Cedar Village: Wheelchair Fall Leaves Resident With 8 Sutures - KS
The date was September 12, 2025, at 3:00 in the afternoon. A nurse followed behind her. The wheelchair had no foot pedals.
The resident, identified in inspection records only as R1, sustained a laceration to her forehead. Staff applied pressure until the bleeding stopped, then helped her back into the wheelchair with the foot pedals placed on, and took her to the emergency room. The primary care provider sutured the wound — eight sutures. A CT scan showed a small frontal scalp hematoma.
She returned to the facility and was monitored. The sutures were expected to come out in seven days.
The nurse who had been following R1 down the hall, identified as LN G, told inspectors she did not normally work the floor that day. She had come out to help provide one-on-one supervision with R1, who had been trying to crawl out of a recliner near the nurses' station. Staff placed R1 in her wheelchair instead. The wheelchair had no foot pedals on it.
LN G described what happened next: R1 was moving down the hall by pulling herself along the handrail. LN G said she would nudge her along occasionally and keep her from going into other residents' rooms. Then R1 put her feet on the floor. "The fall happened so fast there was nothing she could do to prevent it," LN G told inspectors.
The facility's own investigation concluded the fix was straightforward: foot pedals would be placed on every resident's wheelchair, or kept in the resident's room so they could be attached when needed. Staff would be educated. Two administrative nurses would monitor to make sure it was happening.
That was the plan. What actually happened was considerably less.
On October 20, more than five weeks after R1 fell, federal inspectors arrived at Cedar Village on a complaint inspection. At 11:30 in the morning, they observed several residents sitting in the activity room during a music activity. None of the wheelchairs had foot pedals present.
Not one.
When inspectors spoke with Administrative Nurse E, she said the only staff education given after the fall was a note on a Weekly Case Management sheet. The message to staff: make sure foot pedals are on R1's wheelchair when pushing her. The intervention applied to one resident, not the broader population of wheelchair users the facility's own investigation had identified as needing protection.
Administrative Nurse D went further. She told inspectors the facility had not provided any education to staff about ensuring foot pedals were on wheelchairs at all. She said an audit had been performed after R1's fall to check whether all wheelchair-using residents had foot pedals available. The wheelchairs in the activity room, observed by inspectors that same morning, suggested whatever that audit found had not translated into action.
R1 herself was in bed when inspectors checked her room at 10:30 that morning, tossing and turning, appearing restless. No wheelchair was visible in the room. The wound on her head had healed.
The picture the inspection report draws is not of a facility that failed to anticipate a risk. Cedar Village's own fall risk policy, revised in 2020, called for identifying environmental hazards, adding interventions to care plans, and collaborating to address modifiable risk factors. The facility's post-fall investigation named the missing foot pedals as the cause and described a specific remedy. Someone wrote it down. The fix was known.
It just wasn't done.
R1 had dementia and a documented habit of propelling herself through the halls. She didn't like foot pedals on her chair. The staff knew this. The solution the facility settled on, flipping pedals up when a resident wants to propel herself and placing them back when she's being pushed, was simple enough to write into a policy summary. Simple enough that the absence of any pedals at all, on any wheelchair, in a room full of residents five weeks later, is its own kind of answer about how seriously the facility treated what it had promised.
The inspection cited the fall as causing actual harm.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 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.
The date was September 12, 2025, at 3:00 in the afternoon.
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.