Winning Wheels
Inspection Findings
F-Tag F0602
F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
to sign it out in (Narcotic Reconciliation System) and document it in the resident's MAR. If both of those things aren't done, then you cannot assume a medication was given. Furthermore, it is possible to just sign
a medication out of (Narcotic Reconciliation System) and never give it to the resident. You would catch that
on their MAR and it would alert us that they missed a dose. On 12/20/25 at 2:10PM, V6 (Registered Nurse) stated, I followed (V5) after her shift on 9/30 and didn't see anything unusual. I also didn't work with her overnight though and I guess that was a different story. All of the counts were accurate, so I didn't investigate anything further because we don't look at when medications were pulled, just the count to ensure it matches. (Resident R1) complained of pain and he didn't remember getting his pain medicine from (V5) but
it was signed off on the MAR (medication administration record) so all I could offer him was Tylenol & Ibuprofen which he accepted. I did report to the DON (Director of Nursing) immediately that he said he did not get his morning medicine and that's when they started looking at the (Narcotic Reconciliation System) records and noticed discrepancies.On 12/20/25 at 2:50PM, V1 stated, It was so obvious that (V5) was diverting medications. She had to have ingested some of them on her shift with the number of times she was falling asleep, dropping items, and spilling things. She looked at the camera almost every time she took
a medication from a medication card and whenever she put something in her mouth. We have cameras showing her from every angle taking those medications. At one point she was also vaping while she was down the resident hallways. I reported it to (local police department) and they initiated an investigation.
They are opening a larger investigation into (V5) as this isn't the first facility she has done this to in our area. I feel bad because we are supposed to be protecting our residents from this type of thing. She flat out stole from them right on camera.On 12/21/25 at 8:35AM, V2 (Director of Nursing) stated, I was the ADON (Assistant Director of Nursing) during this investigation. The previous DON got alerted from (Narcotic Reconciliation System) of discrepancies and we started looking into it and noticed (V5) was checking out 2 pills at a time for residents at the end of her shift on 9/30/25. The night nurse, V3 (Licensed Practical Nurse) also said something didn't seem right with (V5) and she had been falling asleep all night and not caring for her residents. We did some more digging and made (V1) aware and we watched the cameras to see what (V5) did all night. It was pretty evident right away that she was diverting narcotics. She was falling asleep multiple times throughout her shift and putting things in her mouth and popping pills out of the medication cards and not administering them. We didn't have anything in place before to stop the nurse's from checking out multiple doses in the (Narcotic Reconciliation System) but now we have a lock in the system so they can't document removing more than the ordered dose for each resident.During the course of this investigation, 3 attempts were made to contact V5 without success.The facility's policy titled, Abuse Program: Investigation/Reporting/Response dated 3/17 showed, 8. MISAPPROPRIATION OF RESIDENT PROPERTY means the deliberate misplacement, exploitations, orwrongful, temporary or permanent use of
a resident's belongings or money without the resident's consent .The facility's policy titled, Controlled Substance Administration & Accountability dated 2025 showed, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .G. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/21/2025
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-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm
Program: Investigation/Reporting/Response dated 3/17 showed, Employees are required to immediately notify the Administrator and the Director of Nursesand staff that is on duty of any complaints of, observation of, or suspicion of resident abuse,mistreatment or neglect .Continue the facility investigation as needed, to be concluded within 48-72 hours, if possible.
Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/21/2025
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-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Based on interview and record review, the facility failed to ensure medications were administered per physician's orders for 4 of 6 residents (Resident R4, Resident R5, Resident R6, Resident R14) reviewed for pharmacy services in the sample of
- 14. The findings include:The facility's incident report dated 10/8/25 showed, On 9/30/25 at 7AM, V1
(Administrator) received a phone call from Director of Nursing, stating that it was reported to her that the agency night nurse (V5-Licensed Practical Nurse) had slept most of the night. Concerns were brought up that (V5) did not complete her wound treatments, failed to sign out medications in EMAR (Electronic Medication Administration Record) .2 residents were identified to have not received their scheduled medications .Resident R4's September 2025 MAR (Medication Administration Record) showed Resident R4 receives Amantadine 100mg, fluoxetine 10mg, lactulose 15ml, omeprazole 20mg, baclofen 10mg, buspirone 5mg, diazepam 5mg, levetiracetam 1000mg, Norco 5/325mg at 5:00AM. No documentation was present showing Resident R4 received his 5:00AM medications from V5 on 9/30/25.Resident R5's September 2025 MAR showed Resident R5 receives fluticasone 50mcg spray, omeprazole 40mg, aspirin 81mg, finasteride 5mg, furosemide 40mg, lidocaine 4% patch, trelegy inhalation 100-62.5-25mcg/act, venlafaxine 225mg, doxycycline 100mg, Eliquis 5mg, metformin 1000mg, metoprolol 12.5mg, oxybutynin 5mg, gabapentin 900mg, and baclofen 20mg at 5:00AM. No documentation was present showing Resident R5 received his 5:00AM medications from V5 on 9/30/25.Resident R6's September 2025 MAR showed Resident R6 receives Escitalopram 25mg, scopolamine 1.5mg patch, tizanidine 4mg, Colace 100mg, famotidine suspension 20mg, levetiracetam 2500mg, Lyrica 300mg, and trihexyphenidyl 2mg at 5:00AM. No documentation was present showing Resident R6 received her 5:00AM medications from V5 on 9/30/25.Resident R14's September 2025 MAR showed Resident R14 receives aspirin 81mg, Colace 100mg, amantadine 100mg, propranolol 20mg, and baclofen 15mg at 4:00AM. No documentation was present showing Resident R14 received her 4:00AM medications from V5 on 9/30/25.On 12/21/25 at 12:27PM, V2 (Director of Nursing) stated, If there is nothing documented in the residents MAR we would have to go through the medication cards to see if they were popped or not and that was not done. It would have shown
it was missed or given because our medication cards are dated. We would have been able to see if they were given or not and depending on time if they could receive it or not. I can't recall what was given and what wasn't but that's the process we would take. The residents that are not able minded we just monitored for pain after this incident. The charting system switches when the shift switches over so the next round of meds would have displayed on the screen so it may not have triggered for the next nurse to see that medications weren't given. Surveyor was unable to view the medication cards from September 2025 for Resident R4, Resident R5, Resident R6, Resident R14.The facility's policy titled, Medication Administration dated 2/25 showed, 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 .15. After the resident has taken the medication, immediately sign out on MAR. Never delay this action.
Event ID:
Facility ID:
If continuation sheet
WINNING WHEELS in PROPHETSTOWN, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PROPHETSTOWN, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WINNING WHEELS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.