Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tobacco Root Mountains Care Center during CMS and state inspections, most recent first.
Two residents experienced serious harm due to failures in accident prevention and pain assessment. One terminally ill, dependent resident with severe pain and non-verbal behaviors was known by staff to frequently swing her legs off the bed and onto a nearby baseboard heater, yet no care plan addressed this behavior, repositioning was poorly documented, and room checks were infrequent despite policies requiring regular monitoring. She was later found unresponsive with her leg and foot on or wedged in the heater, sustaining extensive second-degree burns to the calf, toes, heel, and entire plantar surface, while heater surface temperatures in multiple rooms were measured at 190–200°F and above. Another cognitively impaired resident suffered two choking episodes requiring the Heimlich maneuver and then reported persistent right rib pain over several days, with documented pain scores up to 8/10; staff largely relied on the resident’s refusals for hospital evaluation despite severe cognitive impairment, did not obtain diagnostic imaging, inconsistently documented pain assessments, and provided limited PRN analgesia, until a later ER visit for a fall revealed nondisplaced right rib fractures and a complex pelvic fracture.
Two residents at end of life experienced ongoing moderate to severe pain and agitation that were not adequately managed. For one resident, staff recognized significant non-verbal pain, a physician ordered immediate PRN analgesia, but the floor nurse delayed administration for more than four hours due to fear after prior reprimand, and surveillance video did not show required reassessments or regular checks. For the other resident with complex fractures on comfort care and hospice, documentation showed repeated episodes of severe pain and restlessness despite scheduled and PRN opioids and other measures, gaps in available medications, and staff who did not escalate to the prescriber, DON, or hospice overnight due to lack of knowledge and training about hospice and end-of-life processes, contrary to the facility’s pain management policy.
A resident was subjected to staff-to-resident abuse when an agency staff member aggressively pulled the resident’s walker and hurried the resident from the dining area to her room instead of using a gait belt as required, and was later observed being aggressive as they entered the resident’s room. A staff member who witnessed the incident remained at the doorway and did not immediately intervene while the staff member was still present with the resident, choosing instead to signal another staff member to get the nurse and report the incident only after the alleged abuser left the room. The resident, who could be behaviorally challenging, showed no change from baseline and continued normal activities after the event.
Two residents were involved in an altercation over a weekend, and the nurse on duty did not promptly notify the DON or Administrator, resulting in the incident not being recognized by leadership until a chart review was conducted later. An attempt to submit the initial abuse allegation report to the State Survey Agency was made but not successfully saved in the reporting system, and no immediate resubmission occurred. The full investigation, including the initial report, was submitted several days later, causing the initial abuse report to be filed late, despite staff having received prior abuse reporting training.
Nurses lacked competency in hospice and end-of-life pain management, leading to unmanaged pain for two residents. In one instance, a nurse delayed PRN pain medication for several hours despite a physician’s immediate order, influenced by fear after being reprimanded for prior PRN use, even though the resident showed clear nonverbal signs of significant pain. In another case, a nurse caring for a hospice resident with repeatedly high pain scores only used ordered meds and non-pharmacological measures and did not contact hospice, the DON, or the physician, stating she did not know she could reach hospice at night and had received no hospice or end-of-life training from the facility, despite facility documents indicating such training should be part of ongoing education.
A staff member physically and verbally abused a resident with moderately impaired cognition by aggressively moving a wheelchair, striking the resident's leg, and yelling at the resident, resulting in a reddened area and emotional distress. The incident was witnessed by another staff member and confirmed through investigation.
The facility staff failed to revise the care plans for two residents, leading to inadequate care. One resident experienced a lack of pain control due to untreated edema, and another was readmitted with a biliary tube that was not included in the care plan. Staff acknowledged the conditions but did not update the care plans accordingly.
The facility staff failed to administer medications within the prescribed time frame for a resident and did not ensure two residents safely swallowed their medications. Staff member J administered medications and walked away without confirming the residents had fully swallowed them. Additionally, another resident's medications were consistently given late, contrary to the facility's policy.
