Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to keep residents safe from resident to resident
abuse. R2 pushed R1, causing R1 to fall. R2 also was physically abusive to R3.
This applies to 2 of 5 residents (R1 and R3) reviewed for abuse from a total sample of 5.
The findings include:
Incident report dated April 17, 2024, R1 and R2 had an altercation, the actual time of the incident was not
documented but the report shows that it happened after breakfast. R1 walked to her bedroom and was
approached by R2. The encounter resulted to R1 falling on the floor.
Hospital record dated April 17, 2024, shows that R1 was sent to emergency department after a fall and the
nursing home staff reported to the paramedics that R1 was inadvertently knocked down by another resident
at the nursing home who was being disruptive. R1 was released later back to the facility with no significant
injuries.
Physician Progress Notes dated April 22, 2024, documents that R1 had a physical altercation with another
resident the previous week. The note continues to document that R1 fell, hit her head.
On April 30, 2024, at 11:25 AM, R1 was in her bedroom, sitting on her recliner. R1 stated that another
resident pushed her, she fell, and hit her head on the floor. R1 was unable to recall the name of the
resident. There was bruising to her right temporal area and right side of her face by her right ear. R1 also
said she went inside her bedroom when there is no activity because she didn't want to be around that
resident (R2) who attacked her.
Face sheet shows R1 is 83 years-old who has multiple medical diagnoses which include dementia in other
diseases classified elsewhere, mild, with other behavioral disturbance, traumatic subdural hemorrhage with
loss of consciousness status unknown, initial encounter, and repeated falls. Quarterly Minimum Data Set
(MDS) dated [DATE] shows Brief Interview for Mental Status (BIMS) score was 9 which means that R1 has
moderate impairment in cognition.
Face sheet shows R2 is 77 years-old who has multiple medical diagnoses which include Alzheimer's
disease, unspecified, unspecified dementia, unspecified severity without behavioral disturbance, psychotic
disturbance, mood disturbance, and anxiety, major depressive disorder, and deaf non-speaking. Quarterly
MDS dated [DATE] shows that she has a BIMS score of 7 which means that R2 has severe impairment in
cognition.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
146172
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146172
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Creek
777 Draper Avenue
Joliet, IL 60432
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Incident report dated February 26, 2024, at around 5:00 PM, shows that R1 and R2 just finished their
dinner. R1 and R2 were sitting next to each other as they had done for months. At that moment, there was a
misunderstanding between these residents which led R2 to strike R1 in the face and lip. According from R1,
R2 was petting her stuffed animal and she told R2 to give her back her stuffed animal, the next thing R1
knew R2 hit her. R1 later realized that she had mistaken R2 for someone else that is why she demanded
R2 to return her stuffed animal. R1 did not require any special treatment to address the cut to her face.
On April 30, 2024, around 9:30 AM, On April 29, 2024, at 1:43 PM, V5 (Certified Nursing Assistant/CNA)
stated prior to the (4/17/24) incident R1 was in the dining room and stated that if R2 goes to her room she
will give her a black eye because she kept stealing her stuff. R2 got upset when she saw that R1 was
talking about her. They started arguing, they were separated by staff. V6 (CNA) was helping another
resident in a rest room next to the dining room and it was also along the hallway where R1's bedroom was.
V6 heard screaming and saw R2 walking towards the dining room. V6 called the attention of V5. R2 started
gesturing with her hand that she pushed R1. V5 went inside R1's bedroom and found her (R1) sitting on the
floor with her walker tilted and leaning on her. R1 said that R2 pushed her. R1 also said that R2 was taking
her teddy bear. R2 said that R1 hit her first. V6 assumed that R2 went to R1's bedroom to take her teddy
bear. R1 pushed her and R2 pushed her back. R1 was crying and screaming She hit me! She hit me! R2
likes stuffed animals, and she tends to take other resident's stuffed animals.
On April 29, 2024, at 1:14 PM, V2 (Director of Nursing/DON), stated she was alerted by the staff that there
was an altercation that happened between R1 and R2. On April 17, 2024, R1 was found on the floor with
the right side of her head bleeding. According to V2, R1 was very protective of her bedroom and her
belongings and R1 had a habit of confronting individuals entering or coming close to her room. R1 would at
times would tell other residents if they touched her belongings, she would hit the person. R2 is totally deaf
and uses sign language to communicate. R2 gestured in sign language about what happened, but nobody
could understand her explanation because R2's communication boards were misplaced. V2 also stated that
R2 has a different kind of wandering behavior. R2 is familiar with the unit layout. R2 enjoys walking. V2
added that R2 has a behavior of going to other resident's bedroom to take other resident's belongings.
R2 was discharged for psychiatric care after the incident.
On April 29, 2024, at 2:57 PM, V8 (CNA) stated that she had never taken care of R2, but she had taken
care of R1. V8 described R 1 as pleasant and cooperative. R1 was very nice person and did not argue with
other residents unless someone took her belongings. According to V8, R1 would scold the person taking
her items, but she was never physically aggressive.
On April 30 at 11:00 AM, V17 (CNA) stated that R1 was feisty when another resident takes her items but
R1 would not physically hurt anyone. V17 add that R2 has a behavior of entering other resident's rooms to
take their personal belonging. V17 stated that on February 26, 2024 that R1 and R2 were in the dining
room, when R1 started talking and gesturing a threat to R2. R2 got upset with her and slapped her. They
tried to separate them from the table, but R2 kept coming back on the same table where R1 sits. V17 stated
that the staff try to watch R2 as much as they can but it's impossible because they have other residents to
care for. There's no way they can stop her from roaming around and keeping her out of other resident's
rooms. After the 2nd incident happened on 4/17/24 between R1 and R2, R1 spent the majority of her time
in her bedroom away from R2.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146172
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146172
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Spring Creek
777 Draper Avenue
Joliet, IL 60432
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R2's progress notes for February 26, 2024 document that at 4:26PM, staff heard a commotion in the dining
room and it was noted that R2 punched R3 in the face.
2. Face sheet shows that R3 is 79 years-old who has multiple medical diagnoses which include cerebral
palsy, major depressive disorder, and anxiety disorder. R3's Significant change in status MDS dated [DATE]
shows that her BIMS score was 9 which means that R3 has moderate impairment in cognition. R3's
progress notes dated March 20, 2024, at 4:15 PM shows that R3 activated her call light and, staff found
another resident (R2) in the bedroom. R3 stated that the other resident (R2) slapped her on her right arm.
No noted injury, but R3 did say that she was having some discomfort to the area no acute injury was noted.
On April 30, 2024, at 11:20 AM, R3 was resting in bed and she remembered being hit by another resident.
On April 30, 2024, at 1:46 PM, V14 (Nurse) stated that on March 20, 2024, R2 was seen inside R3's
bedroom. V14 was unsure what R2 was doing there or what she did. However, R3 stated that she was
slapped by R2.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146172
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the May 2, 2024 survey of SPRING CREEK?
This was a inspection survey of SPRING CREEK on May 2, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SPRING CREEK on May 2, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.