Ness County Hospital Ltcu Dba Cedar Village

In the surveyor’s words

From the most serious findings on record at Ness County Hospital Ltcu Dba Cedar Village, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 20, 2025

  The facility identified a census of 23 residents, with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure the foot pedals were on Resident (R) 1's wheelchair when staff assisted pushing her in her wheelchair, to prevent avoidable accidents. On 09/12/25, Licensed Nurse (LN) G propelled R1 in her wheelchair, without foot pedals, and R1 put her feet on the ground, which caused R1 to fall headfirst to the floor. R1 sustained a laceration (cut) on her forehead, which measured 7.5 centimeters (cm), a small hematoma, and required emergency transfer to evaluation and eight sutures to close the laceration. […]

• No harm, potential for more than minimal, patternF726Dec 5, 2023

  The facility had a census of 26 residents. Based on record review and interview, the facility failed to provide competent staff with the appropriate training, skills, and knowledge when two Certified Nurse Aides (CNA) administered medication to eight residents, Resident (R) 1, R2, R3,R4, R5, R6, R7, and R8, at the direction of Administrative Nurse D, because the licensed nurse on duty did not feel comfortable passing the medications. This placed the resident's at risk for medication errors and complications related to incompetent staff. Findings included: - The State Agency (SA) intake KS00184350 and KS00184390 reported on 11/25/23, the facility's Certified Medication Aide (CMA) called in due to the weather which left an agency Licensed Nurse (LN) to pass medication. […]

• No harm, potential for more than minimal, isolatedF561Jun 22, 2026

  Based on record review, observation, and interview, the facility failed to provide Resident (R) 1 with choices in daily routines, activities, schedules, and participation in care decisions when staff did not honor Resident (R) 1's wishes not to be showered and scrubbed. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception), mood disturbance (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), anxiety (mental or emotional reaction… […]

• No harm, potential for more than minimal, isolatedF550Mar 5, 2025

  The facility had a census of 22 residents. The sample included 12 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote dignity for one resident, Resident (R) 22, whose pajamas were soiled with urine from her waist down to the back of her knees. The facility further failed to promote dignity for R22 by taking her out into the common area and into an activity in her pajamas. This placed the resident at risk for impaired dignity. […]

• No harm, potential for more than minimal, isolatedF657Mar 5, 2025

  The facility had a census of 22 residents. The sample included 12. Based on observation, record review, and interview, the facility failed to implement effective care plan interventions for Resident (R) 6 from falling and sustaining major injuries. This deficient practice placed R6 at risk for continued falls and injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hypertension (HTN - elevated blood pressure), chronic atrial fibrillation (rapid, irregular heartbeat), fracture (broken bone)… […]