The facility failed to ensure cloth recliners in the resident dayroom were properly cleaned for infection control. Observations noted a strong urine smell, and interviews with staff revealed no consistent cleaning schedule. Facility documents showed inadequate cleaning protocols, contributing to the risk of spreading infectious agents.
Failure to Prevent Heater Burns and Address Post-Heimlich Rib Pain
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and assessment, resulting in serious injuries to two residents. For the first resident, who was actively dying on hospice with lung cancer, poor skin integrity, lethargy, severe pain, and non-verbal pain behaviors, staff did not adequately identify and address the risk posed by a baseboard heater located directly next to the bed. Multiple staff reported that this resident frequently swung or placed her legs off the bed and onto the heater, yet there was no care plan addressing burn risk from the heater prior to the incident. On the night of the burn, documentation showed the resident was to be turned and repositioned every two hours, but the Treatment Administration Record reflected only four documented repositioning times out of 24 opportunities over two days, and surveillance video from midnight to 5:30 a.m. showed only four very brief room entries before the burn was discovered, contradicting staff statements that checks occurred every 30 minutes or every two hours. In the early morning, the resident was found in bed with her left leg hanging off the side and on top of the baseboard heater, with her foot wedged in the heater according to one staff account. Staff described the burn as a significant second-degree burn from the toes to the heel, covering the entire bottom of the left foot, with additional second-degree burns on the left calf and toes, and with substantial fluid and blood drainage. At the time she was found, the resident was not responsive to verbal or physical stimuli and could not report pain. Staff applied cool, wet cloths to the leg and foot. Witnesses reported that the bandage on the burn appeared new when hospice arrived later, despite the burn having occurred earlier that morning, and one staff member stated the leg did not get wrapped until after the resident passed away. The Skin Observation Tool documenting the second-degree burns and identifying the baseboard heater as the cause was not signed until eleven days after the event. The physical environment also contributed to the hazard. The maintenance staff member reported that wall heating units had been damaged over the years, with missing parts and sharp metal edges, and that he relied on floor staff to notify him of damage; several damaged heat registers had not been reported and had no work orders. He stated that room temperatures should be 72–82°F and heat registers 140–150°F, but temperature checks performed with a facility temperature gun in multiple rooms showed heater surface temperatures ranging from 190°F to over 200°F and described as very warm to the touch, with one resident and family member complaining that it was too hot. Maintenance also acknowledged that no heater temperature checks had been completed since the burn incident. These conditions, combined with the resident’s known behavior of placing her legs on the heater, her dependence for repositioning, and the lack of documented frequent monitoring and a specific care plan for heater-related burn risk, led to the resident sustaining extensive second-degree burns. For the second resident, the deficiency centers on the facility’s failure to adequately assess and respond to ongoing rib pain following two choking incidents in which the Heimlich maneuver was performed. This resident had severe cognitive impairment, as evidenced by Brief Interview for Mental Status (BIMS) scores of 4 and later 0, and a history of serious injuries including complex pelvic and rib fractures identified after a later fall. During the first choking incident, staff performed the Heimlich maneuver while the resident remained seated in a chair. Nursing progress notes documented that shortly afterward the resident complained of soreness and then persistent right lower rib pain, with pain levels reported up to 7/10 and later 8/10. The notes show repeated complaints of right rib pain over several days, with the resident sometimes declining hospital evaluation and PRN Tylenol, and at other times accepting Tylenol, which made the pain tolerable but did not resolve it. Despite the resident’s severe cognitive impairment, the facility relied on his stated preference not to go to the hospital and did not consistently re-engage the responsible party after the initial contact, nor did they obtain diagnostic evaluation for the rib pain. Nursing documentation shows that after the first choking event, the resident’s pain complaints continued daily, and a second choking incident occurred a few days later, again requiring the Heimlich maneuver. The provider ordered monitoring for pain after the second choking event, but there were no X-rays or other diagnostic tests ordered in response to the ongoing rib pain. Vital sign records show incomplete documentation of pain scores on several days when progress notes indicated the resident was in pain. The resident’s care plan was later found to be missing from the EHR, and there was no speech/swallow evaluation because the usual hospital-based speech therapist position was vacant. When the resident subsequently fell and was sent to the ER for hip pain, hospital records identified a complex pelvic fracture and nondisplaced fractures of the right 6th and 7th ribs, confirming rib fractures that had not been