Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to utilize a glucose monitoring sensor
per physician orders for 1 of 3 residents (R1) reviewed for physician orders in the sample of 4.
Residents Affected - Few
The findings include:
On 1/7/25 at 10:12 AM, R1 was in bed watching TV. R1 said she was upset with V7 (Registered Nurse-RN)
because she placed her glucose monitoring sensor wrong and now she had to be poked in the finger to
check her blood sugar. R1 said this happened over the weekend. R1 said V7 bent the needle and so it had
to be removed. R1 said the nurses told her a new one couldn't be used since the insurance wouldn't pay for
it. R1 said insurance only pays for 2 per month and now she has to wait 14 days.
On 1/7/25 at 10:30 AM, V5 (Licensed Practical Nurse-LPN) said she was told in report that V7 tried to
insert the glucose sensor and bent the needle so it wasn't working and had to be removed. V5 said they
have to wait for 2 weeks since insurance only covers 2 per month. V5 said she was not sure if V2 (Director
of Nursing-DON) was notified but she was going to tell her today.
On 1/7/25 at 1:08 PM, V2 said she had just applied a new sensor on R1. V2 said they had the second
sensor in the box for the month and just put that one on. V2 said the facility will pay for a new one in 14
days when it is due. V2 said she had not been made aware of the situation.
R1's Physician Orders dated 11/5/24 shows Change (glucose monitoring sensor) every 14 days per
manufacturer's instructions. Apply to back of arms only. These same orders shows accucheck in AM and
HS (bedtime) two times a day related to type 2 diabetes.
R1's Medication Administration Record for December 2024 shows R1's (glucose monitoring sensor) was to
be placed on 12/31/24 (7 days prior) and was charted as HOLD.
The facility's Medication Administration Policy dated 12/2014 shows The facility will provide pharmaceutical
services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering
of all medications to meet the needs of each resident.
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:
145556
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
145556
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Winning Wheels
701 East 3rd Street
Prophetstown, IL 61277
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure residents received
assistance with activities of daily living for 2 of 4 residents (R1, R2) reviewed for activities of daily living
(ADL) in the sample of 4.
Residents Affected - Few
The findings include:
1. On 1/7/25 at 10:12 AM, R1 was in bed watching TV. R1 said staff have to assist her up to her reclining
chair since her electric wheelchair is broke. R1 said she can not propel herself in the reclining chair and
staff don't like to deal with the chair. R1 said she has a pendant call light to use when she is not in her room
for staff to come help her get back to her room.
On 1/7/25 at 11:48 AM, R1 was up in her reclining wheelchair in the dining room. R1 did not have her
pendant call light on. R1 said she didn't have it on today, and staff usually don't put it on unless she asks for
it. R1 said the other day at dinner time, she didn't have her pendant on and staff left her in the dining room.
R1 stated they just left me down here! I had to holler out for help! The kitchen staff heard me and went and
got someone but is was a long time. R2 said it was V6 (Certified Nursing Assistant-CNA) and V8 (Agency
CNA) that left her in the dining room.
On 1/7/25 at 12:15 PM, V6 said she did work that day but was not assigned to R1. V6 said V8 and another
Agency CNA were assigned to R1. V6 said R1 is supposed to have her pendant on when she is not in the
room. V6 said R1 had complained to her that the staff wouldn't help her and told her they didn't have time
for her. V6 said she did not see R1 in the dining room, she was helping residents on her hallway.
On 1/7/25 at 1:08 PM, V2 (Director of Nursing-DON) said R1 has a pendant that she wears, it's a portable
call light since she is unable to move herself in the reclining wheelchair. V2 said R1 should have it when she
is not in her room.
On 1/7/25 at 12:14 PM, a message was left for V8 (Agency CNA) with no return call.
R1's Facesheet shows R1 has a diagnoses of cerebral palsy, chronic respiratory failure, morbid obesity,
stiff-man syndrome, heart failure, type 2 diabetes, muscle wasting and atrophy, and chronic fatigue.
2. On 1/7/25 at 9:50 AM, R2 was up in his wheelchair in his room. R2 had a breath activated call light near
his mouth. R2 said he had already had breakfast. R2 said he has a hard time getting his teeth brushed in
the morning. R2 said the staff will get him changed and up to his chair and then leave. R2 said his teeth had
not been brushed today. R2 said the CNA got him up and then just walked out before he could even say
anything. R2 said it wasn't just today, it happens all the time and he is sick of it. R2 said he likes to get his
teeth brushed before he goes down to breakfast. R2 said he has told the nurses but was not sure if the
message got to V2 (DON). R2 said he is afraid of getting tooth decay if he doesn't get his teeth brushed.
On 1/7/25 at 10:20 AM, V3 (CNA) said R2 is alert and able to voice what he needs 100%. V3 said in the
morning, R2 gets a bed bath, dressed, up to his chair, gets his teeth brushed right away before going to
breakfast. V3 said there was an emergency and she did not get to brush R2's teeth yet today.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145556
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
145556
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Winning Wheels
701 East 3rd Street
Prophetstown, IL 61277
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 1/7/25 at 10:30 AM, V5 (Licensed Practical Nurse-LPN) said R2 has complained to her about not
getting his teeth brushed last week and again this morning. V5 said she brushed R2's teeth for him last
week.
On 1/7/25 at 1:08 PM, V2 (DON) said staff should honor residents preferences for teeth brushing and try to
accommodate as able.
R2's Care Plan shows R2 is dependent on staff due to limited movement- oral hygiene- total assist of 1
twice daily. R2 is unable to perform own oral hygiene due to left hemiparesis- perform mouth care as per
ADL personal hygiene.
The facility's undated Daily Personal Care & Privacy Policy shows Every resident shall be given daily
personal attention. This personal care shall include, but not be limited to, perineal cleanliness, skin care,
nails, hair, and oral hygiene.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145556
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations 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.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
FAQ · About this visit
Common questions about this visit
What happened during the January 7, 2025 survey of WINNING WHEELS?
This was a inspection survey of WINNING WHEELS on January 7, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WINNING WHEELS on January 7, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure services provided by the nursing facility meet professional standards of quality."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.