The most recent inspection on September 16, 2025, found no deficiencies during the recertification visit. Earlier inspections showed a mixed pattern, with some citations related primarily to staff training, tenant evaluations, and updating service plans, especially in inspections from 2023 and 2019. Complaint investigations were mostly unsubstantiated, though some prior investigations identified issues with staffing, service plans, medication administration, and documentation. Enforcement actions included a $500 civil penalty in 2011 related to medication and staffing deficiencies, but no fines or license actions were noted in recent reports. The overall trend suggests improvement, with the most recent inspections showing no deficiencies after earlier issues were addressed.
Deficiencies (last 15 years)
Deficiencies (over 15 years)1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
86420
2004
2006
2008
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2023
2025
Census
Latest occupancy rate5 residents
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Findings
The program failed to meet multiple regulatory requirements including timely nurse delegation training, dependent adult abuse training, tenant evaluations prior to and within 30 days of occupancy, updating service plans based on evaluations, conducting nurse reviews at least every 90 days, and providing dementia-specific education within 30 days of employment.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #110171-C.
Deficiencies (7)
Description
Failed to provide nurse delegation training to staff within 30 days of hire to ensure staff competency.
Failed to provide two hours of dependent adult abuse training within six months of employment for staff.
Failed to evaluate tenants' functional, cognitive, and health status prior to admission for 2 tenants.
Failed to evaluate tenants' functional, cognitive, and health status within 30 days of occupancy for 2 tenants.
Failed to update service plans based on required evaluations for 2 tenants.
Failed to assess and document health status of tenants receiving personal or health-related care at least every 90 days.
Failed to provide eight hours of dementia-specific education and training within 30 days of employment for 7 caregiver staff.
Report Facts
Number of tenants without cognitive impairment: 2Number of tenants with cognitive impairment: 6Total census: 8Number of caregiver staff reviewed for nurse delegation training: 3Number of staff reviewed for dependent adult abuse training: 5Number of tenants reviewed for evaluations and service plans: 2Number of tenants reviewed for nurse review: 2Number of caregiver staff reviewed for dementia training: 7
Employees Mentioned
Name
Title
Context
Staff A
Failed dependent adult abuse training, dementia training, and nurse delegation training
Staff B
Failed nurse delegation training and dementia training
Staff C
Failed dependent adult abuse training and dementia training
Staff D
Failed nurse delegation training, dependent adult abuse training, and dementia training
Staff E
Failed dependent adult abuse training and dementia training (partial 3.5 hours completed)
The inspection was a recertification visit to determine compliance with licensing rules for an Assisted Living Program serving individuals with dementia.
Findings
The program failed to ensure staff competency within 30 days of employment, failed to complete background checks prior to hire for one employee, and failed to provide dementia-specific education within 30 days of hire for two staff members.
Deficiencies (3)
Description
Staffing: Program failed to ensure staff were competent to meet tenant needs within 30 days of employment for 3 of 8 staff reviewed.
Record Checks: Program failed to complete a background check prior to hire for 1 of 1 employees reviewed.
Dementia Specific Education: Program failed to ensure 2 of 8 staff received dementia-specific education within 30 days of employment.
Report Facts
Number of tenants with cognitive disorder: 7Staff reviewed for competency: 8Staff not competent within 30 days: 3Employees reviewed for background check: 1Staff reviewed for dementia education: 8Staff not receiving dementia education within 30 days: 2
Investigation of Complaint 77020-C at Vriendschap Village AL, an assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint 77020-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in general population: 29Number of tenants with cognitive disorder in general population: 3Number of tenants without cognitive disorder in memory care unit: 0Number of tenants with cognitive disorder in memory care unit: 7
Recertification conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification inspection of the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 31Number of tenants with cognitive disorder: 6Total Population of Program at time of on-site: 37Number of tenants without cognitive disorder: 0Number of tenants with cognitive disorder: 7Total Population of Program at time of on-site: 7TOTAL census of Assisted Living Program: 44
Investigation of Incident #63956-I at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #63956-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 34Number of tenants with cognitive disorder in General Population Program: 1Total Population of General Population Program: 35Number of tenants without cognitive disorder in Dementia-Specific Program: 0Number of tenants with cognitive disorder in Dementia-Specific Program: 7Total Population of Dementia-Specific Program: 7TOTAL census of Assisted Living Program: 42
The inspection was conducted as a complaint/incident investigation regarding tenant rights at Vriendschap Village, following an incident involving a tenant fall and injury.
