Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medicalodges Goddard during CMS and state inspections, most recent first.
The facility failed to maintain the required CNA in-service training program, including required topics and at least 12 hours of annual training. Review of records for five CNAs showed two had less than 12 hours of documented training, and two lacked the required training topics. An administrative nurse confirmed the annual training requirement and stated there were no additional training records for those CNAs.
Medication error rates were above the required threshold, with 3 errors in 29 observed medication administrations for a 10.34% error rate. For one resident, a CMA crushed citalopram, folic acid, and senna together and gave them without any order to crush or mix the medications. The EHR had orders for the medications, but no crush order, and both an LPN and an administrative nurse acknowledged that a crush order should have been present; the facility policy required crushing needs to be documented on the resident’s orders and MAR.
Staff failed to follow infection control practices when caring for a resident with an indwelling catheter and wounds and when using shared equipment. CNAs entered the resident’s room without visible EBP signage and without gowns, and a CMA used a glucometer on one resident, then brought it to another resident’s room without cleaning it first. Facility staff later stated the glucometer should be cleaned between uses and that EBP was expected for residents with wounds or indwelling devices.
Missing Staff Background Check: The facility failed to locate the background check for one CNA during review of staff records. An Administrative Nurse stated the background check could not be found, and an Administrative Staff member confirmed that all staff were expected to have background checks per facility policy. The policy required new employees to be investigated before employment for any prior history of abuse, neglect, or exploitation.
Failure to obtain updated psychotropic medication consent: A resident with depression, insomnia, anxiety, and chronic pain had intact cognition and was receiving antidepressant therapy and Lyrica for pain. The EHR showed a psychotropic consent for a lower Lyrica dose, but when the order was increased to TID, there was no evidence the resident or representative received education or informed consent for the dose/frequency change; an LN was unsure who completed consents, and an AN confirmed the consent was not accurate.
Failure to provide transfer and bed hold notifications: Two residents were transferred out for hospital or ER evaluation, but the EMR lacked evidence that written transfer notices and bed hold information were given to the resident or legal representative. The record also lacked evidence that the LTCO was notified. Staff interviews showed confusion about who was responsible for providing the bed hold notice and written transfer documentation.
Failure to Provide ROM and Restorative Services: A resident with dementia, cognitive communication deficit, and a paralytic gait was dependent for most ADLs and had restricted ROM in all extremities, but the record lacked evidence of active or passive ROM or restorative care. Observations showed the resident’s hands curled inward or clenched shut, and staff confirmed he could not use a standard call light, the facility no longer had a restorative program, and no documentation showed ROM services were provided.
Failure to Follow Fall-Prevention Interventions: A resident with anxiety, dialysis, and hyperextension was identified as high risk for falls and had a care plan directing staff to keep a fall mat beside the bed along with other fall precautions. Surveyors observed the resident in bed multiple times without the fall mat in place, including after staff assisted her to her room and bed, and staff interviews confirmed the mat should have been on the floor beside the bed.
A resident with paraplegia, osteomyelitis, and bilateral lower-extremity amputations was not weighed on admission or after multiple hospital returns, despite MD orders for weekly and daily weights and a care plan identifying risk for weight loss. The EMR showed long gaps without weights, including a documented 10-lb loss and later a much lower weight, while staff confirmed CNAs and dietary staff handled weights and the expectation was to weigh residents on admission/readmission and weekly for four weeks.
Failure to maintain a resident’s dignity during care when a CNA was argumentative, used foul language, and refused to leave promptly after the resident requested additional vaginal area cleaning and asked the aide to stop. The resident and an LPN reported the aide was not gentle or respectful during cares and told the resident she was not her mama.
Incomplete Daily Nurse Staffing Postings: The facility failed to ensure the daily nurse staffing sheets posted near the nurse's station included actual hours worked for licensed and unlicensed staff. The posted forms lacked actual hours on multiple days, and review of prior staffing sheets showed several months with missing or incomplete postings. An Administrative Nurse stated the charge nurse completed the sheet without actual hours and the business office filled it in later, while another Administrative Nurse said she was unaware actual hours had to be posted.
A CNA in a facility failed to follow the protocol requiring two staff members during a resident transfer using a Hoyer lift. The resident, who had intact cognition and required assistance for transfers, was moved by the CNA alone. Interviews revealed that the facility expected two staff members for such transfers, although no written policy existed.
