Tobacco Root Mountains Care Center
326 Madison St, Sheridan, MT 59749 · Madison County · 39 certified beds · avg 15 residents/day · certified since Jun 14, 1996
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Apr 1, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 22, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 1, 2026 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 30, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (11)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 21, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 21, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Apr 1, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 1, 2026 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Apr 1, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 1, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 1, 2026 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Apr 9, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 10, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 10, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 10, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 3 | 0 | D |
| 2025 | 1 | 0 | D |
| 2026 | 7 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $22,205, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Apr 1, 2026 | Fine | $22,205 |
| Apr 1, 2026 | Payment Denial | 49 days from May 5, 2026 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Montana avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.74 | 4.82 | 3.95 | top 10% in Montana; top 2% in the U.S. |
| Registered Nurse hours | 1.66 | 1.17 | 0.69 | top 16% in Montana; top 3% in the U.S. |
| Weekend total nurse staffing | 6.09 | 4.26 | 3.50 | top 10% in Montana; top 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.30 | 0.71 | 0.48 | top 7% in Montana; top 3% in the U.S. |
| Total nursing staff turnover (%) | 72.7 | 54.8 | 45.8 | bottom 13% in Montana; bottom 4% in the U.S. |
| RN turnover (%) | 42.9 | 48.3 | 42.9 | top 39% in Montana; bottom 49% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 7.05, RN 1.74, weekend 6.37. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Government - County
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Madison County Finance | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1966 |
| Allhands, Daniel | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2017 |
| Allhands, Daniel | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2017 |
| Forsythe, Jayne | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/06/2020 |
| Hart, James | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2015 |
| Hart, James | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2007 |
| Nye, Ronald | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2015 |
| Nye, Ronald | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2015 |
| Oneill, Bonnie | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/06/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Madison Valley Manor | 23.4 mi | Ennis, MT | ★★★★★ | 5/5 | |
| Pioneer Care and Rehabilitation | 26.7 mi | Dillon, MT | ★★☆☆☆ | 2/5 | |
| Southwest Montana Veterans Home | 37.6 mi | Butte, MT | ★★★★★ | 4/5 | |
| Crest Nursing Home | 39.6 mi | Butte, MT | ★★★★★ | 5/5 | |
| Continental Care and Rehabilitation | 39.8 mi | Butte, MT | ★★★☆☆ | 3/5 | |
| Copper Ridge Health and Rehabilitation Center | 39.8 mi | Butte, MT | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 275147.