Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clara City Care Center during CMS and state inspections, most recent first.
Improper Storage and Dating of Refrigerated Foods: Surveyors observed refrigerated food items in the kitchen that were opened, undated, or past expiration, including cake, salami, ranch dressing, and thousand island dressing. The DM confirmed opened items should be dated and most should be discarded after 7 days, and condiments should be discarded after expiration per facility policy.
A resident with cognitive impairment and a history of falls suffered a hip fracture after being left unsupervised and without an active chair alarm, which staff had failed to reactivate following a transfer. Staff relied primarily on alarms for fall prevention and did not implement individualized supervision interventions, despite the resident's significant risk factors and need for assistance with mobility and toileting.
A resident with dementia and a history of exit-seeking behaviors was able to leave the facility through two unsecured doors after staff failed to revise the care plan or increase supervision, despite prior incidents and a known malfunctioning Wander Guard alarm. Staff did not communicate the resident's intentions or implement individualized interventions, and there was no system in place to ensure exit doors were locked.
Two residents at risk for elopement did not have comprehensive, individualized care plans addressing their exit-seeking behaviors. One resident with dementia and cognitive impairment repeatedly attempted to leave, but the care plan only included a Wander Guard and was not updated after incidents. Another resident with cognitive deficits had a care plan focused on fall risk, lacking specific elopement interventions. Staff performed some interventions but did not document them in care plans, contrary to facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
The facility failed to maintain safe water temperatures in resident rooms, with temperatures ranging from 126 to 130 degrees Fahrenheit, exceeding the guideline of 105 to 115 degrees. Residents reported excessively hot water, and a registered nurse confirmed the risk of burns. The maintenance director acknowledged the issue, linking it to a new hot water heater.
The facility failed to implement proper PPE practices for two residents under enhanced barrier precautions, as staff did not wear gowns during high-contact care activities. Additionally, a nursing assistant did not follow hand hygiene protocols after providing perineal care to a resident. These deficiencies were confirmed through observations and staff interviews, revealing a lack of awareness and adherence to infection control protocols.
A resident with severe cognitive impairment was not treated with dignity and respect when a nursing assistant forcibly tried to take a cup of Miralax from the resident, leading to a struggle and visible distress. The incident was reported by a trained medication aide and confirmed by multiple staff members.
Improper Storage and Dating of Refrigerated Foods
Penalty
Summary
The facility failed to ensure refrigerated food items were properly labeled, dated, and closed after packaging was opened, and failed to ensure refrigerated food items were disposed of after the expiration date or after being opened per facility policy. During an initial tour of the main kitchen with the dietary manager, surveyors observed in the upright refrigerator a small disposable covered container of cake dated 3/5/26 and a plastic half bag of salami slices that was opened and undated. In the walk-in refrigerator, surveyors observed an opened gallon plastic container of ranch dressing that was undated and had an expiration date of 9/25/25, as well as an opened container of thousand island dressing that was undated and had an expiration date of 3/21/26. During a follow-up interview, the dietary manager stated most opened items should be disposed of after seven days, confirmed condiments should be discarded after expiration, and stated foods should be dated when opened so staff would know how old the item was and dispose of it per facility policy.
Failure to Provide Adequate Supervision for Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents for a resident with a known history of falls and cognitive impairment. The resident had multiple risk factors, including dementia, unsteady gait, a recent fracture, and required significant assistance with mobility and toileting. Despite these risks, the primary intervention implemented was the use of chair and bed alarms, which were intended to alert staff when the resident attempted to stand. However, the care plan did not specify any staff supervision interventions tailored to the resident's needs, and staff interviews confirmed that supervision was not consistently provided beyond reliance on alarms. On the day of the incident, the resident was found on the bathroom floor after a fall, which resulted in a left hip fracture. Investigation revealed that the chair alarm, which was supposed to alert staff if the resident attempted to stand, had been turned off by staff during a previous transfer and was not reactivated. Staff relied heavily on alarms as the main intervention for fall prevention and did not provide direct supervision or ensure the alarm was always active. The resident was left unsupervised, and staff only discovered the fall when passing by the room for unrelated reasons. Interviews with various staff members, including medication assistants, nursing assistants, and the DON, indicated a lack of understanding regarding the need for supervision beyond the use of alarms. Staff described the process of responding to alarms but did not mention any protocols for direct supervision or individualized monitoring based on the resident's assessed needs. The facility's fall prevention policy emphasized a team approach and individualized care planning, but in practice, interventions were limited to alarm use without adequate supervision, contributing to the resident's fall and injury.
Failure to Secure Exit Doors and Implement Individualized Elopement Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure that exit doors were secured and did not implement individualized interventions to prevent or reduce the risk of elopement for a resident with a known history of exit-seeking behaviors. The resident, who had diagnoses of dementia, depression, and anxiety, was assessed as being at risk for elopement due to cognitive impairment and independence in wheelchair locomotion. Despite documented exit-seeking behaviors, the resident's care plan only included a Wander Guard device as an intervention, and there was no evidence that the care plan was reviewed or revised after the resident demonstrated further exit-seeking behavior. On the evening of the incident, the resident expressed intentions to leave the facility to both a nursing assistant and a registered nurse. The staff did not increase supervision, communicate the resident's exit-seeking behavior to other staff, or revise the care plan to address the immediate risk. The resident was able to exit the facility through two unsecured doors, one of which had a known malfunctioning Wander Guard alarm that did not activate. The resident left the building unwitnessed and was later found and returned by a passerby. Interviews and document reviews revealed that staff were aware of the resident's risk but did not implement additional or individualized interventions after prior incidents of exit-seeking. There was also a lack of a system to ensure that all exit doors were secured, and staff were not educated on developing or revising care plans to address exit-seeking behaviors. The facility's policy required updating assessments and care plans after an elopement, but this was not followed prior to the incident.