previously evaluated despite days of documented rib pain following the Heimlich maneuvers. Facility leadership stated they did not further review the rib fractures as a concern because the resident was on hospice and they focused on overall pain management, but the record shows limited use of PRN analgesics and no escalation of assessment in response to persistent pain complaints. Facility policies in place at the time required frequent monitoring of terminal residents, a structured and documented repositioning program for residents in bed at least every two hours, and reassessment of acute or significantly worsened pain every 30–60 minutes until relief was obtained. The documented practices for both residents deviated from these expectations. For the first resident, there was inadequate documentation of repositioning and monitoring, no pre-incident care plan addressing known heater-related behaviors, and environmental heater temperatures far exceeding the stated range. For the second resident, there was incomplete pain assessment documentation, reliance on the expressed wishes of a severely cognitively impaired resident without consistent involvement of the responsible party, absence of diagnostic evaluation despite persistent rib pain after forceful abdominal thrusts, and a missing care plan in the EHR. These actions and inactions led surveyors to cite the facility under F689 for accidents and hazards, with an Immediate Jeopardy determination related to the first resident’s heater burns.
Failure to Provide Adequate End-of-Life Pain Management for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and timely pain management for two residents at the end of life. For the first resident, multiple staff interviews described that the resident was always in a lot of pain during checks and changes and that she was not very verbal, requiring staff to rely on non-verbal indicators such as grimacing to assess pain. One nurse reported that the resident would mumble what she thought was "no" when asked about pain, but her facial expressions indicated she was in significant pain. The same nurse stated that the resident’s medication orders were a "debacle," with orders not matching and the facility not receiving medications as ordered. During physician walking rounds, the physician directed that this resident receive PRN pain medication immediately due to signs of significant pain. A staff member reported that she notified another nurse, who then instructed the floor nurse to administer the PRN pain medication immediately. However, the floor nurse did not administer the medication for more than four hours after being told to do so. The floor nurse later stated she was fearful of giving the pain medication because she had been reprimanded the prior day for giving too much PRN pain medication to another resident, leading her to second-guess herself about administering pain medications. Pain assessment documentation showed a pain score of 6/10 at 12:30 a.m. with medication reportedly given at 1:07 a.m., but facility surveillance video from midnight to 5:30 a.m. showed only brief, infrequent entries into the resident’s room and did not show staff entering every two hours or 30–60 minutes after medication administration as required by facility policy. For the second resident, who had a complex pelvic fracture and rib fractures and was returned to the facility on comfort care with hospice involvement, progress notes documented repeated episodes of severe pain, agitation, and restlessness that were not effectively controlled. The resident cried out in pain with movement after the initial fall and later had multiple episodes where scheduled pain medication, PRN morphine, repositioning, and a lidocaine patch were ineffective, requiring additional PRN opioids before some relief was achieved. Subsequent notes described the resident as agitated, yelling, trying to throw himself on the floor, pulling at his catheter, and experiencing delusions, with PRN pain medications and non-pharmacological interventions often noted as ineffective. Staff contacted hospice several times, but at points no new PRN orders were received, and there were periods when only limited medications (such as Phenergan suppositories) were available. Further documentation showed that the resident continued to experience high pain scores (up to 10/10) and ongoing agitation and restlessness despite administration of ordered PRN medications. One nurse reported that Ativan had expired and that the physician initially wanted her to use the expired medication; she refused and had to wait for new medication to arrive. Another nurse stated that the resident was always in so much pain, that she gave medications as ordered and tried non-pharmacological interventions, but she did not attempt to call the physician, DON, or hospice for additional pain management because she believed the day shift had already made a plan and did not think she should call in the middle of the night. She also stated she did not know she could contact hospice on night shift and had received no training on hospice or end-of-life care. The DON confirmed that this nurse had not had training on end-of-life care or hospice and acknowledged a training opportunity. Pain vital records showed persistent moderate to severe pain throughout the day, and the facility was unable to provide requested surveillance video for part of the relevant period. The facility’s own pain policy required reassessment of acute or significantly worsened pain every 30–60 minutes until relief and immediate contact with the prescriber if pain was not adequately controlled, which was not consistently followed for this resident.