Findings
The investigation found regulatory insufficiency related to tenant rights, specifically that a tenant did not receive adequate care, treatment, and services as required. The tenant sustained injuries due to lack of proper assistance and use of a gait belt during transfers.
Complaint Details
Complaint investigation of Incident 58763-I regarding tenant rights. The tenant, a 95-year-old with multiple diagnoses, fell and sustained a compression fracture due to staff not using a gait belt as required by the service plan. Staff were unaware of the need to use the gait belt until after the incident. The tenant's service plan and task sheets lacked proper notation and direction for staff assistance.
Deficiencies (1)
Description
Tenant rights not met as the program did not ensure a tenant received services as directed by the service plan, resulting in injury.
Report Facts
Civil penalty amount: 2500Reduced civil penalty amount: 1625Census: 38Tenant age: 95Date of incident report: Feb 26, 2016Date of tenant admission: Feb 19, 2007
Employees Mentioned
Name
Title
Context
Rose Boccella
Program Coordinator
Contact person for questions regarding the report and penalty.
The inspection was conducted as a complaint/incident investigation following two complaint/incident intake numbers (#54414-I and #54603-I) related to tenant falls and regulatory insufficiencies in staffing and service plans at Vriendschap Village Assisted Living.
Findings
No regulatory insufficiencies were found related to the fall incident (#54414-I). However, regulatory insufficiencies were cited for staffing and service plans during the investigation of incident #54603-I, including insufficient staff training on the baby monitor door alarm system and failure to meet specific service needs of a tenant who eloped.
Complaint Details
The complaint investigation involved two incidents: #54414-I where a tenant fell and sustained a fracture but no regulatory insufficiencies were found, and #54603-I where regulatory insufficiencies were found related to staffing and service plans. Tenant #2, an 85-year-old with dementia, eloped twice, and staff were not properly trained on the baby monitor system. The service plan failed to address exit-seeking behavior. The complaint was substantiated with required plans of correction.
Deficiencies (3)
Description
Staffing: A sufficient number of trained staff were not available at all times to fully meet tenants' identified needs.
Staff were not sufficiently trained on the use of the baby monitor door alarm system.
Service plans did not meet the specific service needs of Tenant #2, including failure to identify exit-seeking behavior and interventions.
Report Facts
Census: 45Number of tenants without cognitive disorder: 29Number of tenants with cognitive disorder: 8Number of tenants without cognitive disorder: 1Number of tenants with cognitive disorder: 7Total Population of Program at time of on-site: 37Total Population of Program at time of on-site: 8
Employees Mentioned
Name
Title
Context
Rose Boccella
Program Coordinator, Adult Services Bureau
Author of the cover letter regarding the complaint investigation report
Inde Miller
Executive Director
Named in relation to interviews and plan of correction
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification requirements for an Assisted Living Program.
Findings
No regulatory insufficiencies or deficiencies were found during the evaluation. The recertification documents were accepted, and the Assisted Living Program Certificate was issued.
Report Facts
Number of tenants without cognitive disorder: 32Number of tenants with cognitive disorder: 16Total Population of Program at time of on-site: 40Total Population of Program at time of on-site: 8TOTAL census of Assisted Living Program: 48
Employees Mentioned
Name
Title
Context
Rose Boccella
Program Coordinator, Adult Services Bureau
Signed letter regarding the Final Recertification Monitoring Evaluation Report
The inspection was conducted as a complaint/incident investigation based on allegations regarding tenant alarms for fall prevention and staff documentation practices at Vriendschap Village.
