Cycle 1
Health 2024-12-31 · Fire 2024-12-31
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Burkburnett, TX
Sheridan Medical Lodge
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1119 S. Red River Expressway, Burkburnett, TX
(940) 569-9500
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foursquare Healthcare
Operator or chain grouping
Approved since
2017-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 4 health / 1 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.04
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.54
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.64
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,972
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0001
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.94
Baseline 24.81% · Performance 19.02% · Measure score 6.94 · Achievement 5.20 · Improvement 6.94
Healthcare-associated infections
5.72
Baseline 9.04% · Performance 6.53% · Measure score 5.72 · Achievement 4.38 · Improvement 5.72
Total nurse turnover
5.23
Baseline 54.65% · Performance 42.31% · Measure score 5.23 · Achievement 5.23 · Improvement 3.64
Adjusted total nurse staffing
0.76
Baseline 2.13 hours · Performance 2.59 hours · Measure score 0.76 · Achievement 0 · Improvement 0.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 240 · Observed rate 10.83% · Lower 95% interval 7.92% |
| Discharge to community | 53.28% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 216 · Observed rate 48.61% · Lower 95% interval 47.36% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.02% |
95.27%
3.8 pts better
|
Numerator 203 · Denominator 205 |
| Falls with major injury | 1.46% |
0.77%
0.7 pts worse
|
Numerator 3 · Denominator 205 |
| Discharge self-care score | 68.09% |
53.69%
14.4 pts better
|
Numerator 64 · Denominator 94 |
| Discharge mobility score | 72.34% |
50.94%
21.4 pts better
|
Numerator 68 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 5 · Denominator 205 · Adjusted rate 2% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 5.34% · Lower 95% interval 4.27% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 63.64% |
42%
21.6 pts better
|
Numerator 70 · Denominator 110 |
| Discharge function score | 74.47% |
56.45%
18 pts better
|
Numerator 70 · Denominator 94 |
| Transfer of health information to provider | 85.25% |
95.95%
10.7 pts worse
|
Numerator 52 · Denominator 61 |
| Transfer of health information to patient | 85.71% |
96.28%
10.6 pts worse
|
Numerator 66 · Denominator 77 |
| Resident COVID-19 vaccinations up to date | 11.38% |
25.2%
13.8 pts worse
|
Numerator 14 · Denominator 123 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.8 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 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 | 8.7% |
3.3%
5.4 pts worse
|
3.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.2% · Q3 9.9% · Q4 8.5% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 35.6% |
2.7%
32.9 pts worse
|
11.4%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.9% · Q2 39.8% · Q3 21.7% · Q4 32.6% · 4Q avg 35.6% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
3.3%
2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 1.3% · Q4 1.4% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.2% |
18.9%
15.3 pts worse
|
19.6%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 38.1% · Q3 29.4% · Q4 34.5% · 4Q avg 34.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
10.8%
6 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.4% · Q3 7.8% · Q4 6.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.8% |
15.4%
1.4 pts worse
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 8.4% · Q3 7.8% · Q4 34.8% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
16.1%
1.1 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 19.8% · Q3 8.5% · Q4 26.2% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
15.0%
4.1 pts worse
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 21.8% · Q3 20.8% · Q4 12.4% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.2%
0.1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.9% · Q3 5.1% · Q4 1.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
12.0%
About the same
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
88.0%
11.3 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
25.9%
0.3 pts better
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 23.0% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
7 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-13 · Fire 2022-09-13
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-31
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 2025-01-31
D · Potential for more than minimal harm
2024-12-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-03-29
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 2024-04-04
E · Potential for more than minimal harm
2024-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-17
E · Potential for more than minimal harm
2023-10-19
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-19
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 2023-10-27
E · Potential for more than minimal harm
2023-10-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-19
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-10-19
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 2023-11-02
E · Potential for more than minimal harm
2023-04-14
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 2023-05-14
E · Potential for more than minimal harm
2022-09-13
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-09-28
E · Potential for more than minimal harm
2022-09-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-09-14
E · Potential for more than minimal harm
2022-09-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-04
E · Potential for more than minimal harm
2022-09-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-09-27
E · Potential for more than minimal harm
2022-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-04
D · Potential for more than minimal harm
2022-09-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-09-14
C · Minimal harm
2022-09-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-09-14
C · Minimal harm
2022-09-13
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2022-10-04
Penalties and ownership
What sits behind the stars
Ownership
Nocona Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burke Nh Realty Ltd
5% Or Greater Mortgage Interest · Organization
Campbell, John
Operational/Managerial Control · Individual
Campbell, Kenneth
Operational/Managerial Control · Individual
David W Miller Gs Trust
Operational/Managerial Control · Organization
Dwm 5x5 Trust
5% Or Greater Mortgage Interest · Organization
Fairbrook Partners, LP
5% Or Greater Mortgage Interest · Organization
Foursquare Texas 16 LLC
Operational/Managerial Control · Organization
Jec Gs Trust
Operational/Managerial Control · Organization
Jem 5x5 Trust
5% Or Greater Mortgage Interest · Organization
John E Miller Gs Trust
Operational/Managerial Control · Organization
Kingsbury Capital LLC Series F
Operational/Managerial Control · Organization
Kjc Gs Trust
Operational/Managerial Control · Organization
Lewis, Shane
Operational/Managerial Control · Individual
Lion Plaza LP
Operational/Managerial Control · Organization
Meekins, Greg
Corporate Director · Individual
Miller, David
Operational/Managerial Control · Individual
Miller, Don
5% Or Greater Mortgage Interest · Individual
Miller, John
Operational/Managerial Control · Individual
Miller, Richard
Operational/Managerial Control · Individual
Mnh-Inv Series LLC Series D
Operational/Managerial Control · Organization
Montague Nh, LP
5% Or Greater Mortgage Interest · Organization
Richard M Miller Gs Trust
Operational/Managerial Control · Organization
Rmm 5x5 Trust
5% Or Greater Mortgage Interest · Organization
Rockett, LP
5% Or Greater Mortgage Interest · Organization
Sdl Gs 5x5 Trust
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Avir at Burkburnett
Burkburnett, TX
1-star overall rating with 3-star inspections with $64,646 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Texhoma Christian Care Center Inc
Wichita Falls, TX
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Swan Health At Wichita Falls
Wichita Falls, TX
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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