Inspection Reports for Camelot Village
1105 S 3rd St, Council Bluffs, IA 51503, IA, 51503
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Inspection Report
Plan of Correction
Deficiencies: 0
Dec 18, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Ramsey Village, certifying the facility in compliance based on acceptance of a credible allegation of substantial compliance and plan of correction.
Findings
The facility was found to be in substantial compliance, and the plan of correction was accepted, resulting in certification of compliance effective December 18, 2025. No specific deficiencies are detailed in the report.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 1, 2025
Visit Reason
A complaint investigation was conducted for Complaints #2651736-C, #2667858, and #2674970-C from November 24, 2025 to December 1, 2025.
Findings
The facility was found to be in compliance with no deficiencies cited during the complaint investigation.
Complaint Details
Complaint investigation for Complaints #2651736-C, #2667858, and #2674970-C was conducted and the facility was found to be in compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 12, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a survey ending on August 28, 2025, with certification compliance effective September 27, 2025.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and the submitted Plan of Correction for the prior survey.
Report Facts
Survey end date: Aug 28, 2025
Certification effective date: Sep 27, 2025
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Oct 23, 2025
Visit Reason
Investigation of complaints #2643383-C conducted from October 22 to October 23, 2025, regarding care deficiencies and infection control issues at Ramsey Village.
Findings
The facility failed to provide adequate repositioning and incontinence care for Resident #6, failed to ensure proper use of mechanical lifts and wheelchair safety for multiple residents, and failed to maintain infection control practices including sanitizing equipment and proper hand hygiene during perineal care. Staff also failed to remove PPE before exiting a resident room on Enhanced Barrier Precautions.
Complaint Details
The visit was triggered by complaints #2643383-C. Deficiencies cited were related to failure in care provision, safety during transfers, and infection control practices. The complaints were substantiated as evidenced by the findings.
Severity Breakdown
SS = D: 2
SS = E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide repositioning and incontinence care for Resident #6 as required by care plan. | SS = D |
| Failure to ensure mechanical lifts were used correctly, wheelchairs were locked during transfers, and foot pedals were attached during transport for multiple residents. | SS = E |
| Failure to establish and maintain an infection prevention and control program including disinfecting mechanical lifts between uses, performing hand hygiene during perineal care, and removing PPE before exiting rooms on Enhanced Barrier Precautions. | SS = D |
Report Facts
Resident census: 69
BIMS scores: 3
BIMS score: 4
BIMS score: 11
Deficiency count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Involved in transfer and repositioning deficiencies for Residents #1, #2, and #5 |
| Staff B | Certified Nurse Aide (CNA) | Involved in transfer deficiencies and mechanical lift use for Residents #1 and #2 |
| Staff C | Certified Nurse Aide (CNA) | Involved in transfer deficiencies and wheelchair safety for Resident #2 |
| Staff D | Hospice Certified Nurse Aide (CNA) | Transported Resident #3 in wheelchair without foot pedals |
| Staff E | Certified Nurse Aide (CNA) | Involved in mechanical lift use and transfer for Resident #5 and infection control deficiencies |
| Staff F | Certified Nurse Aide (CNA) | Involved in mechanical lift use and transfer for Resident #4 and infection control deficiencies |
| Staff G | Certified Nurse Aide (CNA) | Involved in mechanical lift use and infection control deficiencies during perineal care for Resident #4 |
| Staff H | Certified Nurse Aide (CNA) | Observed leaving resident room with PPE gown on, violating infection control policy |
| Director of Nursing | Director of Nursing (DON) | Provided statements on proper use of lifts, wheelchair safety, infection control, and PPE removal |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 8
Aug 28, 2025
Visit Reason
The inspection was an annual recertification survey conducted from August 25, 2025 to August 28, 2025 to assess compliance with federal regulations for Ramsey Village.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant changes in residents' conditions, inadequate care plans for residents receiving psychotropic medications, failure to ensure safe and accurate delivery of oxygen therapy, insufficient nursing staff to safely feed residents, and inadequate infection prevention and control practices.