Findings
No regulatory insufficiencies were identified during the investigation. The review included tenant files, staff interviews, and policy reviews, which did not reveal concerns regarding falsification of alarm check records or retaliation against staff.
Complaint Details
The complaint alleged that a tenant had alarms for fall prevention that were not checked as required and that staff were directed to falsify documentation. Another allegation was that administration threatened staff with termination if the Department was called. The investigation found no substantiated regulatory insufficiencies or retaliation.
Report Facts
Number of tenants without cognitive disorder: 26Number of tenants with cognitive disorder: 4Total Population of Program at time of on-site: 30Number of tenants without cognitive disorder: 0Number of tenants with cognitive disorder: 6Total Population of Program at time of on-site: 6TOTAL census of Assisted Living Program: 36
Employees Mentioned
Name
Title
Context
Inde Miller
Executive Director
Named as recipient of report and interviewed during investigation
Stephanie Cummins
MA
Monitor conducting the complaint/incident investigation
The inspection was conducted as a final complaint/incident investigation following a complaint regarding an alarm not sounding when Tenant #1 exited the dementia unit.
Findings
No regulatory insufficiencies were identified during the investigation. The report details the incident involving Tenant #1 exiting the dementia unit without the alarm sounding, the subsequent investigation, staff interviews, and corrective actions taken to ensure alarms function properly.
Complaint Details
The complaint alleged that the alarm did not sound when Tenant #1 exited the dementia unit. The investigation found that the back door alarm was unalarmed and not working initially, but was repaired after staff and maintenance intervention. Tenant #1 was monitored closely, no injuries or hypothermia were noted, and no regulatory insufficiencies were found.
Report Facts
General Population Program tenants without cognitive disorder: 32General Population Program tenants with cognitive disorder: 3Total Population of General Population Program: 35Dementia-Specific Program tenants without cognitive disorder: 0Dementia-Specific Program tenants with cognitive disorder: 5Total Population of Dementia-Specific Program: 5Total census of Assisted Living Program: 40Distance walked by Tenant #1: 200Temperature: 98Pulse: 90Respiration: 12Blood Pressure: 129/70Outside temperature at Pella Regional Airport: 5Wind speed: 10Wind chill: -10
Employees Mentioned
Name
Title
Context
Margaret Kaltefleiter
RN MS
Monitor conducting the complaint/incident investigation
The inspection was conducted as a complaint/incident investigation following reports that staff members gave a tenant medications not ordered for them, resulting in hospitalization.
Findings
The investigation found multiple medication errors involving four tenants over several months, including incorrect dosages and administration of another tenant's medications. Tenant #4 experienced recurrent nosebleeds and a medication error involving swallowing another tenant's medications, leading to hospitalization. No regulatory insufficiencies were identified.
Complaint Details
The complaint alleged that staff gave a tenant medications not ordered for them, causing hospitalization. The investigation substantiated multiple medication errors but found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 25Number of tenants with cognitive disorder: 4Total Population of General Population Program: 29Number of tenants without cognitive disorder: 0Number of tenants with cognitive disorder: 7Total Population of Dementia-Specific Program: 7Total census of Assisted Living Program: 36Medication omissions in September: 4Medication omissions in October: 4Medication omissions in November: 1
The inspection was conducted as a complaint/incident investigation following allegations related to tenant smoking near the memory care unit and missing personal items, as well as a staff response to a tenant experiencing pain.
Findings
The investigation found no regulatory insufficiencies related to tenant rights and theft. However, deficiencies were identified in nurse review, evaluation, service plans, and tenant documentation, including lack of documentation of nurse reviews, incomplete evaluations, missing service plan updates, and inadequate documentation of health-related care.
Complaint Details
The complaint alleged that a tenant was smoking cigarettes near the program and smoke was entering the memory care unit dining room, and that a tenant was missing personal items. Another allegation was that a staff member called the director for assistance when a tenant was in pain but the nurse did not return the call. The complaint was investigated and partially substantiated with findings related to nursing documentation and care.
