Inspection Reports for Camelot Village
1105 S 3rd St, Council Bluffs, IA 51503, IA, 51503
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 18, 2025 found the facility to be in substantial compliance with no deficiencies cited. Earlier inspections showed a pattern of deficiencies mainly related to resident care, infection control, and care planning, with several complaint investigations substantiating issues such as inadequate repositioning, improper use of equipment, and infection prevention lapses. Notable events included substantiated complaints involving resident abuse and medication diversion, as well as failures in timely assessments and staff background checks. Enforcement actions such as staff suspension were reported, but fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement, with the latest surveys showing compliance following prior citations.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a October 2025 inspection.
Census over time
| 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 |
| 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 |
| 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 |
| 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. | — |
| 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. |
| 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 |
| 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. |
| 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 |
| 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. |
| 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 |
| 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 |
| Description | Severity |
|---|---|
| Failure to provide care and treatment by competent staff, including diversion of controlled medications by Staff B affecting 5 residents. | E |
| 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 |
| 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. |
| 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 |
| 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 |
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