Inspection Reports for Holy Spirit Retirement Home
1701 W 25th St, IA, 511031705
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 9, 2025, found deficiencies related to inconsistent retention of tenant records for the required three years. Earlier inspections showed a pattern of documentation issues, including incomplete occupancy agreements, tenant evaluations, and service plans, as well as gaps in staff training and incident reporting. Complaint investigations have occasionally substantiated issues with recordkeeping and tenant rights, while many complaints were found unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history indicates ongoing challenges with documentation and procedural compliance, with some improvements noted in recent years but persistent areas needing attention.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
13 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 1
Jul 9, 2025
Visit Reason
The inspection was conducted as a complaint investigation for Complaint #129092-C and a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The program failed to consistently retain tenant records for a minimum of three years after transfer or death, affecting 1 of 3 current tenants and 1 of 4 former tenants reviewed. Missing records included service plans and other documentation such as medication records and safety checks.
Complaint Details
Investigation of Complaint #129092-C revealed incomplete record keeping affecting current and former tenants, confirmed by the Assisted Living Manager.
Deficiencies (1)
| Description |
|---|
| Failure to consistently ensure tenant records were retained for three years as required. |
Report Facts
Number of tenants without cognitive impairment: 3
Number of tenants with cognitive impairment: 10
Total census: 13
Complaint number: 129092
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assisted Living Manager | Interviewed and confirmed findings regarding incomplete record keeping |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 0
May 15, 2025
Visit Reason
Investigation of Complaints #128419-C and #128443-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Complaints #128419-C and #128443-C were investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 5
Number of tenants with cognitive impairment: 11
Total census: 16
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 5
Jan 15, 2025
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#122237-C, 122877-C, 125779-C) and a revisit from a previous complaint (#121682-C).
Findings
The facility failed to include all required information in occupancy agreements, failed to include required statements in marketing materials, did not complete tenant evaluations prior to signing occupancy agreements, failed to maintain accurate documentation of personal and health-related care for tenants unable to advocate for themselves, and inconsistently developed service plans prior to occupancy agreements being signed.
Complaint Details
The visit was complaint-related, investigating complaints #122237-C, 122877-C, 125779-C and a revisit from complaint #121682-C dated 10/23/24.
Deficiencies (5)
| Description |
|---|
| Occupancy Agreements failed to include the correct telephone number for the long-term care ombudsman, did not clearly state that Dependent Adult Abuse should be reported to DIAL, and lacked a statement that tenant landlord law applies to assisted living programs. |
| Marketing materials failed to include a statement informing the public that a copy of the occupancy agreement is available upon request. |
| Tenant evaluations were not completed prior to signing the occupancy agreement for one tenant. |
| The program failed to consistently maintain accurate documentation of personal and health-related care (task sheets) for tenants unable to advocate for themselves. |
| Service plans were not consistently developed prior to signing the occupancy agreement for one tenant. |
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 14
Total census: 39
Global Deterioration Scale (GDS) score: 5
Global Deterioration Scale (GDS) score: 4
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 15
Oct 23, 2024
Visit Reason
The inspection was conducted as part of the investigation of Complaint #121682-C regarding regulatory insufficiencies at the assisted living program.
Findings
The facility was found deficient in multiple areas including incomplete and outdated occupancy agreements, failure to complete required tenant evaluations, inadequate notification for involuntary tenant transfers, missing legal documentation in tenant records, incomplete and unsigned service plans, failure to include other service providers in plans, lack of required staff training, and absence of operating door alarms on exit doors.
Complaint Details
The inspection was conducted following Complaint #121682-C which triggered the investigation of regulatory insufficiencies at the facility.
Deficiencies (15)
| Description |
|---|
| Occupancy agreements failed to include required information such as correct telephone numbers for long-term care ombudsman and reporting dependent adult abuse, and tenant landlord law statement. |
| Occupancy agreements were not reviewed and updated to reflect changes in services or financial arrangements. |
| Tenant evaluations were not completed as required, specifically failure to use Global Deterioration Scale for moderate cognitive decline. |
| Failure to notify legal representative properly of involuntary tenant transfer including ombudsman contact information. |
| Tenant records lacked copies of durable power of attorney documentation. |
| Tenant records were not retained for the required minimum of three years after transfer or death. |
| Service plans were not consistently based on evaluations. |
| Service plans were not updated, signed, and dated within 30 days of tenant occupancy. |
| Service plans were not signed and dated at least annually. |
| Service plans failed to include other service providers such as hospice care in a timely manner. |
| Service plans failed to include person-centered planned and spontaneous activities for tenants with dementia. |
| Delegating nurse did not receive required training within six months of hire. |
| Staff failed to receive required eight hours of dementia-specific education within 30 days of employment. |
| Staff failed to receive required eight hours of dementia-specific continuing education annually. |
| Operating alarm system was not connected to each exit door in the dementia-specific program. |
Report Facts
Number of tenants without cognitive impairment: 26
Number of tenants with cognitive impairment: 14
Total census: 50
Room charge: 6120
Room charge: 6242
Room charge: 6492
Occupancy date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Failed to complete eight hours of dementia-specific education within 30 days of employment | |
| Staff B | Failed to complete eight hours of dementia-specific continuing education annually | |
| Assisted Living Manager | ALM | Confirmed failures in tenant record documentation and evaluations |
Inspection Report
Renewal
Census: 24
Deficiencies: 1
Mar 9, 2023
Visit Reason
The inspection was conducted as a recertification (renewal) of the Assisted Living Program to ensure compliance with regulatory requirements.