Severity Breakdown
Level D: 7
Level E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to notify the physician of blood sugar levels outside ordered parameters for Resident #22. | Level D |
| Failure to ensure residents receiving psychotropic medications had targeted behaviors listed on physician orders and care plans. | Level D |
| Failure to develop and implement comprehensive person-centered care plans for residents. | Level D |
| Failure to develop care plans that are up-to-date and accurate for residents. | Level D |
| Failure to ensure safe and accurate delivery of oxygen therapy for residents requiring respiratory care. | Level D |
| Failure to have sufficient nursing staff to provide safe feeding assistance to residents requiring help during meals. | Level D |
| Failure to ensure residents are free from significant medication errors, including proper priming of insulin pens. | Level D |
| Failure to establish and maintain an infection prevention and control program that includes proper hand hygiene and sanitizing of equipment. | Level E |
Report Facts
Census: 62
Dates of survey: 4
Number of residents reviewed: 17
Number of residents with psychotropic medication issues: 2
Number of residents reviewed for respiratory care: 3
Number of residents reviewed for medication errors: 62
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 3, 2025
Visit Reason
A revisit of the survey ending April 24, 2025 was conducted from May 21, 2025 to June 3, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective May 5, 2025.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Apr 21, 2025
Visit Reason
The inspection was conducted as a result of investigations into Complaints #127337-C, #128044-C, and Facility Reported Incident #127261-I from April 21, 2025 to April 24, 2025.
Findings
The facility was found to have substantiated complaints related to quality of care, including failure to provide timely assessments and interventions for a resident's wound, and failure to complete background checks on staff. The facility reported a census of 61 residents during the investigation.
Complaint Details
Complaints #127337-C and #128044-C and Facility Reported Incident #127261-I were substantiated based on investigation findings.
Severity Breakdown
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to appropriately provide assessments and interventions for necessary care and services for Resident #1, including delayed notification and intervention for a wound on the left foot. | SS=G |
| Failure to run a complete background check on 1 of 3 staff reviewed, specifically Staff A, a Certified Nurse Aide. | — |
Report Facts
Resident census: 61
Staff members reviewed for background checks: 3
Staff members without complete background check: 1
Staff members in facility records: 125
Staff hired during week of Staff A: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | MDS Coordinator | Completed assessment of Resident #1 and documented no skin issues on admission. |
| Staff E | Assistant Director of Nursing (ADON) | Notified staff of Resident #1's wound and responsible for wound assessments and notifications. |
| Staff F | Medical Director (MD) | Conducted in-house visit for Resident #1 and ordered chest x-ray. |
| Staff G | Doctor of Nursing Practice (DNP) | Wound nurse who assessed Resident #1's wound and ordered treatments. |
| Staff A | Certified Nurse Aide (CNA) | Failed to have a complete background check prior to employment. |
| Executive Director | Notified facility of incomplete background check on Staff A and provided explanations. | |
| Human Resources Director (HRD) | Provided information about staff hiring and onboarding during the week Staff A was hired. | |
| Director of Nursing (DON) | Stated expectations for nursing staff assessments and interventions. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 14, 2025
Visit Reason
A complaint investigation for Complaints #124039-C, #124146-C, and #125234-C was conducted from January 13, 2025 to January 14, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for Complaints #124039-C, #124146-C, and #125234-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 6, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective November 3, 2024.
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 6
Oct 3, 2024
Visit Reason
The inspection was an annual recertification survey conducted from September 30, 2024 to October 3, 2024 to assess compliance with federal regulations.
Findings
The facility failed to complete and transmit Minimum Data Set (MDS) assessments timely for some residents, failed to develop and implement comprehensive person-centered care plans, and did not meet infection prevention and control requirements including Enhanced Barrier Precautions. Deficiencies were noted in medication administration, care planning, skin and wound care, and infection control policies and procedures.