A resident with chronic osteomyelitis and pressure ulcers did not receive proper infection control during wound care, as a nurse failed to cleanse hands between glove changes. Despite being aware of the need for hand hygiene, the nurse did not follow standard procedures, as confirmed by an administrative nurse. The facility's policy aimed to prevent skin breakdown and promote healing, but was not adhered to in this instance.
CNA In-Service Training Deficiencies
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNAs that included the required topics and at least 12 hours of annual training. The facility reported a census of 45 residents. Review of training records for five CNAs employed for more than one year showed that CNA HH had only one documented hour of in-service training in the previous 12 months and CNA II had eight documented hours, both below the required 12 hours. The same record review showed that CNA HH and CNA II did not have the required in-service training topics for the previous 12 months. Administrative Nurse D confirmed that CNAs were required to have 12 hours of training annually and stated there were no records of additional training for those CNAs. The facility did not provide a policy.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
Medication error rates were found to be 10.34% based on 29 medication administrations observed with three errors identified, exceeding the required rate of less than 5%. The facility was cited for failing to ensure the medication error rate remained below five percent during observation, record review, and interviews involving a sample of 13 residents from a census of 45. For one resident, the electronic health record showed orders for citalopram 10 mg once daily, folic acid 1 mg once daily, and senna 8.6 mg, two tablets twice daily, but there were no orders to crush or mix the medications. During observation, a CMA crushed citalopram, folic acid, and senna together and administered them to the resident. In interviews, the CMA stated the medications were always crushed together, and a licensed nurse and an administrative nurse acknowledged that there should have been an order to crush the medications; the administrative nurse also stated that if medications were crushed and given without a crush order, it was not a medication error. The facility policy stated that the need for crushing medications must be indicated on the resident's orders and MAR.
Infection Control Failures With EBP and Shared Equipment
Penalty
Summary
The facility failed to clean reusable shared equipment between residents and failed to use proper Enhanced Barrier Precautions for a resident with an indwelling catheter and wounds. On 01/14/26 at 07:55 AM, two CNAs entered the resident’s room to transfer him with a mechanical lift, and there was no visible EBP notification on the door. The resident had an indwelling catheter visible, including the tubing, and the CNAs did not wear gowns during the care. On 01/14/26 at 10:17 AM, a CMA completed a blood glucose check for one resident and did not clean the glucometer before taking it to another resident’s room. The CMA placed the glucometer and gloves on the overbed table, washed her hands, applied gloves, and performed the blood glucose check for the second resident. An Administrative Nurse observed the activity and later cleaned the glucometer, stating it should be cleaned between uses. The CMA stated she was not aware the glucometer had to be cleaned between residents and said she had never been taught that it needed to be done. Facility staff stated they expected CNAs to utilize EBP for residents with wounds or artificial openings and expected staff to clean glucometers between each use. The facility policy stated EBP was to be used for residents with wounds or indwelling medical devices, and the skills check documented that the glucometer was to be cleaned after use.
Missing Staff Background Check
Penalty
Summary
The facility failed to implement its policy for preventing abuse, neglect, and exploitation when it could not locate the background check for one CNA, HH. The facility had a census of 45 residents, and five staff were reviewed for background checks. On 01/14/26 at 3:05 PM, Administrative Nurse D stated she was unable to locate the background check for CNA HH and acknowledged that background checks were required for all staff. On 01/15/26 at 10:23 AM, Administrative Staff A stated it was the facility expectation that all staff have background checks, consistent with the facility policy Abuse, Neglect, and Exploitation dated 10/02/22, which stated all new employees would be investigated prior to employment for a previous history of abuse, neglect, or exploitation.
Failure to Obtain Updated Psychotropic Medication Consent
Penalty
Summary
The facility failed to inform Resident 18 and/or his representative regarding the risks related to psychotropic medications. Resident 18 had diagnoses of depression, insomnia, anxiety, and chronic pain, and his annual MDS documented a BIMS score of 15, indicating intact cognition. The Psychotropic Drug Use CAA documented that he had been administered antidepressant medications, and the Pain CAA documented that he reported pain almost constantly with a pain value of 7 to 10 on a numeric rating scale. Resident 18's care plan documented medication use for chronic and acute pain, and an intervention included Lyrica 50 mg three times daily for pain. The EHR contained a psychotropic consent signed on 05/08/25 that listed Lyrica 50 mg twice daily, but a new order on 12/15/25 changed Lyrica to 50 mg three times daily for chronic pain. The record lacked evidence that Resident 18 or his representative received education and/or informed consent regarding the increased Lyrica dose and frequency. During interviews, an LN stated she was unsure when psychotropic consents were completed or who was responsible, and an Administrative Nurse reported that consents were to be completed on admission, before starting a psychotropic medication, and any time there was a medication change, confirming that Resident 18's consent was not accurate.