Findings
The program failed to ensure all staff responsible for food preparation or service received orientation and annual training on sanitation and safe food handling prior to handling food. This deficiency affected all 5 staff reviewed and potentially all 24 tenants.
Deficiencies (1)
| Description |
|---|
| Failure to ensure all staff received orientation and annual training on sanitation and safe food handling prior to handling food. |
Report Facts
Staff affected: 5
Tenants potentially affected: 24
Census: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Resident Care Attendant | Did not receive orientation on sanitation and safe food handling prior to handling food |
| Staff D | Resident Care Attendant | Did not receive orientation on sanitation and safe food handling prior to handling food |
| Staff E | Resident Care Attendant | Did not receive orientation on sanitation and safe food handling prior to handling food |
| Staff F | Resident Care Attendant | Did not receive orientation on sanitation and safe food handling prior to handling food |
| Staff G | Resident Care Attendant | Did not receive orientation on sanitation and safe food handling prior to handling food |
Inspection Report
Renewal
Census: 28
Deficiencies: 0
Nov 2, 2020
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program, including an onsite infection control survey and investigation of a complaint.
Findings
No regulatory insufficiencies were cited during the recertification visit, the infection control survey, or the complaint investigation.
Complaint Details
Complaint #93802-C was investigated and no regulatory insufficiencies were cited.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 16
Number of tenants with cognitive disorder in General Population Program: 3
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 9
Total census of Assisted Living Program for People with Dementia: 28
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Sep 17, 2019
Visit Reason
Investigation of Incident #84559-I at the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #84559-I; no deficiencies found.
Report Facts
Number of tenants without cognitive disorder (General Population): 15
Number of tenants with cognitive disorder (General Population): 0
Number of tenants without cognitive disorder (Memory Care Unit): 4
Number of tenants with cognitive disorder (Memory Care Unit): 9
Total Census of Assisted Living Program for People with Dementia: 28
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Apr 9, 2019
Visit Reason
The inspection was conducted as an investigation of Complaint #81972-C regarding regulatory insufficiencies at the assisted living program.
Findings
The investigation found that the program failed to report all incidents affecting tenants, including a fire alarm pull and a fall incident, and failed to ensure staff treated tenants with consideration and respect, particularly regarding confidentiality breaches involving digital tenant information.
Complaint Details
Investigation of Complaint #81972-C found substantiated regulatory insufficiencies related to incident reporting and tenant rights, including breaches of confidentiality and failure to report incidents.
Deficiencies (2)
| Description |
|---|
| Program policies and procedures failed to indicate all accidents or unusual occurrences within the program's building that affected tenants shall be reported as incidents. |
| Program failed to ensure all staff treated tenants with consideration and respect and failed to follow confidentiality policies concerning viewing digital tenant information. |
Report Facts
Number of tenants without cognitive disorder in General Population Program: 10
Number of tenants with cognitive disorder in General Population Program: 0
Total population of General Population Program: 10
Number of tenants without cognitive disorder in Dementia-Specific Program: 4
Number of tenants with cognitive disorder in Dementia-Specific Program: 14
Total population of Dementia-Specific Program: 18
Total census of Assisted Living Program: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Logan | Assisted Living Coordinator | Named in Plan of Correction letter as contact person and author |
| Teresa Lagge | RN BSN AL Coordinator | Named as contact person after 5-28-19 in Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Dec 19, 2018
Visit Reason
Investigation of Incident #78938-I at the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #78938-I.
Complaint Details
Investigation of Incident #78938-I resulted in no regulatory insufficiencies cited.
Report Facts
Number of tenants without cognitive disorder in General Population: 12
Number of tenants with cognitive disorder in General Population: 0
Number of tenants without cognitive disorder in Memory Care Unit: 5
Number of tenants with cognitive disorder in Memory Care Unit: 14
Total Census of Assisted Living Program for People with Dementia: 31
Inspection Report
Renewal
Census: 32
Deficiencies: 0
Apr 10, 2018
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program for People with Dementia (ALP/D).
