Cedar Village: Wheelchair Fall Leaves Resident With Head Laceration - KS
The resident, identified in inspection records only as R1, had been moving down the hall by pulling herself along the handrail when she abruptly put her feet on the floor. Her wheelchair had no foot pedals. She pitched forward onto the floor. Licensed Nurse G, who had come in that day to help provide one-on-one supervision, told inspectors the fall happened so fast there was nothing she could have done to prevent it.
R1 was helped off the floor by three staff members and taken to the emergency room. Her laceration was cleaned and sutured. A CT scan showed a small frontal scalp hematoma. She was expected to have the sutures removed within a week.
The facility's own investigation concluded that every wheelchair should have pedals either on the chair or in the resident's room, and that all staff would be educated on the change. Two administrative nurses were assigned to monitor compliance.
When inspectors arrived on October 20, more than five weeks after the fall, they found several residents sitting in the activity room during a music program. None of the wheelchairs had foot pedals.
The two nurses responsible for overseeing the fix gave inspectors contradictory accounts of what education had actually been provided. Administrative Nurse E said staff had been informed through a weekly case management sheet that foot pedals should be on R1's wheelchair when she was being pushed. Administrative Nurse D said the facility had not provided any education to staff at all about foot pedals on wheelchairs.
R1 was in bed when inspectors observed her, restless and turning. No wheelchair was visible in her room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ness County Hospital Ltcu Dba Cedar Village from 2025-10-20 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
NESS COUNTY HOSPITAL LTCU DBA CEDAR VILLAGE in NESS CITY, KS was cited for violations during a health inspection on October 20, 2025.
Her wheelchair had no foot pedals.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.