Removal Plan
- Provide education with knowledge checks to all nursing staff on revising care plans for individualized, immediate interventions for exit seeking behaviors.
- Provide education with knowledge checks to all staff on identifying exit seeking behaviors, implementing appropriate interventions for redirection and increased supervision.
- Provide education on when to notify and communicate with other staff about elopement risk concerns.
- Provide education on 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.
- Identify staff who have a key to the locked door.
- Develop a door lock check system that assures the two doors involved with the elopement are locked.
- Check the doors by nursing staff and document in a sign off sheet.
- Review the elopement policy and procedure.
- Educate staff on the elopement policy and procedure.
Failure to Develop and Implement Comprehensive Elopement Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents identified as being at risk for elopement. One resident with dementia, depression, and anxiety was assessed as at risk for elopement due to cognitive impairment and independent wheelchair use, and had demonstrated exit-seeking behaviors, including attempting to leave the facility and making statements about going home. Despite these behaviors, the resident's care plan only included a Wander Guard device and did not provide individualized interventions or address the resident's specific exit-seeking actions. The care plan was not reviewed or revised after the resident exhibited further exit-seeking behavior, and staff did not increase supervision or implement additional interventions when the resident attempted to leave with belongings. Another resident with hemiplegia, cognitive deficits, and anxiety was also identified as at risk for elopement, but their care plan only addressed fall risk and included a Wander Guard on the wheelchair handle, without a focus area or individualized interventions for elopement or exit-seeking behavior. Staff interviews revealed that interventions for exit-seeking behaviors were being performed but not documented in the care plans, and there was confusion among staff about where such interventions should be recorded. The facility's policy required comprehensive assessments and care plans for residents at risk of elopement, but these were not fully implemented for the residents reviewed.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Excessive Hot Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically concerning hot water temperatures in resident rooms. During an inspection, it was observed that the water temperatures in six resident rooms were excessively high, ranging from 126 to 130 degrees Fahrenheit, which is above the facility's policy and state and federal guidelines of 105 to 115 degrees Fahrenheit. The maintenance director confirmed these temperatures using a digital thermometer and acknowledged that the newly installed hot water heater might have contributed to the elevated temperatures. Interviews with residents revealed that they experienced excessively hot water, with one resident expressing concern about potential burns. A registered nurse confirmed that all six residents were at risk for burns due to the high water temperatures. The facility's Water Management Plan for Legionella, updated in October 2024, mandates adherence to anti-scalding guidelines, which were not followed in this instance. The maintenance director and the administrator both acknowledged the deviation from expected water temperature standards, which posed a risk to resident safety.
Failure in PPE Use and Hand Hygiene in Infection Control
Penalty
Summary
The facility failed to implement proper donning and doffing of personal protective equipment (PPE) practices for two residents, R32 and R16, who were observed under enhanced barrier precautions (EBP) to prevent the transmission of multidrug-resistant organisms. Observations revealed that staff members, including a hospice aide and nursing assistants, did not wear gowns while providing high-contact care activities such as dressing, transferring, and providing hygiene to these residents, despite the presence of signs indicating the requirement for gown and glove use. Interviews with staff members indicated a lack of awareness regarding the necessity of wearing gowns during these activities, as they believed gowns were only required during direct wound care. Resident R32, who had moderate cognitive impairment and a significant change in condition, required extensive assistance with activities of daily living and had an unstageable pressure ulcer. Despite the care plan indicating the need for EBP due to the risk of developing a multidrug-resistant organism infection, staff members were observed not wearing gowns during personal care activities. Similarly, Resident R16, with severe cognitive impairment and open draining wounds, required substantial assistance with daily activities. The care plan for R16 also lacked specific EBP interventions for high-contact care activities, leading to staff not wearing gowns during these interactions. Additionally, the facility failed to ensure proper hand hygiene practices during personal care for Resident R30. A nursing assistant was observed not removing gloves after providing perineal care and proceeded to touch non-contaminated items in the room, such as a toothbrush and hairbrush. This action was confirmed by the nursing assistant during an interview, acknowledging the failure to remove gloves and perform hand hygiene as per the facility's policy. The infection preventionist and director of nursing confirmed the expectations for PPE use and hand hygiene, highlighting the deficiencies in adherence to infection control protocols.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect. The incident involved a trained medication aide (TMA-C) administering morning medications to a resident (R1) when a nursing assistant (NA-L) intervened. NA-L lunged towards R1 from behind and attempted to take a cup of Miralax from R1, despite R1's refusal. This led to a struggle between R1 and NA-L, during which R1 screamed and was visibly upset. TMA-C intervened to stop the struggle and calm R1. The incident was reported to the director of nursing (DON) and other staff members, who all agreed that NA-L did not treat R1 with respect and dignity. R1's medical history included severe cognitive impairment, altered mental status, aphasia, stroke, and constipation. R1 was dependent on staff for mobility and daily activities and had a care plan that emphasized avoiding overstimulation and power struggles. Despite these care plan interventions, NA-L's actions directly contradicted the prescribed approach for managing R1's behavior and communication needs. The facility's policy on resident respect and dignity was not adhered to in this instance, as confirmed by multiple staff interviews.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clara City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avera Granite Falls Care Center | 12.8 mi | ★★★★★ | 5 | 0 |
| Parkview Home | 13.3 mi | ★★★★★ | 8 | 0 |
| Renville Health Services | 14.6 mi | ★★★★★ | 6 | 0 |
| Luther Haven | 16.7 mi | ★★★★★ | 2 | 0 |
| Cura Of Willmar | 18 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.