Federal inspectors found the facility failed to develop a person-centered care plan for Resident 1, who had developed a paralyzing fear of falling. When the physical therapist tried to get the resident to walk, they were too frightened to cooperate.
The Director of Nursing confirmed that Resident 1 had "a fear of falling and refusal to walk." She also confirmed there was no care plan to help the resident overcome this fear.
Without proper intervention, the consequences could be permanent. "If staff did not assist a resident with exercise or walking when needed, it could lead to a loss of mobility," the Director of Staff Development told inspectors on September 22.
The facility's own policy requires care plans that meet individual resident needs through an interdisciplinary team approach. The policy specifically states that care planning must include "measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs."
Staff knew what they were supposed to do. The Director of Staff Development explained that certified nursing assistants should inform nurses when a resident refuses help with activities of daily living or shows fear of falling during walking attempts. "The nurse needs to create a care plan, so the staff know how to properly take care of the residents," she said.
The importance of having a written plan was clear to facility leadership. "A care plan was important because it informed the staff what to do to help the residents," the Director of Staff Development stated.
But no such plan existed for Resident 1.
The facility's care planning policy outlines exactly what should have been included. Care plans must address resident refusals of treatment, document the right to refuse treatment, note alternate treatments attempted, and include resident education components.
The policy requires care plans to help residents "attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being." For a resident afraid to walk, this would mean developing strategies to address both the fear and the physical need for mobility.
Federal regulations require nursing homes to develop comprehensive care plans that address each resident's individual needs and preferences. When residents refuse care or express fears about treatment, facilities must work with them to find acceptable alternatives rather than simply accepting the refusal.
Fear of falling is common among nursing home residents, particularly those who have experienced previous falls or witnessed others falling. Without proper intervention, this fear can lead to a cycle of decreased activity, muscle weakness, and increased fall risk.
The inspection found that multiple staff members understood the problem. The physical therapist encountered the resident's fear during treatment attempts. The Director of Nursing was aware of both the fear and the refusal to walk. The Director of Staff Development knew the protocols for addressing such situations.
Yet despite this awareness across different departments, no coordinated care plan emerged to help Resident 1.
The facility's policy, dated October 28, 2017, emphasizes person-centered care planning through interdisciplinary team collaboration. It requires that care plans be "consistent with the resident rights" and include coordination of care to address clinical issues.
For Resident 1, this interdisciplinary approach never materialized. The resident remained trapped by fear, unable to participate in the walking and exercise needed to maintain mobility and independence.
The inspection classified this as a violation with minimal harm or potential for actual harm affecting few residents. But for Resident 1, the impact was more significant. Each day without a proper care plan meant continued immobility and the progressive loss of strength and function that comes with it.
The Director of Staff Development's warning about mobility loss was not theoretical. Research consistently shows that prolonged inactivity in nursing home residents leads to muscle atrophy, decreased bone density, and increased fall risk when movement finally occurs.
Resident 1's case illustrates a fundamental breakdown in the care planning process. The facility had the knowledge, the policies, and the staff awareness needed to address the situation. What it lacked was the follow-through to translate that understanding into action.
The fear that kept Resident 1 from walking was real and understandable. The facility's failure to address it was not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestwood Manor - 104 from 2025-09-18 including all violations, facility responses, and corrective action plans.