Severity Breakdown
SS=B: 1
SS=D: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to complete and transmit resident MDS assessments timely, including discharge assessments. | SS=B |
| Failure to accurately complete MDS assessments reflecting resident status. | SS=D |
| Failure to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes. | SS=D |
| Failure to provide services meeting professional standards of quality. | SS=D |
| Failure to provide timely assessment and intervention for skin conditions and wounds. | SS=D |
| Failure to establish and maintain an infection prevention and control program including Enhanced Barrier Precautions. | SS=D |
Report Facts
Census: 62
Residents reviewed for MDS assessments: 16
Residents reviewed for care plans: 16
Residents reviewed for infection control: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | MDS Coordinator | Reported on MDS assessment completion, submission, and care plan updates; interviewed residents and family; involved in medication administration observations. |
| Staff A | Licensed Practical Nurse | Observed preparing and administering medications and enteral feedings through gastrostomy tube; did not wear gown during procedure. |
| Staff B | Licensed Practical Nurse | Observed accessing and flushing PICC line and port; administered IV antibiotics; did not wear gown during procedure. |
| Staff D | Registered Nurse, Unit Manager | Interviewed regarding skin condition and wound documentation and care. |
| Director of Nursing | Director of Nursing | Reported on MDS audits, care plan monitoring, infection control policies, and expectations for Enhanced Barrier Precautions. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 7, 2024
Visit Reason
The document serves as a plan of correction following a survey, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility will be certified in compliance effective September 7, 2024, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 4
Aug 5, 2024
Visit Reason
The inspection was conducted from August 5th to August 7th, 2024, following investigations of Complaints #118135-C, #119057-C, #119963-C, and a Facility Reported Incident #122578-I. The visit was complaint-driven to investigate allegations of resident abuse and medication administration issues.
Findings
The facility failed to treat a resident with respect and dignity, substantiating Complaint #119963-C. The facility also failed to notify the physician when medication was unavailable and failed to report suspected abuse within required timeframes. Deficiencies were found related to resident rights, abuse reporting, and medication administration.
Complaint Details
Complaint #119963-C was substantiated. The investigation revealed verbal and possible physical abuse by Staff B, Certified Medication Aide, towards Resident #7. Staff A, Certified Nurse Aide, reported the incident. Staff B was suspended immediately. The facility failed to report suspected abuse within the required two-hour timeframe for Resident #9.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to treat a resident with respect and dignity during care. | Level D |
| Failure to notify physician when medication was unavailable and not administered for one resident. | Level D |
| Failure to report suspected dependent adult abuse within the required two-hour timeframe for one resident. | Level D |
| Failure to transcribe and administer medication as ordered by the physician for one resident. | Level D |
Report Facts
Census: 61
Dates of inspection: Inspection conducted from August 5th to August 7th, 2024.
Number of residents reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Reported abuse allegations and concerns regarding Staff B and Resident #7. |
| Staff B | Certified Medication Aide (CMA) | Alleged to have been verbally aggressive and attempted to place a glove in Resident #7's mouth. |
| Staff C | Licensed Practical Nurse (LPN) | Received abuse report from Staff A and reported it to management. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication administration and physician notification policies. |
| Executive Director | Executive Director | Signed the report and responsible for facility oversight. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 18, 2024
Visit Reason
A complaint investigation was conducted for complaints 116209-C, 116864-C, and 118019-C from January 10, 2024 to January 18, 2024.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints 116209-C, 116864-C, and 118019-C; facility found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 11, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective August 11, 2023.
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 8
Jul 20, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and Facility Reported Incident #114228-I was substantiated.
Findings
The facility failed to notify the Long Term Care Ombudsman of a resident transfer, failed to ensure accurate Minimum Data Set (MDS) assessments, failed to submit required Level 2 PASRR evaluations for residents with new mental health diagnoses, failed to update comprehensive care plans, failed to administer insulin according to accepted standards, failed to provide sufficient fluid intake to a resident, failed to answer call lights timely for multiple residents, and failed to maintain accurate and complete records for controlled medications.
