Health inspection·July 1, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure a timely ambulance transfer for a resident experiencing respiratory distress. Residents Affected - Few This applies to 1 resident (R1) reviewed for change in condition in a sample of 4. The findings include: On 6/26/25 at 11:47 AM, V6 (LPN/Licensed Practical Nurse) said on 6/22/25, R1 requested to go the emergency room multiple times because she was short of breath and didn't feel well. V6 said she called for a routine ambulance for R1, but the ambulance dispatcher told her to call 911 due to R1's abnormal vital signs. Nursing Progress Note dated 6/22/25 at 20:30 documents R1's vitals were as follows: Blood pressure 79/49, heart rate 103, respiratory rate 18, and oxygen saturation 79% on 4 liters per nasal cannula. V6 said that when she increased R1's oxygen, R1 did not say she felt better and R1 told her to call 911. On 6/27/25 at 2:25 PM, V12 ADON (Assistant Director of Nursing) said for a change condition related to respiratory distress, nursing staff should not wait and should call 911 without delay. On 6/27/2025 at 11:10 AM, V8 (LPN) stated R1 is alert an oriented and has a lot of respiratory issues with her quadriplegia diagnosis and she has a hard time coughing. V8 stated if vital signs change all at once, she would call 911. On 6/27/2025 at 1:30 PM, V9 (LPN) stated if a resident has a decrease in blood pressure with increased heart rate and is complaining of difficulty breathing, that warrants a 911 call. V9 stated R1 is a full code and she would not hesitate to call 911. On 6/26/25 at 12:28 PM, V4 (EMT/Emergency Medical Technician) said V20 (Ambulance Dispatcher) advised V6 (LPN) to call 911 due to the time it would take for ambulance to arrive, but V6 said she was going to try other ambulance companies instead. V4 said V6 called V20 back 20 minutes later requesting their service again. V4 said when she arrived at the facility on 6/22/25, there was no nurse present at R1's bedside and R1 was observed gasping for air. V4 said at 9:15 PM upon her arrival to facility, R1's vital signs were as follows; heart rate 108 bpm (beats per minute); respirations 28 bpm (breaths per minute); blood pressure was critically low at 66/46 mmHg (millimeters of mercury), and oxygen saturation was 91% on 5 liters of oxygen via nasal cannula. V4 said R1 told her that she was not usually on oxygen. Upon assessment, V4 noted R1 with diminished breath sounds in all fields. V4 said she was concerned R1's lungs sounded junky (congested). V4 said V6 did not mention why she didn't call 911. V4 said she started a breathing treatment right away and R1 was transferred to the hospital. Per V4, she was concerned because R1 is paraplegic and is unable call 911 herself. On 6/27/2025 at 2:45 PM, V2 DON (Director of Nursing) stated if an ambulance dispatcher said to call 911 instead of waiting for routine ambulance transport due to a resident's condition and vital (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 4 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 07/01/2025 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)