Failure to Protect a Resident From Staff Abuse and Lack of Immediate Staff Intervention
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident abuse. On the date of the incident, an agency staff member (NF9) was observed on camera and by staff pulling the resident’s walker and gesturing for the resident to hurry while directing the resident from the dining area to her room, instead of using a gait belt as required by facility practice. A staff witness later reported that NF9 was aggressive with the resident as they entered the resident’s room. At that time, the resident was described as a person who could be difficult with behaviors but was not different from her baseline after the incident and continued to participate in activities, attend meals, and maintain her usual routine. The deficiency also includes the failure of a witnessing staff member to intervene at the time of the alleged abuse. The witness stated she remained at the resident’s doorway after seeing NF9 being aggressive with the resident but did not intervene because NF9 was no longer touching the resident and was putting items away while the resident sat in a recliner. Instead of intervening immediately, the witness motioned for another staff member to get the nurse and reported the incident only after NF9 left the room. The facility’s investigation, based on witness statements and video review, substantiated that NF9’s actions constituted verbal and physical mistreatment that did not follow facility practices and that staff present did not fully follow the policy requiring intervention when suspecting abuse.
Failure to Timely Report Suspected Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an incident of suspected resident-to-resident abuse to the State Survey Agency within the required timeframe for two of ten sampled residents. On 7/5/25, a Saturday, two residents were involved in an altercation. The nurse on duty did not immediately report this incident up the chain of command to the DON or Administrator. As a result, the altercation was not identified by leadership until 7/7/25, a Monday, when it was discovered during a chart review of medical record notes. The facility attempted to submit the initial abuse allegation report to the State Survey Agency on 7/7/25, but the submission was not saved in the reporting system, and the facility did not attempt to resubmit the incident at that time. Instead, the facility submitted the full investigation, which included both the initial report and the final investigation, on 7/11/25, making the initial report late. Interview with staff member A confirmed the sequence of events, including that the incident occurred over the weekend, was found during chart review the following Monday, and that the initial report submission on 7/7/25 was not successfully saved. Review of staff abuse training logs showed that staff member T had completed abuse-related training within the last 12 months.
Failure to Ensure Nurse Competency in Hospice and End-of-Life Pain Management
Penalty
Summary
The facility failed to ensure nurses were competent to provide pain management for hospice and end-of-life care, resulting in unnecessary pain for two residents. In one case, during physician walking rounds, the physician directed that a resident receive PRN pain medication immediately due to signs of significant pain. A staff member relayed this instruction to the floor nurse, but the nurse delayed administering the PRN pain medication for more than four hours. The nurse later stated she was fearful of giving the medication because she had been reprimanded the prior day for giving too much PRN pain medication. She also reported that when she asked the resident about pain, the resident would mumble what she interpreted as "no," but the resident’s facial grimacing indicated the resident was in a lot of pain. In another case, a nurse reported that a hospice resident was always in significant pain and that she administered the ordered medications and used non-pharmacological interventions, but did not attempt to contact the physician, DON, or hospice agency for additional pain management options. The nurse stated she did not know she could contact hospice during the night shift and reported receiving no training on hospice processes or end-of-life care, noting she was new and had no experience with end-of-life care and death. The resident’s electronic health record documented multiple high pain scores, including maximum severe pain and severe pain on the same day. Review of the nurse’s employee file showed no facility-provided education on hospice or end-of-life care, despite the facility’s assessment tool indicating that hospice and end-of-life care training was to be provided as part of ongoing staff education.