Severity Breakdown
SS=D: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to notify the Long Term Care Ombudsman for 1 of 1 residents who transferred to the hospital (Resident #56). | — |
| Failed to ensure each resident received an accurate Minimum Data Set (MDS) assessment reflective of the resident's status (Resident #16). | SS=D |
| Failed to submit a Level 2 PASRR evaluation for 2 of 2 residents with new mental health diagnoses (Residents #16 and #42). | SS=D |
| Failed to update the Comprehensive Care Plan for 1 of 17 residents reviewed (Resident #16). | SS=D |
| Failed to administer insulin according to accepted standards of clinical practice for 1 of 2 residents reviewed (Resident #37). | SS=D |
| Failed to provide sufficient fluid intake to 1 resident (Resident #8). | SS=D |
| Failed to answer call lights timely (within 15 minutes) for 3 of 5 residents reviewed (Residents #2, #31, and #68). | SS=D |
| Failed to maintain accurate and complete records for controlled medications for 2 of 2 residents reviewed (Residents #8 and #57). | SS=D |
Report Facts
Census: 67
Call light response times: 26
Call light response times: 7
Morphine Sulfate Solution: 29.75
Morphine Sulfate Solution: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed failure to notify Ombudsman of resident transfer; provided morphine bottles and controlled drug sheets during narcotic count investigation |
| Staff B | Registered Nurse | Noted discrepancies in narcotic medication blister packs and counts during shift on 7/9/23 |
| Staff C | Registered Nurse | Counted narcotics and signed narcotic count sheet; involved in narcotic count discrepancy investigation |
| Staff F | Certified Nurse Aide | Reported staffing shortages and inability to always answer call lights within 15 minutes |
| Staff G | Certified Nurse Aide | Reported usually having 5-6 CNAs on day shift and call lights answered within 15 minutes |
| Pharmacist | Pharmacist | Verified pharmacy records and shipment of morphine sulfate bottles; noted no facility request for duplicate shipments |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated expectation that all residents should have water available in their rooms at all times |
| Assistant Administrator | Assistant Administrator | Stated expectation for call lights to be answered as soon as possible |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Apr 27, 2023
Visit Reason
The inspection was conducted as a result of investigations into complaints #106506-C, #111876-C, and a facility reported incident #112122-I from April 18, 2023 to April 27, 2023.
Findings
The facility failed to ensure resident care and treatment was provided by competent staff in accordance with professional standards. Staff B, a registered nurse, was found to have diverted controlled medications from several residents and ingested them, leading to a substantiated incident.
Complaint Details
The investigation substantiated the facility reported incident #112122-I and complaints #106506-C and #111876-C regarding Staff B's diversion of controlled medications and impaired performance.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care and treatment by competent staff, including diversion of controlled medications by Staff B affecting 5 residents. | E |
Report Facts
Residents affected: 5
Medication ingestion amount: 8
Facility reported census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Named in medication diversion and ingestion incident |
| Staff A | Registered Nurse | Witness and reporter of Staff B's behavior and incident |
| Staff C | Certified Nurse Aide | Witness to Staff B's behavior |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 15, 2022
Visit Reason
The document serves as a plan of correction following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility was certified in compliance effective July 15, 2022, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 8
Jun 15, 2022
Visit Reason
The inspection was conducted as an annual recertification survey combined with an investigation of multiple complaints and reported incidents from June 7 to June 15, 2022.
Findings
The facility was found to have multiple deficiencies including failure to address resident fears and preferences, inadequate notice before transfer or discharge, insufficient nursing staff to meet resident needs, and lack of proper care planning and implementation for residents with cognitive impairments and pressure ulcers. Several complaints and incidents were substantiated.
Complaint Details
Complaints 96753-C, 96826-C, 97838-C, 97852-C, 99328-C, 99489-C, 101178-C, and 103678-C were substantiated. Facility reported incidents 96948-I and 100445-I were substantiated.