Failure to Provide Transfer and Bed Hold Notifications
Penalty
Summary
The facility failed to provide written transfer notification and bed hold information for a resident who was transported to the hospital after another facility arrived to pick her up and staff were unable to arouse her. The resident’s progress note documented that EMS was called and transported her to the hospital, but the electronic medical record lacked evidence that the facility gave written notification of the transfer or a bed hold notice to the resident or her representative. The facility was also unable to provide evidence that the Office of the Long-Term Care Ombudsman was notified of the transfer. The facility also failed to provide written notification of transfer for another resident who was sent to the emergency room after staff documented that she was not able to have a sensible conversation, could not voice her pain levels, and could not wheel herself in her wheelchair as normal. The resident was later readmitted from the hospital, but the electronic medical record lacked evidence that the resident or her legal representative received written notification, and lacked evidence that the LTCO was notified of the transfer. During interviews, staff gave differing accounts of who provided bed hold notices and written transfer notifications, while the facility policy stated residents, family members, or legal representatives were to receive written notice of bed hold policies at admission and again at transfer to a hospital or for therapeutic leave.
Failure to Provide ROM and Restorative Services
Penalty
Summary
The facility failed to provide an assistive program to maintain range of motion (ROM) and prevent further decline in ROM and mobility for a resident with dementia, cognitive communication deficit, and a paralytic gait. The resident’s MDS showed he was unable to complete the BIMS interview, had short- and long-term memory deficits, was rarely or never understood when expressing wants or ideas, and received antidepressant and antipsychotic medications. His care plan documented that he was dependent with all ADLs except eating, which required maximum assistance, and the record lacked evidence that active or passive ROM or restorative care was provided. Observations showed the resident sitting in a high-backed wheelchair with his hands curled inward and held close to his chest, later in the same position, and on another occasion with his hands under a blanket while he sat with his eyes closed and a facial grimace. Staff fed him while his arms and hands remained under the blanket. Another observation showed his right hand clenched shut with very limited ability to open and close it, and he nodded yes when asked if it was difficult to open and close his hands. Staff interviews confirmed he was not able to use a call light because of limited ROM in his hands, that he had restricted ROM in all extremities, that the facility no longer had a restorative program, and that there was no documentation of ROM services to prevent further decline.
Failure to Follow Fall-Prevention Interventions
Penalty
Summary
The facility failed to follow a fall-prevention intervention for a resident who was identified as high risk for falls. The resident’s EMR documented diagnoses including anxiety, dialysis, and hyperextension, and the MDS documented a BIMS score of 14 with intact cognition and no falls within the prior six months or while admitted. Her care plan identified her as at risk for falls related to confusion and directed staff to place her wheelchair by her bed, use anti-roll back brakes, keep a bed alarm in place, check on her frequently, lower the bed to the lowest position, and ensure a fall mat was in place. Survey observations and interviews showed the fall mat was not in place on multiple occasions. On 01/13/26, the resident was observed in bed with a large bruise on the left side of her face from her forehead to her neck, lying toward the side of the bed closest to the wheelchair, and no fall mat was on the floor beside the bed. Later that day, she was again observed sleeping on the side of the bed without a fall mat in place. On 01/14/26, a CNA assisted her to her room and bed, placed the wheelchair in the bathroom, and did not place the fall mat beside the bed; another observation later that morning again showed no floor mat beside the bed. A CNA stated the resident was high risk for falls and staff were to put a fall mat on the floor on the side of the bed, and an Administrative Nurse stated the resident’s fall interventions included a fall mat next to the bed and that staff were expected to follow those interventions.