Deficiencies (4)
Description
Lack of documentation of completion of a nurse review with changes noted by staff in Tenant #2's health status.
Lack of evidence of completion of functional and health evaluations within required timeframes for Tenant #4.
Failure to update service plans at least annually and when changes occur, as noted for Tenant #3.
Documentation for each tenant was incomplete, lacking required medical information and nurses' notes.
Report Facts
General Population Program tenants without cognitive disorder: 24General Population Program tenants with cognitive disorder: 4Total General Population Program tenants: 28Dementia-Specific Program tenants with cognitive disorder: 4Total Dementia-Specific Program tenants: 4Total census of Assisted Living Program: 32
Employees Mentioned
Name
Title
Context
Joyce Kix
RN
Monitor of the complaint/incident investigation
Brenda Colvin
Director
Director providing policy information and interview statements during investigation
The inspection was conducted as a complaint/incident investigation following a report of a tenant sounding suicidal at Vriendschap Village Assisted Living.
Findings
The investigation found no regulatory insufficiencies. The tenant was found with an open bottle of morphine pills, and the incident was handled appropriately with staff interviews and review of incident reports confirming no suicidal ideations prior to the event.
Complaint Details
The complaint involved a tenant who was found lying on the floor with an open bottle of morphine pills on the nightstand. Staff and family members reported concerns about suicidal behavior. The police and ambulance were called, and the tenant was admitted to acute care. The program nurse and staff confirmed the incident was handled properly and no regulatory insufficiencies were identified.
Report Facts
Number of tenants without cognitive disorder: 30Number of tenants with cognitive disorder: 8Total Population of Program at time of on-site: 36
Employees Mentioned
Name
Title
Context
Rose Boccella
Program Coordinator
Signed cover letter and contact person for the report
The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate compliance with Iowa Administrative Code chapters 231C and 481.
Findings
No regulatory insufficiencies were found during this evaluation. The program did not receive any regulatory insufficiencies during this certification period, and the onsite monitoring evaluation noted no deficiencies.
Report Facts
Number of tenants without cognitive disorder: 27Number of tenants with cognitive disorder: 5Total Population of Program at time of on-site: 32Number of tenants without cognitive disorder: 0Number of tenants with cognitive disorder: 4Total Population of Program at time of on-site: 4TOTAL census of Assisted Living Program: 36Tenants in satisfaction meeting: 25
Employees Mentioned
Name
Title
Context
Brenda Colvin
Executive Director
Named as Executive Director of Vriendschap Village Assisted Living
The inspection was conducted as a complaint/incident investigation regarding allegations of missing controlled substances (narcotics) from tenants' locked drawers at Vriendschap Village Assisted Living.
Findings
The investigation found regulatory insufficiencies related to medication administration and policies. Medications were missing or incorrectly documented, staff had access to medication keys, and the program failed to ensure medications were available as ordered by physicians. Incident reports were not consistently completed when medications were missing.
Complaint Details
Complaint/Incident Allegation: Controlled substances (narcotics) disappeared from locked drawers of multiple tenants during 6-16-12 through 6-18-12. The investigation included review of medication administration records, staff interviews, and monitoring observations. The complaint was substantiated with findings of missing medications and regulatory insufficiencies.
Deficiencies (3)
Description
Failure to ensure medications administered by staff to tenants were available as ordered by the tenant's physician.
Incident reports were not completed when medications were missing or not in medication planners for several tenants.
Policies and procedures on incident reports did not include all accidents or unusual occurrences affecting tenants.
Report Facts
Civil penalty amount: 500Reduced civil penalty amount: 325Total census: 36General Population Program tenants: 33Dementia-Specific Program tenants: 3
Employees Mentioned
Name
Title
Context
Hal L. Chase
RN BSN MPH
Monitor during complaint/incident investigation.
Joyce Kix
RN
Monitor during complaint/incident investigation.
Rose Boccella
Program Coordinator mentioned in civil penalty and appeals process.