Staff Member Commits Physical and Verbal Abuse Against Resident
Penalty
Summary
A staff member physically and verbally abused a resident with moderately impaired cognition while the resident was seated in the dayroom with his left leg elevated in a recliner. The staff member moved the resident's wheelchair in an aggressive manner, striking the resident's left leg with the wheelchair, which resulted in a dime-sized reddened area. The staff member then yelled at the resident as she left the dayroom, causing the resident to become notably upset. The incident was witnessed by another staff member, and the resident was assessed for injuries immediately after the event. The resident's assessment showed a red mark on his left leg, but no open area or need for medical treatment. The resident's cognitive status was documented as moderately impaired, with a BIMS score of 9. The staff member involved had previously received education on the facility's abuse policy. The facility's investigation, including video review and interviews with staff and residents, substantiated the allegations of both physical and verbal abuse by the staff member toward the resident.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility staff failed to revise the care plans for two residents, leading to inadequate care. Resident #16 experienced a lack of pain control in her legs due to edema, which was not addressed in her care plan. Despite observations of swollen legs and tight shoes, and an increase in her diuretic medication, the care plan did not include any focus, goals, or interventions for her edema or refusal to elevate her legs. Staff members acknowledged the resident's condition but did not update the care plan accordingly. Resident #73 was readmitted from the hospital with a newly placed biliary tube, which required specific care instructions. However, the care plan did not include any mention of the biliary tube or instructions for its monitoring and maintenance. Staff members indicated that care plan updates were discussed in interdisciplinary team meetings, but the necessary updates were not made. The facility's policy required care plans to be reviewed and revised upon readmission from the hospital, but this was not followed.
Medication Administration Deficiencies
Penalty
Summary
The facility staff failed to ensure medications were administered within the one-hour time period before or after the prescribed administration time for one resident and failed to ensure two residents safely swallowed their medications. Specifically, staff member J administered medications to a resident and walked away without confirming the resident had fully swallowed the medications. Similarly, another resident was given medications, and staff member J left the room without observing the resident swallowing the medications safely. These actions were observed during a survey on 4/9/24. Additionally, the facility staff did not administer medications to another resident within the prescribed time frame. The electronic medical record (EMR) showed that the resident's medications were consistently given late, with delays ranging from 33 minutes to over four hours past the scheduled time. Staff member J admitted to administering the medications late due to the resident's preference to sleep in, and another staff member confirmed that morning medications should not be given later than 9 a.m. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in this case.
Inadequate Cleaning of Cloth Recliners in Resident Dayroom
Penalty
Summary
The facility failed to maintain a system to ensure cloth recliners in the resident dayroom were monitored for necessary cleaning for infection control prevention. During an observation, a strong urine smell was noted in the dayroom, where eight cloth recliners were present, six of which were occupied by residents. Interviews with staff members revealed that there was no consistent cleaning schedule for the recliners, and the chair covers were only washed weekly or when visibly soiled. Staff members also acknowledged that the cloth recliners were difficult to clean and could harbor bacteria, infections, and germs, posing a risk for the spread of infectious agents. A review of facility documents showed that the cleaning protocol for the recliners was inadequate and not consistently followed. The facility's Infection Prevention and Control Program Policy aimed to provide a safe and sanitary environment but did not effectively address the cleaning and disinfection of the cloth recliners. The Centers for Disease Control infection control standards recommend barrier protection for surfaces that are frequently touched or difficult to clean, which was not adequately implemented in this case. The lack of a proper cleaning schedule and the use of cloth recliners that are hard to disinfect contributed to the deficiency in infection control prevention.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sheridan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Valley Manor | 23.5 mi | — | 0 | 0 |
| Pioneer Care And Rehabilitation | 26.7 mi | — | 1 | 0 |
| Southwest Montana Veterans Home | 37.6 mi | — | 0 | 0 |
| Crest Nursing Home | 39.6 mi | — | 0 | 0 |
| Continental Care And Rehabilitation | 39.8 mi | — | 1 | 0 |
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