Findings
No regulatory insufficiencies were cited during the recertification inspection for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive disorder in general population: 22
Number of tenants with cognitive disorder in general population: 1
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 9
Total census: 32
Inspection Report
Monitoring
Census: 33
Deficiencies: 0
May 4, 2016
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, including approval of evacuation plans.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 0
Total Population of General Program: 22
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 9
Total Population of Dementia-Specific Program: 11
TOTAL census of Assisted Living Program: 33
Inspection Report
Monitoring
Census: 33
Deficiencies: 4
Oct 27, 2014
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation following a survey by the Department of Inspections and Appeals on October 27 and 28, 2014, to evaluate regulatory insufficiencies in the Assisted Living Program at Holy Spirit Assisted Living.
Findings
The report identified regulatory insufficiencies related to tenant evaluations and individualized service plans, including failure to complete evaluations prior to admission and inadequate service plans that did not meet tenants' identified needs. Specific tenant incidents and care issues were documented, highlighting areas needing correction.
Deficiencies (4)
| Description |
|---|
| Failure to evaluate each prospective tenant's functional, cognitive, and health status prior to signing the occupancy agreement and taking occupancy. |
| Failure to evaluate each tenant's functional, cognitive, and health status within 30 days of occupancy and as needed with significant changes. |
| Service plans did not identify behaviors of aggression or interventions for Tenant #1 and did not meet the identified needs of Tenant #1. |
| Service plan for Tenant #2 did not identify interventions for confusion and did not meet the identified needs of Tenant #2. |
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 0
Total Population of Program at time of on-site: 22
Number of tenants without cognitive disorder: 11
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 11
TOTAL census of Assisted Living Program: 33
Tenant #1 age: 83
Tenant #2 age: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Rose Boccella | Program Coordinator | Author of the cover letter and contact for the report |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
May 14, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding medication tampering allegations at Holy Spirit Assisted Living.
Findings
The investigation found that medication belonging to two tenants had been tampered with, specifically switching Hydrocodone/Acetaminophen tablets with extra strength Tylenol. The program failed to follow its policy for narcotic counts and medication administration, with multiple staff confirming improper handling of narcotics.
Complaint Details
The complaint involved medication tampering where one Hydrocodone/Acetaminophen (Lortab) 5mg/325mg from each tenant's bubble pack had been switched with extra strength Tylenol. The investigation confirmed inconsistencies in narcotic counts and improper medication administration practices by multiple staff members.
Deficiencies (2)
| Description |
|---|
| The program did not follow their policy for medication administration, including the completion of narcotic counts. |
| The program did not administer medications in accordance with requirements governing nurse delegation related to the administration of medications. |
Report Facts
Number of tenants without cognitive disorder: 23
Number of tenants with cognitive disorder: 0
Total Population of General Population Program: 23
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 10
Total Population of Dementia-Specific Program: 11
Total census of Assisted Living Program: 34
Date of complaint/incident investigation: May 14, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
| Jim Berkley | Program Coordinator | Signed cover letter regarding acceptance of Plan of Correction |
Inspection Report
Monitoring
Census: 34
Deficiencies: 2
Nov 8, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation to assess regulatory insufficiencies related to Structural Requirements and Transportation at Holy Spirit Assisted Living in Sioux City, IA.
Findings
The report identified regulatory insufficiencies including issues with driver licensing for transportation and unsecured chemicals and electrical devices in the dementia unit. A $500 civil penalty was assessed and a Plan of Correction was accepted.
Deficiencies (2)
| Description |
|---|
| Driver did not have a valid and appropriate Iowa driver's license or commercial driver's license as required by law for transporting tenants. |
| Chemicals and electrical devices were not secured in the dementia unit; buildings and grounds were not well-maintained, clean, safe, and sanitary. |
Report Facts
Civil penalty amount: 500
Days to remit penalty: 30
Tenants in General Population Program: 23
Tenants in Dementia-Specific Program: 11
Total census: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Tomscha | Administrator | Administrator of Holy Spirit Assisted Living named in report |
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Jim Berkley | Program Coordinator | Contact person for appeal and penalty payment |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Dec 6, 2010
Visit Reason
The investigation was conducted in response to a complaint regarding missing Hydrocodone tablets from a tenant's locked narcotic box at Holy Spirit Assisted Living.
Findings
The investigation found that 47 Hydrocodone 10mg/650mg tablets were missing, and the facility failed to report the missing narcotics within the required 24-hour timeframe. A dependent adult abuse investigation is ongoing.
Complaint Details
Complaint Intake #31646-M involved a report of 47 Hydrocodone tablets missing from a tenant's locked narcotic box. The Administrator reported the loss late, not within the required 24 hours. The complaint investigation found regulatory insufficiency related to failure to report suspected dependent adult abuse.