Brenda Colvin
Administrator
Administrator of Vriendschap Village Assisted Living, named in report.
Staff RN #1
Registered Nurse
Interviewed regarding medication administration and missing medications; resigned 6-22-12.
The inspection was conducted as a final complaint investigation and recertification visit at Vriendschap Village Assisted Living in response to allegations regarding service plan, medications, and record checks.
Findings
The investigation found regulatory insufficiencies related to individualized service plans, medication administration, staff training, and employee record checks. The program was assessed a $500 civil penalty and the Plan of Correction was accepted.
Complaint Details
Complaint investigation #31983-C involved allegations that medications were not administered per physician's orders, narcotic patch counts were inaccurate, and falsified documentation of staff training and staffing patterns occurred. The complaint was substantiated with findings of regulatory insufficiencies.
Deficiencies (4)
Description
The service plan was not individualized and did not include planned and spontaneous activities based on tenant abilities and interests.
Medications were not administered per physician's orders and narcotic patch counts were inaccurate.
Staff training documentation was falsified and staffing patterns were inadequate to ensure timely medication administration and tenant care.
Personnel files lacked evidence of completion of required criminal history evaluations before employment.
Report Facts
Civil penalty amount: 500Days for Plan of Correction submission: 10Census count: 41Tenants without cognitive disorder: 32Tenants with cognitive disorder: 3Tenants in Dementia Specific Program: 6
Employees Mentioned
Name
Title
Context
Joyce Kix
RN
Monitor during complaint investigation
Lori Miner
RN
Monitor during complaint investigation
Margaret Kaltefleiter
RN
Monitor during complaint investigation
Ann Martin
Bureau Chief, Adult Services Bureau
Signed conclusion letter regarding penalty and Plan of Correction
An on-site monitoring evaluation was conducted at Vriendschap Village Assisted Living to assess compliance with regulatory requirements during the recertification period.
Findings
No regulatory insufficiencies were noted during the monitoring visit. Tenant feedback was positive regarding the quality of care, safety, and program activities.
Report Facts
Current number of tenants without cognitive disorder: 34Current number of tenants with cognitive disorder: 4Total Population: 38Current number of tenants in Dementia Specific Program: 5Current number of tenants without cognitive disorder: 0Total Population: 5
Employees Mentioned
Name
Title
Context
Brenda Colvin
Administrator
Administrator of Vriendschap Village Assisted Living
The visit was a recertification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations at Vriendschap Village.
Findings
The evaluation found multiple regulatory insufficiencies including inconsistent completion of health, functional, and cognitive evaluations as needed with changes in condition, incomplete service plans lacking planned and spontaneous activities for tenants with cognitive decline, failure to update service plans as needed, and inadequate staff training regarding Activities of Daily Living (ADLs).
Complaint Details
There were no substantiated complaints during this certification period.
Deficiencies (4)
Description
The program does not consistently complete health, functional and cognitive evaluations, as needed with a change in condition.
The program does not consistently include planned and spontaneous activities on tenants’ service plans who are unable to plan their own including those tenants with dementing illness.
The program does not consistently update tenants’ service plans as needed with a change in condition.
The program does not have appropriately trained staff regarding Activities of Daily Living (ADLs).
Report Facts
Current number of tenants without cognitive disorder: 29Current number of tenants with cognitive disorder: 3Total Population: 31
An on-site monitoring evaluation was conducted at Vriendschap Village as part of the assisted living program re-certification process.
Findings
No regulatory insufficiencies were found during this monitoring evaluation. Tenant and family feedback was positive, noting caring and competent staff, adequate activities, and a safe environment.
Complaint Details
No complaints on file during this certification period.
Report Facts
Number of tenants without cognitive disorder: 27Number of tenants with cognitive disorder: 9Total population: 36
Employees Mentioned
Name
Title
Context
Hal Chase
RN
Monitor during the on-site evaluation
Jan O’Briant
LISW
Monitor during the on-site evaluation
Dot Beason
Administrator
Administrator of Vriendschap Village
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