Clara City Care Center: Elopement Plan Gaps Found - MN
A complaint inspection on October 23, 2025 found that nursing staff were using interventions for residents with exit-seeking behaviors, but those steps were missing from the residents' care plans, the documents that are supposed to guide everyone who touches a patient's care.
When a registered nurse identified in the report as RN-B was interviewed on October 22, she acknowledged the gap directly. Residents who are elopement risks have a section in their care plans covering safety and falls, she said, but interventions staff were actually using when residents had been exit-seeking were not documented there. She said those interventions could be added.
Could be. They hadn't been.
A nursing assistant interviewed later the same afternoon, identified as NA-B, could list the specific interventions for each resident with exit-seeking behaviors. But when asked where those interventions were documented, she said she wasn't sure.
That gap, between what staff know and what the paperwork reflects, is exactly the kind of breakdown that puts residents in danger. An elopement, when a resident with dementia or cognitive impairment leaves a facility undetected, can turn fatal within minutes. The care plan exists so that every staff member, including someone new to a shift or unfamiliar with a resident, knows what to watch for and what to do.
The facility's own policy, last modified in January 2021, requires that elopement risk be assessed on admission, quarterly, and whenever a resident's condition changes significantly.
Inspectors rated the harm level as minimal or potential for actual harm, with few residents affected.
What the inspection does not say is whether any resident with exit-seeking behaviors was ever left without a staff member who happened to know, from memory alone, what the care plan had never bothered to record.
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.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
CLARA CITY CARE CENTER in CLARA CITY, MN was cited for violations during a health inspection on October 23, 2025.
When a registered nurse identified in the report as RN-B was interviewed on October 22, she acknowledged the gap directly.
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.