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Complaint Investigation

Wells Ltc Nursing & Rehabilitation

February 24, 2026 · Wells, TX · 46 May Street
Citations 2
CMS Rating 1/5
Beds 90
Provider ID 676103
Healthcare Facility
Wells Ltc Nursing & Rehabilitation
Wells, TX  ·  View full profile →
Inspection Summary

Wells LTC Nursing & Rehabilitation in Wells, TX — inspection on February 24, 2026.

Found 2 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.

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Inspection Findings

FF0755
Pharmacy Service Deficiencies

During an interview on [DATE] at 9:10am, The administrator said at the time of the drug diversion the ADON office door was not secure and was able to be easily opened by bumping the door with your hip.

She said the drug destruction closet had 1 door handle lock.

She said during the investigation of the drug diversion the DON was able to get a butter knife from the kitchen and easily break into the drug destruction closet.

She said at the time of the drug diversion the narcotic medications were not being stored inside the locked safe.

She said the new ADON had started logging the narcotics for destruction and that is how they were able to determine if there were missing narcotics.

She said the prior ADON did not log the narcotics at the time of placing them in the closet but only logged them when the pharmacist was at the facility to do the drug destruction.

She said the facility could not determine if there were any other missing narcotics because they were not being logged as they were received so anyone could take them without the facility knowing.

Record review of the Facility Drug Destruction Log dated [DATE] indicated 43 tablets of Resident #1's hydrocodone/acetaminophen 5/325mg were Not destroyed, Not found in in lock box, DON will research signed by the DON and the Pharmacist.

Review of the facility policy and procedure titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April of 2021, stated Develop and implement policies and protocols to prevent and identify: .theft, exploitation or misappropriation of resident property.

Review of the facility policy and procedure titled Controlled Substances, dated [DATE], stated 1.

Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises. 3.

Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications.

Review of the facility policy and procedure titled Discarding and Destroying Medications, dated [DATE], stated 1.

All unused controlled substances are retained in a securely locked area with restricted access until disposed of.

676103 02/24/2026

Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

Based on observation, interview, and record review the facility failed to ensure in accordance with

temperature controls, and permitted only authorized personnel to have access to 1 of 1 medication destruction storage closet reviewed for medication storage.

The facility failed to ensure the medication destruction closet was secured and was unable to be accessed by unauthorized personnel between 12/04/2025 through 1/15/2026.This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication.

Findings included:During an observation on 2/23/2026 at 9:10 am, the medication destruction closet located inside the ADON office revealed the door to the ADON office was open with no staff present.

The medication destruction closet had a pad lock that was locked, a door handle that was locked and a deadbolt lock that was not locked.

Inside of the medication destruction closet revealed a safe that contained the narcotic medications waiting to be destroyed.

The safe was not permanently affixed and was able to be picked up and moved.

During an interview and observation on 2/23/2026 at 12:24 pm, the DON unlocked the pad lock and the door handle on the medication destruction closet door which contained the narcotic safe.

The DON opened the narcotic safe and tilted the safe forward which indicated the narcotic safe was not permanently affixed to the shelf.

During an interview on 2/23/2026 at 9:10 am the ADON said she had been trained by the previous ADON for about 1 week.

She said all she knew was the medications were supposed to be in the closet locked but did not know they needed to be in the locked safe with the safe permanently affixed to the shelf.

Review of the facility policy and procedure titled Controlled Substances, dated April 2019, stated 1.

Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises. 3.

Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications.

Review of the facility policy and procedure titled Discarding and Destroying Medications, dated November 2022, stated 1.

All unused controlled substances are retained in a securely locked area with restricted access until disposed of.

Review of the facility policy and procedure titled Medication Labeling and Storage dated February 2023 indicated: .7.

Controlled substances (listed as schedule II-V of Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

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 Wells, TX, (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 Wells LTC Nursing & Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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