Inspection·February 13, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure controlled medications were signed off in the electronic narcotic inventory system at the time the controlled medications were administered for 7 of 10 residents (R4-R10) in the sample of 10. The findings include: On 2/13/25 between 9:12 AM and 10:20 AM, a medication pass by V4 (Licensed Practical Nurse-LPN) was observed on the B wing of the facility. At 10:20 AM, V4 said she had completed the AM medication pass for the residents she was assigned to, and there were no more residents with AM medications due on the B wing. At 10:47 AM, V4 was informed that this surveyor would like to do a narcotics count with her for the B wing medication cart. V4 said she had to sign off on her narcotics prior to doing the narcotics count. V4 was informed that we would go ahead and do the narcotics count at that time. During the narcotics count, controlled medications for R4-R10 were not signed off in the electronic narcotic inventory system at the time they were administered to R4-R10. The narcotic count showed the following: R4's Tramadol (a schedule IV-controlled substance used to treat moderate to severe pain) 50 mg (milligram) tablets. Dosage 1 tablet. The count in the facility's electronic narcotic inventory system showed 28 and 8 tablets. R4's medication cards showed 28 and 7 tablets. R4's Pregabalin (a schedule V-controlled substance used to treat nerve and muscle pain) 75 mg pills. Dosage 1 pill. The count in the facility's electronic narcotic inventory system showed 77 pills. R4's medication cards showed 76 pills. R5's Morphine (a schedule II-controlled substance used to treat moderate to severe pain) 15 mg. Dosage 0.5 pill. The count in the facility's electronic narcotic inventory system showed 12.5 pills. R5's medication card had 12 pills. R5's Klonopin (a schedule IV-controlled substance used to treat seizures, panic disorders, and anxiety) 0.5 mg. Dosage 1 pill. The count in the facility's electronic narcotic inventory system showed 65 pills and R5's medication card had 64 pills. R6's Tramadol (a schedule IV-controlled substance used to treat moderate to severe pain) 50 mg tablets. Dosage 1 tablet. The count in the facility's electronic narcotic inventory system showed 68 tablets and R6's medication card had 67 tablets. (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: 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 02/13/2025 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)