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Nursing HomeMedicaid Investigative

Tobacco Root Mountains Care Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

326 Madison St, Sheridan, MT 5974939 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.8/5

based on 22 Google reviews

5
4
3
2
1

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1/ 10
low Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • High staff turnover (61%)

Top 10% in MT · Meets national RN staffing standard · Above recommended total nurse staffing · No penalties on record · Very few deficiencies

Source: Medicare data

What this means for your family

This facility is highly regarded for its compassionate staff and clean environment, making it a strong candidate for long-term care. However, families should inquire about current kitchen management, as recent feedback suggests a decline in meal quality that you may want to verify during your tour.

Google Reviews

Google Reviews

22 reviews on Google
Tobacco Root Mountains Care Center is frequently praised for its compassionate, attentive, and friendly staff who make residents feel well-cared for. While the facility is generally noted for being clean and welcoming, recent feedback indicates a decline in food quality due to changes in kitchen staff. Families consistently report feeling reassured by the professional and kind environment provided for their loved ones.

Quality Themes

Tap a score for details
Food5.0Staff9.0Clean9.0Activities8.0MedsN/AMemoryN/AComms8.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Clean and well-maintained facility
  • Welcoming atmosphere for visitors
  • Strong focus on resident wellbeing

Concerns

  • Recent decline in food quality and preparation (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02017(1)4.82020(6)5.02022(7)4.82023(9)3.02024(1)5.02025(1)

Distribution · 25 analyzed

5
21
4
3
3
1
2
0
1
0

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the facility's 5-star staffing rating, how does the team ensure that the high level of personal attention mentioned by families remains consistent throughout the day?
  • 2With the recent feedback regarding dining, could you share how the kitchen team is working to improve the quality and variety of meals served to residents?
  • 3Since the facility maintains such a high standard of cleanliness, what are the daily routines in place to ensure the environment remains comfortable and well-maintained for residents?
  • 4Could you walk me through how the staff handles medical needs or emergencies to ensure residents receive prompt care while maintaining the facility's excellent health inspection record?
  • 5What types of daily activities or social programs are currently prioritized to keep residents engaged and connected with the welcoming community here?
  • 6With only one state violation reported in the last year, what steps does the leadership team take to proactively address and resolve any operational concerns that arise?

Personalized based on this facility's data


Key Review Excerpts

Excellent staff, clean facility. All employees from management to kitchen staff have treated my mom and myself with compassion, professionalism, very friendly, already have made efforts to really get to know her.

Long-term resident's family · 2022★★★★★

The staff are the best and so patient and kind with all the patients as well as each other. My hat is off to these wonderful people and all facility.

Family member · 2022★★★★★

I love visiting with the people here. Very nice and friendly. They have fun things for them to do here. They have bingo, sewing groups can come in and sing and play fir them.

Visitor · 2020★★★★★
Source: 22 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
2.01hrs
OK
Registered nurses for medical care
Total Nursing
7.79hrs
OK
All nurses + aides combined
Staff Turnover
65%
Lower is better (< 30% = good)
RN Turnover
29%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 14 measures

Medicare Rating
1/ 5
Better Than Avg

4

measures

Worse Than Avg

8

measures

Mixed Results

2

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility32.8%
Worse than Avg
Here
32.8%
US
19.4%
MT
25.2%
Madison
19.4%
😔

Residents with depression symptoms

↓ Lower is better
This Facility8.1%
Mixed vs Avgs
Here
8.1%
US
12.1%
MT
5.0%
Madison
19.6%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🩺

Residents with a long-term catheter

↓ Lower is better
This Facility11.2%
Worse than Avg
Here
11.2%
US
0.9%
MT
2.4%
Madison
0.9%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility14.5%
Better than Avg
Here
14.5%
US
19.5%
MT
16.4%
Madison
24.5%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
MT
93.7%
Madison
91.2%
⚠️

Residents who fell and were seriously hurt

↓ Lower is better
This Facility11.6%
Worse than Avg
Here
11.6%
US
3.2%
MT
4.3%
Madison
3.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

4deficiencies
1penalties
Well below state avg (11.3)
6 complaint-triggered

Most concerning is a recent complaint from a family regarding resident abuse protection, though this was corrected. The facility shows a pattern of deficiencies across infection control, care planning, and quality of care areas. While most issues have been addressed with correction dates, the recurring problems with infection control across multiple surveys and the serious nature of the abuse protection complaint warrant careful consideration during your visit.

Apr 1, 2026Complaint
5
0689Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0697Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0726Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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.

Apr 9, 2025Complaint
1
0600Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Apr 10, 2024Routine
5
0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0921Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Mar 16, 2023Routine
11
0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0920Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0740Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

0745Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Federal Penalties

Fine

Apr 1, 2026

$22,205

Ownership & Operations

Who Operates This Facility

Owner / Operator

Tobacco Root Mountains Care Center

Organization Type

government

Ownership & Management

Owners

Madison County Finance

Owner · Organization

100%

Key personnel

Allhands, DanielW-2 Managing EmployeeForsythe, JayneW-2 Managing EmployeeHart, JamesW-2 Managing EmployeeNye, RonaldW-2 Managing EmployeeOneill, BonnieW-2 Managing Employee
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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