Deficiencies (1)
| Description |
|---|
| Failure to report suspected dependent adult abuse related to missing narcotics within the required timeframe. |
Report Facts
Missing Hydrocodone tablets: 47
Current number of tenants without cognitive disorder: 22
Current number of tenants with cognitive disorder: 0
Total Population of General Population Program: 22
Total Population of Dementia Specific Program: 11
Total Census of Assisted Living Program: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the investigation |
| Patrick Tomscha | Administrator | Named in report as facility administrator |
Inspection Report
Monitoring
Census: 34
Deficiencies: 0
Mar 16, 2010
Visit Reason
The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa Code and Administrative Code for the assisted living program at Holy Spirit Assisted Living.
Findings
No regulatory insufficiencies were found during the evaluation. The program was found to be in substantial compliance with regulations, and the recertification documents were accepted.
Report Facts
Current number of tenants without cognitive disorder: 22
Current number of tenants with cognitive disorder: 1
Total Population of GPP: 23
Total Population of Dementia Specific Program (DSP): 11
Total Census of Assisted Living Program (ALP): 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor conducting the on-site monitoring evaluation |
Inspection Report
Monitoring
Census: 35
Deficiencies: 0
Feb 6, 2008
Visit Reason
The visit was a final recertification monitoring evaluation conducted to assess compliance with assisted living program regulations at Holy Spirit Assisted Living.
Findings
No regulatory insufficiencies were identified during the monitoring visit. Tenant and family satisfaction was high, with positive feedback on staff, services, safety, and activities. There were no substantiated complaints during the certification period.
Report Facts
Current number of tenants in Dementia Specific Program: 9
Current number of tenants without cognitive disorder: 26
Total Population: 35
Tenant/Family meeting attendance: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Streepy | RN | Monitor conducting the on-site monitoring evaluation |
| Patrick Tomscha | Administrator | Administrator of Holy Spirit Assisted Living |
Inspection Report
Monitoring
Census: 34
Deficiencies: 2
Jan 19, 2006
Visit Reason
An on-site monitoring evaluation was conducted at Holy Spirit Assisted Living to assess compliance with assisted living program regulations and tenant care standards.
Findings
The evaluation found two regulatory insufficiencies related to medication administration and nurse documentation practices. Staff did not wash hands between medication administrations, and the nurse did not time physician orders as required.
Deficiencies (2)
| Description |
|---|
| The program does not administer medications to tenants according to accepted medication protocol. |
| The program nurse does not time orders received as required under state regulation. |
Report Facts
Current number of tenants without cognitive disorder: 20
Current number of tenants with cognitive disorder: 2
Current number of tenants in Dementia Specific Program: 12
Total Population: 34
Tenants attending community meeting: 12
Tenant files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the on-site evaluation |
| Debbie Logan | LBSW Administrator | Administrator of Holy Spirit Assisted Living |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 4
Oct 6, 2004
Visit Reason
A complaint investigation on-site visit was conducted at Holy Spirit Assisted Living to investigate allegations related to tenant care and program compliance.
Findings
The investigation found multiple regulatory insufficiencies including failure to transfer a tenant requiring higher level care, failure to update individualized service plans, inadequate dementia-specific education for staff, and insufficient trained staffing to meet tenant needs.
Complaint Details
The complaint alleged that the program did not provide appropriate care to a tenant diagnosed with dementia. The complaint was investigated and multiple regulatory insufficiencies were identified.
Deficiencies (4)
| Description |
|---|
| The program did not transfer a tenant that was identified as requiring a higher level of care and meets the criteria for exclusion of tenant. |
| The program did not design an individualized service plan to meet the specific service needs of the tenant. |
| The program did not provide six hours of dementia-specific education and training prior to or within 90 days of employment or at the beginning of a contract with a third-party provider. |
| The program did not provide sufficient trained staff to fully meet tenants’ identified needs. |
Report Facts
Current number of tenants without cognitive disorder: 15
Current number of tenants with cognitive disorder: 5
Total General Population: 20
Current number of tenants in Dementia Specific Program: 10
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 0
Jun 16, 2004
Visit Reason
A complaint investigation on-site visit was conducted at Holy Spirit Assisted Living to investigate allegations that the program was not providing kind and considerate care to tenants.
Findings
Interviews with tenants, staff, and management indicated that overall staff were kind and considerate, with tenants feeling respected and well cared for. No instances of abuse, neglect, or mistreatment were reported or observed. Staff received appropriate training and background checks. One employee was noted to sometimes talk sarcastically, but this was known and accepted by tenants.
Complaint Details
The complaint alleged that the program was not providing kind and considerate care to tenants. The investigation found no regulatory insufficiencies or evidence of abuse or neglect. Staff training and documentation were appropriate.
Report Facts
Current General Population ALP Census: 14
Current number of tenants with dementia: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Dean | RN | Monitor conducting the complaint investigation |
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