D
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Infection Control1D
- D
Provide and implement an infection prevention and control program.
Inspection history
2026-05-21
7 health deficiencies · 1 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2025-04-09
1 health deficiencies · 0 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2024-04-10
3 health deficiencies · 2 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
4
Nursing time per resident, per day
Each resident here gets about 7 h 38 min of nursing staff time a day, 1 h 43 min of it from a registered nurse.
This home
7 h 38 min
Montana average
4 h 1 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 76% of nursing staff and 75% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$20,100 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2026-04-01 | Fine | $20,100 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.3 pts better | 100.0% | 96.7% | 93.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury7.3 pts worse | 11.7% | 4.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms12.6 pts worse | 18.9% | 6.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight4.4 pts better | 2.0% | 6.4% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication1.7 pts better | 13.7% | 15.4% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3 pts worse | 23.7% | 20.7% | 15.4% |
| Percentage of long-stay residents who were physically restrained7.7 pts worse | 8.3% | 0.6% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened13.7 pts worse | 29.8% | 16.1% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased11.5 pts worse | 30.0% | 18.5% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder7.4 pts worse | 9.4% | 2.0% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1.3 pts better | 1.7% | 3.0% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence8.6 pts worse | 30.7% | 22.1% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.6 pts better | 3.6% | 6.2% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine11.1 pts better | 95.2% | 84.1% | 82.3% |
·
Who owns and runs it
9 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Madison County Finance | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Allhands, Daniel | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Allhands, Daniel | Corporate Officer · Individual | 0% | 1 facilities |
| Forsythe, Jayne | W-2 Managing Employee · Individual | 0% | 2 facilities |
| Hart, James | W-2 Managing Employee · Individual | 0% | 2 facilities |
| Hart, James | Corporate Officer · Individual | 0% | 2 facilities |
| Nye, Ronald | W-2 Managing Employee · Individual | 0% | 2 facilities |
| Nye, Ronald | Corporate Officer · Individual | 0% | 2 facilities |
| Oneill, Bonnie | W-2 Managing Employee · Individual | 0% | 1 facilities |
·
Fire safety
3 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Gas, Vacuum, and Electrical Systems2F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure that testing and maintenance of electrical equipment is performed.
Smoke1F
- F
Inspect, test, and maintain automatic sprinkler systems.
·
Other homes nearby
-
Madison Valley Manor
Ennis, MT
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- —
- Fines
- $0
-
Pioneer Care And Rehabilitation
Dillon, MT · Sweetwater Care
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 39 min
- Fines
- $138,054
-
Southwest Montana Veterans Home
Butte, MT · Eduro Healthcare
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 43 min
- Fines
- $0