Failure to Obtain Ordered Weights and Track Weight Loss
Penalty
Summary
The facility failed to promote Resident 3’s highest practicable nutritional status when staff did not weigh the resident on admission and after hospital stays to establish a baseline and identify weight loss. Resident 3 had diagnoses of paraplegia, osteomyelitis, a right above-the-knee amputation, and a left below-the-knee amputation. The quarterly MDS documented a BIMS score of 15 and noted weight loss of 5% or more in the last month or 10% or more in the last six months. The care plan identified the resident as at risk for weight loss or gain due to disease process and directed staff to weigh him as ordered by the physician. The physician ordered weekly and daily weights at various times, including after admissions and readmissions, but the EMR lacked an admission weight until 09/09/25, and no weight was obtained during several hospital return stays. After one readmission, the EMR did not show a weight assessment for 19 days, and the next recorded weight on 10/29/25 showed a 10-pound loss from the prior documented weight. After another readmission, no weight was obtained during the stay, and after a later readmission the EMR again lacked a weight assessment until 12/11/25, when the resident weighed 222.2 pounds. Staff interviews confirmed that CNAs and dietary staff were involved in weighing residents and entering weights, and the administrative nurse stated the expectation was to weigh residents on admission or readmission weekly for four weeks, then monthly unless otherwise ordered.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to protect the dignity of Resident 33 when a CNA was argumentative and used foul language while providing care. During an observation and interview, Resident 33 stated she had asked staff to perform additional vaginal area cleaning because of itching and irritation, but the staff member began arguing with her, used foul language, and told her she was not her mother before leaving after the resident asked her to go several times. A nurse later reported that Resident 33 had complained that an evening aide was not handling her gently during cares and was not speaking to her appropriately, and that the resident had to tell the CNA several times to leave. The nurse stated the CNA told Resident 33 that she was not her mama and was argumentative with her. An administrative nurse also reported being informed of the interaction. The facility policy stated residents are to be treated with respect, kindness, dignity, and care and kept free from abuse and neglect.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information, including actual staff hours worked per shift for licensed and unlicensed staff providing resident care. During observation, the daily staffing sheet posted near the nurse's station for the census of 45 residents lacked actual hours worked for the licensed and unlicensed staff on the posted forms. Review of staffing sheets from September 2025 through January 14, 2026 showed that some September sheets were completed correctly, there were no staffing sheets for October 2025, November and December sheets lacked actual hours, and January 1 through 6 sheets also lacked actual hours worked, while January 7 through 12 sheets included actual hours worked. An Administrative Nurse stated she completed the staff sheet but did not enter actual hours on the posted sheet because the business office completed it later, and another Administrative Nurse stated she was not aware the requirement was to have actual hours posted on the daily staff sheet. The facility's BIPA Nurse Staff Posting policy, revised 12/2019, stated the total hours worked this shift would be completed by the charge nurse at the end of the shift and the actual hours worked would be verified by the business office.
Failure to Follow Transfer Protocols with Hoyer Lift
Penalty
Summary
The facility failed to ensure an environment free of accident hazards when a Certified Nurse Aide (CNA) did not adhere to the standard of care during a resident transfer. On the specified date, CNA M transferred a resident from a wheelchair to a bed using a Hoyer lift without the assistance of another staff member, contrary to the facility's protocol. The resident involved had a Brief Interview for Mental Status (BIMS) score indicating intact cognition and required staff assistance for all transfers as per their care plan. Interviews conducted with staff revealed that the facility's protocol required two staff members to be present during transfers using a Hoyer lift. CNA M, however, believed that if the resident was light, they could perform the transfer alone. Administrative Nurse D confirmed that the facility did not have a written policy regarding transfers but expected staff to follow known standards of care, which included using two staff members for such transfers. This incident highlights a failure in adhering to established protocols, potentially compromising resident safety.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to implement proper infection control measures during a wound dressing change for a resident diagnosed with chronic multifocal osteomyelitis and pressure ulcers. The resident, who had intact cognition, was at risk for skin integrity issues due to limited mobility and pain. The care plan included specific instructions for wound care, including the use of hypochlorous acid, Santyl, and calcium alginate, with dressing changes scheduled every other day. However, during an observation, a licensed nurse did not cleanse her hands between glove changes while performing wound care on the resident's right hip, right stump, and left hip. The nurse acknowledged awareness of the need to use hand sanitizer or wash hands between glove changes, yet failed to do so during the procedure. An interview with the administrative nurse confirmed that the expectation was for nurses to follow standard procedures for wound care. The facility's policy on wound prevention and management aimed to provide a systematic approach to identifying residents at risk for skin breakdown and to develop interventions to decrease the incidence of pressure ulcers. Despite these guidelines, the facility did not adhere to infection control measures, as evidenced by the nurse's actions during the wound care process.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 286 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Goddard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Family Health & Rehabilitation Center | 6.6 mi | ★★★★★ | 7 | 0 |
| Rolling Hills Health And Rehab | 7.1 mi | ★★★★★ | 0 | 0 |
| Sandpiper Healthcare & Rehabilitation Center | 9.8 mi | ★★★★★ | 0 | 0 |
| Via Christi Village Ridge | 10.5 mi | ★★★★★ | 23 | 0 |
| Wichita Presbyterian Manor | 10.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Medicalodges Goddard.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.