Wells Ltc Nursing & Rehabilitation
Wells LTC Nursing & Rehabilitation in Wells, TX — inspection on September 4, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wells Ltc Nursing & Rehabilitation
46 May Street Wells, TX 75976
SUMMARY STATEMENT OF DEFICIENCIES
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Wells Ltc Nursing & Rehabilitation
46 May Street Wells, TX 75976
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
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.
- 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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