Cycle 1
Health 2025-05-15 · Fire 2025-05-15
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Sioux City, IA
Holy Spirit Retirement Home
4-star overall rating with 2-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1701 West 25th Street, Sioux City, IA
(712) 252-2726
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
61
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,591
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.30
Baseline 21.88% · Performance 19.07% · Measure score 5.30 · Achievement 5.10 · Improvement 5.30
Healthcare-associated infections
2.74
Baseline 6.08% · Performance 7.02% · Measure score 2.74 · Achievement 2.74 · Improvement 0
Total nurse turnover
2.76
Performance 52.38% · Measure score 2.76 · Achievement 2.76 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.44
Baseline 3.75 hours · Performance 4.06 hours · Measure score 3.44 · Achievement 3.44 · Improvement 1.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 134 · Observed rate 8.21% · Lower 95% interval 6.24% |
| Discharge to community | 57.38% |
50.57%
6.8 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 52.78% · Lower 95% interval 49.02% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 97 · Denominator 97 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 97 |
| Discharge self-care score | 41.77% |
53.69%
11.9 pts worse
|
Numerator 33 · Denominator 79 |
| Discharge mobility score | 45.57% |
50.94%
5.4 pts worse
|
Numerator 36 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 97 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.01% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 104 |
| Staff flu vaccination coverage | 9.27% |
42%
32.7 pts worse
|
Numerator 14 · Denominator 151 |
| Discharge function score | 49.37% |
56.45%
7.1 pts worse
|
Numerator 39 · Denominator 79 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 38 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 21.15% |
25.2%
4.1 pts worse
|
Numerator 11 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.9% |
94.0%
13.1 pts worse
|
93.4%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 83.3% · Q3 77.6% · Q4 77.8% · 4Q avg 80.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
95.2%
1.2 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.7%
1.3 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.6% · Q3 5.2% · Q4 5.6% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.0%
4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
4.9%
1.6 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.9% · Q3 8.3% · Q4 0.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.2% |
20.6%
8.4 pts better
|
19.6%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 10.4% · Q3 14.0% · Q4 10.4% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
19.8%
6.3 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 12.5% · Q3 12.5% · Q4 11.4% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.1% |
18.5%
11.4 pts better
|
16.3%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 4.5% · Q3 6.0% · Q4 9.5% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
18.3%
10 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 6.5% · Q3 2.0% · Q4 8.3% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 12.7% |
1.7%
11 pts worse
|
1.0%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 14.6% · Q3 12.7% · Q4 11.9% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.5%
0.6 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.0% · Q3 1.8% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
26.0%
4.8 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 34.0% · Q3 32.3% · Q4 30.0% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
4.3%
3.8 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.3% |
84.3%
20 pts worse
|
81.7%
17.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.3% · Q2 67.9% · Q3 64.4% · Q4 58.3% · 4Q avg 64.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
13.1%
4.9 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.3% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.2% |
73.3%
6.1 pts worse
|
79.7%
12.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
21.3%
2 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 15.9% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-22 · Fire 2024-05-22
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-03-16 · Fire 2023-03-16
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-15
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-06-14
F · Potential for more than minimal harm
2025-05-15
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2025-06-14
F · Potential for more than minimal harm
2025-05-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-06-14
F · Potential for more than minimal harm
2025-05-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-14
F · Potential for more than minimal harm
2025-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-14
F · Potential for more than minimal harm
2024-05-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-12
F · Potential for more than minimal harm
2024-05-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-11
F · Potential for more than minimal harm
2024-05-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-05-22
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-05-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-05-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-05-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-05
F · Potential for more than minimal harm
2023-03-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-05
F · Potential for more than minimal harm
2023-03-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-23
E · Potential for more than minimal harm
2023-03-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-03-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-10-08
E · Potential for more than minimal harm
2025-05-15
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-15
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-15
F826 · Quality of Life and Care Deficiencies
Health
Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
F · Potential for more than minimal harm
2024-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-22
E · Potential for more than minimal harm
2024-05-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-22
E · Potential for more than minimal harm
2024-05-22
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-06-22
E · Potential for more than minimal harm
2024-05-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-22
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-22
D · Potential for more than minimal harm
2024-05-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-22
E · Potential for more than minimal harm
2024-02-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-11
D · Potential for more than minimal harm
2024-02-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-11
E · Potential for more than minimal harm
2023-03-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-03-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-04-16
Penalties and ownership
What sits behind the stars
Ownership
The Diocese Of Sioux City
5% Or Greater Direct Ownership Interest · Organization
Bloch, Amy
Corporate Director · Individual
Jung, Michael
Operational/Managerial Control · Individual
Kreber, Jacqueline
Operational/Managerial Control · Individual
Larson, Tracy
Corporate Director · Individual
Ranniger, Royce
Corporate Officer · Individual
The Diocese Of Sioux City
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Casa De Paz Health Care Center
Sioux City, IA
1-star overall rating with 2-star inspections with 11 recent health deficiencies
#2
Westwood Specialty Care
Sioux City, IA
1-star overall rating with 1-star inspections with Special Focus status with $263,192 in total fines with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
St Luke's Regional Medical Center SNF
Sioux City, IA
5-star overall rating with 5-star inspections
Jump out