Wells Ltc Nursing & Rehabilitation

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

[Resident #7] went to turn over on his back, we could clearly see his penis was in [Resident #8's] buttocks, [Resident #7] had BM on his hands and could see where he had placed his penis in [Resident #8] rectum, [Resident #8] he had BM on his butt cheek and around his rectum, myself and nurse helped [Resident #8] get up out the bed, got him cleaned up and clothes on and covered up in bed. He was weak and very confused to what was going on!! After removing [Resident #8] to another room, I asked [CNA N] to help me to get [Resident #7] cleaned up, had him to get up in his wheelchair, so bed could be cleaned up, he had took his soiled brief off and it was thrown at the end of the bed when we entered the room, (I) saw it, the bed had a small urine stain that was wet under where [Resident #7] was laying & BM on the sheet on the back side where he [Resident #7] was laying., he had BM on his hands, face, legs!! I asked [Resident #7] why he did that to [Resident #8], he stated he didn't know, I asked him had he did that to him before and he said NO!! End of Statement!!! During an interview on 9/02/2025 at 10:20 AM CNA B said Resident #7 would make sexual comments such as you can suck it or can you touch it while she would provide care.

She said when she told Resident #7 to stop talking like that he would. She said she knew Resident #7 had made sexual comments to staff but she had never seen Resident #7 make inappropriate sexual comments or gestures to any other residents prior to the incident. During an interview on 9/02/2025 at 10:40 AM Resident #7 said he had been sexually inappropriate with another resident at the facility. He said it was not last night, but it was maybe a month ago and it was not his roommate. He refused to say what resident the incident had occurred with. Resident #7 said he never penetrated anyone with his penis, but he got in the bed with that resident and went through the sexual motions. When asked why Resident #7 did what he did to the other resident he said it was his sexual mind. During an interview on 9/02/2025 at 3:45pm the RCN and COO said they had not been told by the previous facility that Resident #7 had any sexual behaviors prior to being admitted to the facility. The COO then said he thought by placing Resident #7 in the male secure unit they did not think that there would be any inappropriate sexual behaviors since all prior inappropriate sexual behaviors had been towards female staff members. During an interview on 9/02/2025 at 6:18pm LVN J said she was doing a room check at 1:30am and said it was the first time she had seen Resident #7 or Resident #8 since the start of her shift at 6pm. She said when she opened the door to their room, she saw Resident #8 lying in Resident #7s bed with Resident #7

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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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wells Ltc Nursing & Rehabilitation

46 May Street Wells, TX 75976

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

not last night, but it was maybe a month ago and it was not his roommate. He refused to say what resident

the incident had occurred with. Resident #7 said he never penetrated anyone with his penis, but he got in

the bed with that resident and went through the sexual motions. When asked why Resident #7 did what he did to the other resident he said it was his sexual mind. During an interview on 9/02/2025 at 3:45pm the RCN and COO said they had not been told by the previous facility that Resident #7 had any sexual behaviors prior to being admitted to the facility. The COO then said he thought by placing Resident #7 in the male secure unit they did not think that there would be any inappropriate sexual behaviors since all prior inappropriate sexual behaviors had been towards female staff members. During an interview on 9/02/2025 at 6:18pm LVN J said she was doing a room check at 1:30am and said it was the first time she had seen Resident #7 or Resident #8 since the start of her shift at 6pm. She said when she opened the door to their room, she saw Resident #8 laying in Resident #7s bed with Resident #7 behind Resident #8 and both residents were laying on their right sides facing the window in the room. She said she was shocked with what she saw so she stepped back in the hallway and called for the CNA to come and help her. She said when they walked back in the room they said, what's going on? She said when they said that Resident #7 jumped and turned to see who was coming in the room which caused his penis to withdraw from Resident #8's rectum. She said both residents had a large amount of feces on them, but Resident #7 had feces caked in his front groin area. She said she asked both residents what happened, and Resident #8 said he did not know what happened. She said Resident #7 said he knew what he did and then said, I'm sad my son died. She said Resident #8 seemed to be extremely confused and k

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wells Ltc Nursing & Rehabilitation

46 May Street Wells, TX 75976

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 0725 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

none exhibited. Resident #2 was on hospice services and is now deceased . 3. 7/30/25 Resident #3 had emotional distress assessment completed for 72 hours post the incident of #3 being hit. 7/30/25 Resident #3 was assessed for injuries and no injuries were present from the altercation with Resident #4. Psych referral was completed on 7/31/25 for Resident #3 and NP visit took place on 8/11/25 with order changes.

1. 4. 7/30/25 Resident #4 was placed on 1:1 following the incident. Resident #4's psych physician was

updated regarding the incident 7/30/25 and gave an order for psych behavioral placement. Resident #4 left

the faciity on 7/31/25.5. 7/13/25 Resident #5 was placed on 1:1 supervision in response to the incident that occurred. Resident #5 was moved to a different hallway on 7/13/25. A psych physician visit took place on 7/14/25 with orders for behavioral health placement. Resident #5 was admitted to behavioral psych services on 7/14/25.6. Resident #3 was assessed for injuries on 7/13/25 and none were present. Resident #3 had emotional distress monitoring completed for 72 hours post the incident with Resident #5. Neuros were initiated per protocol. Resident #3 had no emotional distress related to the incident with resident #5.7.

Resident #6 was placed on 1:1 supervision in response to the resident-to-resident altercation with resident #5 on 8/28/25. Psych services was contacted on 8/28/25 regarding the incident and orders were obtained to send to behavioral health for review. Resident #6 left the facility per the order on 8/28/25. Resident #5 had no injuries in response to the incident.8. Resident #8 was assessed by the nurse and sent to the ER for evaluation and admitted for alternate placement as the admitting diagnosis. Resident #8 is set to return to

the facility on 9/3/25 with no updated orders at this time and the facility will change interventions according to any new orders.9. Res

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