Resident #101 scored just 4 out of 15 on a cognitive assessment in July, indicating severe impairment. Staff documented his wandering as routine baseline behavior, yet the facility failed to develop any care plan addressing his constant movement through the building or the safety risks it created.
His family member understood the behavior as stress relief. During a phone interview, the resident's durable power of attorney described how she would walk alongside his wheelchair during visits, guiding him through what she called "walking the sun" — touching doors at the end of each hallway before returning to start the circuit again through the facility's four halls that branched from a central circle.
The family member explained that the resident was confused about where his room was and often entered other residents' rooms thinking they were his own.
Multiple staff members confirmed the daily wandering pattern. The MDS coordinator reported the resident was "often wheeling around the building, wandering." An LPN said he "would spend all day going up and down the hallways." A certified nursing assistant observed him wandering down halls and sitting at the door looking outside.
Two other nursing assistants told inspectors the resident "wandered around the facility, in and out of other resident's rooms." A registered nurse confirmed he "wandered around the building and didn't know how to get to his room."
Facility notes from September documented the wandering as normal behavior. One entry stated the resident was "wandering throughout the facility per usual today and is easily redirectable." Another noted meeting with the resident "who is wandering down hallway per baseline" and "remains confused per baseline and easily redirectable."
Despite universal staff awareness of the resident's condition and behavior patterns, his care plan failed to address any aspect of his wandering. The plan contained no indication that he wandered the building, was unable to locate his room, or entered other residents' rooms.
The resident's medical history included cognitive disturbances, stroke, and joint replacement surgery. His severe cognitive impairment score placed him in the category requiring the most intensive monitoring and intervention for safety.
The facility's failure to plan for his wandering behavior violated federal requirements for comprehensive care planning. Nursing homes must develop individualized care plans that address each resident's specific needs and behaviors, particularly for those with severe cognitive impairment who may pose safety risks to themselves or others.
The inspection found the facility provided minimal harm to few residents through this deficiency. However, the lack of formal planning for a severely impaired resident who regularly entered other residents' rooms represented a significant gap in care coordination.
Staff described the resident as "easily redirectable," suggesting they had developed informal methods for managing his wandering. But without formal care plan documentation, there was no systematic approach to ensure consistent care across all shifts or guarantee that new staff would understand his needs and behaviors.
The resident's family had clearly adapted to his condition, developing the "walking the sun" routine that provided him comfort while ensuring his safety. Their understanding that he wandered as stress relief demonstrated the kind of individualized approach that should have been reflected in his official care plan.
Federal inspectors completed their review on October 8, finding that the facility's care planning process had failed to account for behaviors that every interviewed staff member recognized as the resident's daily routine.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Optalis Health and Rehabilitation of Three Rivers from 2025-10-08 including all violations, facility responses, and corrective action plans.
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