Health 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. Page 1 of 3 145556 145556 02/13/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R7's Lyrica (a schedule V-controlled substance used to treat nerve and muscle pain) 150 mg capsules. Dosage 1 capsule. The count in the facility's electronic narcotic inventory system showed 104 capsules. R7's medication cards showed 103 capsules. R8's Tramadol Hcl (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 104 and R8's medication cards had 103 tablets. R9's Lacosamide (a schedule V-controlled substance used to treat seizures) 150 mg pills. Dosage 1. The count in the facility's electronic narcotic inventory system showed 62 pills and R9's medication cards showed 61 pills. R10's Lorazepam (a schedule IV-controlled substance used to treat anxiety, sleeping problems, and seizure disorders) 0.5 mg tablets. Dosage 1 tablet. The count in the facility's electronic narcotic inventory system showed 63 tablets and R10's medication card showed 62 tablets. On 2/13/25 at 11:04 AM, V4 (LPN-Agency nurse) said controlled medications should be signed out in the electronic narcotic inventory system when given, to prevent medication count errors. On 2/13/25 at 1:00 PM, V2 (Director of Nursing-DON) said the nurses should sign off controlled medications as they are giving them to the residents. V2 said they should have the (electronic narcotic inventory system) up and sign off in conjunction with the residents' MARS (medication administration records) for tracking purposes. V2 said the facility uses the (electronic narcotic inventory system) in place of the medication reconciliation binder. V2 said it is important to do this for safe medication administration, to monitor the counts, to make sure the counts are accurate, and to ensure there is no medication diversion. R4's Order Summary Report, printed by the facility on 2/13/25, showed an order for Tramadol Hcl 50 mg tablet one time a day for pain in the morning, and an order for Pregabalin 75 mg capsule. One capsule two times a day related to chronic pain syndrome. R5's Order Summary Report, printed by the facility on 2/13/25, showed an order for Clonazepam (Klonopin) 0.5 mg tablet. Give 1 tablet two times a day related to tremor. The report showed an order for Morphine Sulfate IR 15 mg. Give 0.5 tablet two times a day related to pain. R6's Order Summary Report, printed by the facility on 2/13/25, showed an order for Tramadol Hcl 50 mg tablet. Give one tablet two times a day related to pain. R7's Order Summary Report, printed by the facility on 2/13/25, showed an order for Pregabalin (Lyrica) 150 mg capsule. Give 150 mg three times a day for nerve pain. R8's Order Summary Report, printed by the facility on 2/13/25, showed an order for Tramadol Hcl 50 mg tablet. Give one tablet three times a day for left leg pain. R9's Order Summary Report, printed by the facility on 2/13/25, showed an order for Lacosamide 150 mg tablet. Give one tablet two times a day for seizures. R10's Order Summary Report, printed by the facility on 2/13/25, showed an order for Lorazepam 0.5 mg tablet. Give one tablet two times a day related to generalized anxiety disorder. 145556 Page 2 of 3 145556 02/13/2025 Winning Wheels 701 East 3rd Street Prophetstown, IL 61277

F 0755 On 2/13/25, the facility provided the following electronic narcotic inventory system printouts showing: Level of Harm - Minimal harm or potential for actual harm R4's Tramadol Hcl 50 mg tablet and Pregabalin 75 mg tablet showed they were signed off in the electronic narcotic inventory system on 2/13/25 at 11:17:40 and 11:17:44 AM respectively. Residents Affected - Some R5's Morphine 15 mg 0.5 tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:16:57 AM. The printout did not include R5's Klonopin information. R6's Tramadol Hcl 50 mg tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:20:35 AM. R7's Lyrica 150 mg capsule showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 2:41:22 PM. R8's Tramadol Hcl 50 mg tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:36:36 AM. R9's Lacosamide 150 mg tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:22:32 AM. R10's Lorazepam 0.5 mg tablet showed it was signed off in the electronic narcotic inventory system on 2/13/25 at 11:13:17 AM. The facility's January 2001 policy and procedure titled Controlled Medications-Ordering and Receipt showed Medications included in the Drug Enforcement Administration classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations .The form used to check in a schedule II-controlled substance is also used as the special dose administration record required by federal guidelines. The medication will be entered into the (electronic narcotic inventory system) and will be used as the special dose administration record required by federal guidelines. 145556 Page 3 of 3