Clara City Care Center: Elopement Immediate Jeopardy - MN
Nobody stopped him. Nobody had a system in place to make sure the doors were locked in the first place.
The resident, identified in inspection records only as R1, later showed a social worker exactly how he did it. He pointed out the hallway he went down, the two exit doors he passed through, the ductwork he recognized in between them. Outside, he told the social worker he recognized the curb he rolled his wheelchair down.
The facility's maintenance manager confirmed that both doors were unlocked and that the Wander Guard alarm on the final door was not functioning. It had never beeped. That failure had been raised at department head meetings multiple times. No fix had been implemented. There was no system, the maintenance manager said, to ensure the exit doors were locked at any given time.
Federal inspectors classified the elopement as an immediate jeopardy, the most serious level of harm designation available under Medicare oversight.
What made the elopement worse was what had come before it. Eleven days earlier, on October 2, R1 had shown exit-seeking behavior. The Director of Nursing confirmed during an interview on October 22 that no interventions were put in place after that incident. Then, on the evening of October 13, the charge nurse on duty, identified as RN-A, became aware of exit-seeking behavior again. There was no immediate communication with other staff. No interventions were implemented before R1 left the building.
RN-A told inspectors she had implemented two-hour checks on R1. She could not explain how she determined two hours was appropriate or how it was individualized to him.
After the elopement, the facility moved to one-hour checks and placed a bed alarm on R1's bed. A system to check the two involved doors was implemented, but only during evening hours. Staff received education on the elopement procedure itself. What they did not receive, the Director of Nursing acknowledged, was any training on developing individualized interventions, revising care plans to reflect exit-seeking risk, or implementing measures specifically tailored to a resident who had already tried to leave.
That gap showed up in staff interviews. A trained medication aide said he had received the elopement procedure training but that exit-seeking interventions were never addressed. He noted that care plans should include elopement risks and specific interventions. A nursing assistant said the same: she had the procedure training, but nothing about what to actually do when a resident is trying to get out the door.
The care plan failure ran through the entire sequence of events. R1 demonstrated exit-seeking behavior on October 2. No care plan update followed. He demonstrated it again on October 13. No interventions were implemented before he left. After the elopement, the charge nurse did not update the care plan with individualized interventions. The two-hour checks that were put in place were not grounded in any documented clinical reasoning.
Inspectors arrived on October 21. The social worker's interview that day, in which R1 walked her through his route out of the building from memory, made clear he had known exactly what he was doing and where he was going.
The immediate jeopardy was not removed until October 23, after the facility completed a series of corrective actions. Staff received education with knowledge checks on revising care plans for individualized exit-seeking interventions. All staff were trained on identifying exit-seeking behavior, redirection, supervision, and when to communicate elopement risk to colleagues. The facility identified which staff hold keys to the locked door. A new door-check system was put in place requiring nursing staff to verify both involved doors are locked at least once per shift, documented on a sign-off sheet.
R1 had been wearing a sweatshirt, sweatpants, and tennis shoes when he left. It was October in Minnesota.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clara City Care Center from 2025-10-23 including all violations, facility responses, and corrective action plans.
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 7, 2026 · Our methodology
CLARA CITY CARE CENTER in CLARA CITY, MN was cited for immediate jeopardy violations during a health inspection on October 23, 2025.
Nobody had a system in place to make sure the doors were locked in the first place.
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.