Clara City Care Center
CLARA CITY CARE CENTER in CLARA CITY, MN — inspection on October 23, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
plan should indicate if a resident is at risk for elopement. On 10/22/25 at 12:45 p.m., RN-B was
residents had been exit seeking. RN-B said those interventions could be added to the care plans. On
for each resident with exit seeking behaviors but was unsure where those interventions were documented.
The facility policy, Resident MDS and Care Planning, last modified on 1/13/21 directs that all residents will have a comprehensive assessment completed upon admission, annually and with a significant change.
Risk factors and assessment to be competed by a nurse on an admission, quarterly and PRN and includes elopement.
245573 10/23/2025
Clara City Care Center 1012 North Division Street Clara City, MN 56222
During an interview on 10/21/25 at 2:08 p.m., social worker (SW) stated R1 was able
duct work in between the two exit doors.
Outside, R1 told the social worker he recognized the curb that he went down in his wheelchair.
During an interview on 10/22/25 at 8:22 a.m., maintenance manager (MM) indicated R1 exited through two unsecured unlocked doors that were supposed to be locked.
The Wander Guard system on the last door was not functioning properly. It was a known issue that the Wander Guard on that door does not beep, it was discussed at department head meetings several times. MM indicated there previously was not a system in place to ensure the exit doors were always locked.
After the incident MM inspected all the doors and only found that the doors were unlocked not that there were mechanical issues.
During an interview on 10/22/25 at 9:19 a.m., DON reviewed R1's record, she explained there was no interventions put into place after R1 demonstrated exit seeking behaviors on 10/2/25.
The evening of 10/13/25, after RN-A became aware of the exit seeking behavior there was a lack of communication between staff and no immediate interventions were implemented to prevent/mitigate R1's risk for elopement.
After R1 eloped on 10/13/25, immediate interventions of two-hour checks were implemented, but no other individualized interventions were implemented that addressed R1's exit seeking behavior. DON stated prior to the elopement there was not a system in place to assure all the doors in the facility were secured.
After the elopement and prior to survey entrance on 10/21/25, every-two hour safety checks were changed to every one hour, a bed alarm as placed on R1's bed, and a system to check the doors only during the evening was implemented.
Additionally, staff had received education on elopement procedures and checking locked doors however, indicated staff were not educated on developing interventions, revision of the care plan, and implementing interventions that addressed exit seeking behaviors was not addressed.ˆˆ
During an interview at 10/22/25 at 12:30 p.m., trained medication aide (TMA)-A stated he had received training on the elopement procedure but exit seeking interventions was not addressed. He stated care plans should include elopement risks and interventions.
During an interview at 10/22/25 at 1:30 p.m., NA-B stated she had education on the elopement procedure but there was no mention of interventions for exit seeking behavior.ˆ The facility policy Missing Resident/Elopement Policy and Procedure last revised 10/14/25 directed that after an elopement, the charge nurse will update the resident's assessment and care plan as needed.
The charge nurse will orient staff to any new interventions or procedures to reduce the risk of future problems for this or other residents.ˆ The IJ was removed on 10/23/25 at 4:15 p.m., when it was verified the facility implemented the following corrective actions: *The facility provided education with knowledge checks to all nursing staff on revising care plans for individualized, immediate interventions for exit seeking behaviors. *The facility provided education with knowledge checks to all staff on identifying exit seeking behaviors, implementing appropriate interventions for redirection and increased supervision.
When to notify and communicate with other staff about elopement risk concerns.
When to ask passerby citizens about an elopement, such as where the resident was found, what the resident was doing and what their mental status was. *Identified staff who have a key to the locked door. *Developed a door lock check system that assures the two doors involved with the elopement are locked.
The doors are checked at least once per shift by nursing staff and documented in a sign off sheet. *Reviewed the elopement policy and procedure.
Educated staff on the elopement policy and procedure.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.