Deficiencies (8)
| Description |
|---|
| Failure to address fears and preferences of Resident #18 regarding male caregivers at night and lack of specific staff directives. |
| Failure to provide proper notice before transfer or discharge for 3 of 3 residents sampled. |
| Failure to coordinate PASARR assessments and submit required preadmission screening and resident reviews. |
| Failure to develop and implement comprehensive care plans consistent with resident needs and rights. |
| Failure to prevent pressure ulcers and provide consistent treatment and interventions. |
| Failure to provide adequate supervision and assistance to prevent accidents and hazards. |
| Failure to assess and provide proper care for residents with feeding tubes. |
| Failure to maintain sufficient nursing staff to meet resident care needs and respond to call lights in a timely manner. |
Report Facts
Residents reviewed: 20
Residents sampled: 3
Residents census: 71
Call light response time: 15
Residents with pressure ulcers reviewed: 2
Residents with feeding tubes sampled: 1
Residents requiring assistance with call lights: 3
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 9
Feb 23, 2021
Visit Reason
A recertification survey and investigation of Complaint #93990-C was conducted from 2/9/21 to 2/23/21, triggered by allegations including abuse, neglect, and injuries of unknown origin.
Findings
The facility was found deficient in multiple areas including failure to ensure a cognitively intact resident signed an Advance Beneficiary Notice, failure to report an injury of unknown source within 24 hours, failure to prevent pressure ulcers, failure to address significant weight loss, failure to monitor and obtain consent for bed rails, failure to employ qualified dietary staff, failure to label and date food items properly, failure to hold quarterly QAPI meetings, and failure to maintain infection prevention and control practices.
Complaint Details
Complaint #93990-C was substantiated. The complaint involved allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown origin. The facility failed to report an injury of unknown source within 24 hours and failed to investigate and report appropriately.
Severity Breakdown
SS=D: 7
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure a cognitively intact resident signed his Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage. | — |
| Failed to report an injury of unknown source within 24 hours to the State Survey Agency. | SS=D |
| Failed to ensure a resident received care consistent with professional standards to prevent pressure ulcers. | SS=D |
| Failed to adequately address significant weight loss in a resident. | SS=D |
| Failed to assure ongoing monitoring and assessment of bed rails and failed to obtain informed consent. | SS=D |
| Failed to ensure the Dietary Service Manager had required qualifications in absence of a full-time dietitian. | SS=D |
| Failed to label and date food items stored in the main kitchen walk-in refrigerator and freezer. | SS=D |
| Failed to maintain a Quality Assessment and Assurance committee that met at least quarterly. | SS=D |
| Failed to implement infection control per standards of practice including failure to place a barrier between surface and supplies during blood glucose testing and failure to document oxygen tubing changes. | SS=D |
Report Facts
Resident census: 47
Weight loss: 6.8
Pressure ulcer size: 3
Medication dosage: 500
Oxygen liters: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Performed blood glucose check without placing barrier between supplies and surface |
| Staff B | Licensed Practical Nurse | Documented open blister area on Resident #17's foot |
| Staff C | Registered Nurse | Received nursing order for nutritional supplement for Resident #198 |
| Director of Nursing | Interviewed regarding multiple deficiencies including injury reporting, infection control, pressure ulcer care, oxygen tubing, and QAPI meetings | |
| Administrator | Interviewed regarding complaint investigation, QAPI meetings, and dietary manager certification | |
| Dietary Manager | Reported completion of dietary management course but not certified; responsible for food labeling and dating |
Inspection Report
Routine
Census: 40
Deficiencies: 0
Aug 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 08/17/2020 to 08/19/2020 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 32
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 18, 2020
Visit Reason
The inspection was conducted to investigate complaints #85545 and #88151 at the facility.
Findings
Both complaints #85545-C and #88151-C were investigated and found to be not substantiated, resulting in no deficiencies.
Complaint Details
Complaints #85545 and #88151 were investigated ending on 2/18/2020 and resulted in no deficiencies. Complaint #85545-C was not substantiated. Complaint #88151-C was not substantiated.
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