Inspection·March 12, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of a facility event report dated 10/04/2023 at 7:45 p.m. indicated CNA A reported Resident #1 had fallen in the dining area and did not hit his head. Resident #1 was assessed, and no injuries found, resident denied pain and was unable to give a description of what had happened. Record review of a facility event dated 10/05/2023 at 10:45 a.m. indicated the Administrator had reviewed video footage of the above reported incident in the dining area of the men's locked unit. It was reported to the nurse by the CNA that resident fell in the dining room. It was reported that resident did not hit his head. The nurse assessed resident and did not see any injuries. However, the morning of 10/05/2023, upon review of the surveillance cameras to see how the fall occurred, it was seen that resident (Resident #1) and CNA (CNA A) were standing by the water cooler in the dining room on A hall. CNA and resident are seen conversing with each other, and resident (Resident #1) becomes agitated and tosses a cup of water at the CNA, splashing her in the face and front of her shirt. CNA (CNA A) then reaches out and shoves resident on the shoulder and hits him (with what appears to be an open hand) across the left side of his head. Resident stumbles backwards, tripping, and falls on the floor, hitting his back on the chair behind him and his head on the chair seat. The CNA then walks away and gets a towel for her shirt. Record review of an emergency room summary report dated 10/05/2023 indicated Resident #1 had CT (computed tomography) scans of the head, face, spine, neck, chest, abdomen, and pelvis with no negative findings and was discharged back to the facility with no new orders. Record review of an employee file for CNA A indicated a hire date of 08/28/2023. The file included a termination report for CNA A with a suspension date of 10/05/2023 and termination dated 10/06/2023 due to workplace violence, violating federal or state care standards and was signed by the Administrator and DON. A completed criminal history check, nurse aide registry check and referrals indicated CNA A had an active certification and was employable. CNA A had completed abuse training on 08/24/2023 before her active hire date on 08/28/23. During an interview and observation on 03/11/2024 at 10:00 am CNA D was assisting CNA C with Resident #1 preparations for a shower. Resident #1 was walking in the hallway to the shower room. When asked if he was doing well today, Resident #1 looked up and nodded yes. CNA D stated he had cared for Resident #1 since his admission in September of 2023 to the male locked unit. CNA C said he has worked the unit for 10 years and resident altercations of abuse and must be reported to the administrator immediately. He said it is difficult with the A Hall locked unit being all male but by working with them for so long he can recognize a mood change and intervene early but sometimes the newer residents you don't know their signs yet. He said that Resident #1 he gets aggravated quickly and will strike out towards other residents and staff. He said Resident #1 had been to the Psych hospital after the incident on 10/04/23. He said he had been better recently. CNA C said all abuse physical, verbal, mental, financial, and sexual was to be reported immediately to the administrator. He said if a resident reports something it was his responsibility to report so the resident was protected. He said once things are reported the administrator starts her investigation and reports the abuse to the state. He said that residents have to be able to report without being afraid and no staff should retaliate against a resident or family for reporting. CNA C said if retaliation occurs the administrator will terminate them. He said he has been trained on deescalating behaviors and how to deal with difficult behaviors. He said at no time can a staff member hit a resident. During an interview on 03/11/2024 at 3:14 pm LVN C said he has worked at the facility for 1 ½ years and resident altercations are reported to the DON and Admin. He said he tries to recognize a behavior change early before an altercation occurs but does not always work that way. He said if an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 2 of 9 Printed: 05/15/2026 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 676103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few altercation occurs residents are separated and depending on the severity 1:1 and or every 5 min checks are done. 1:1 continues until behavioral hospital admission or psych MD evaluates and makes changes, it really depends on the resident and their behaviors. No 2 incidents are the same. LVN C said he has been trained on abuse and knows the types of abuse: physical, verbal, sexual, mental and financial. He said no one is to take any resident belongings or money at no time. He said that all forms of abuse must be reported immediately to the administrator and then management starts their investigation. He said all abuse should be reported to the state. He said no matter how difficult the resident is never okay to hit or harm them. He said they have been trained on how to report abuse, preventing abuse, dealing with dementia and how to deescalate behaviors and to use those training tools to deal with difficult residents. During an interview on 3/11/2024 at 4:00 pm the Administrator said she would see if she could retrieve the video footage of the incident involving Resident #1 and CNA A, since it had been some time since the incident of abuse occurred on 10/04/23. The Administrator said she gave the Chief of Police a copy for his investigation when she reported the abuse to the required authorities. The Administrator said she reported to the police department, HHS, the Ombudsman, Resident #1's medical doctor and psychiatric doctor and his family after she saw the footage of the strike made by CNA A. She said the DON received orders to send Resident #1 to the emergency room for evaluation. Resident #1 had several CT scans and returned to the facility, there were no injuries. The Administrator said the staff were in serviced on 10/05/23 on numerous topics to prevent and ensure reporting and she would provide evidence of those trainings. She said the incident was reviewed by the QAPI team on 10/05/23 to determine if any other topics needed to be addressed. During an interview on 03/12/2024 at 10:20 am with the Chief of Police, he said there was an open case #OR- 100423-01 for the arrest of CNA A. He said he had conducted an investigation after receiving a report of abuse from the facility Administrator on 10/05/23 at 10:55 am. The Chief of Police said the administrator had advised him when she arrived at work on the morning of 10/05/23 she had been advised that one of the residents (Resident #1) had gotten disruptive during the evening of 10/04/23 and had fallen but had no injuries. The Chief of Police said the Administrator had told him she located the video footage of the dining area for viewing, as she usually does after an incident in the area. The Administrator was able to determine the event was not as previously reported by the CNA, as the resident (Resident #1) was pushed and hit by CNA A and had not just fallen as reported by CNA A. The Chief of Police said he had viewed the video footage of the incident on 10/04/2023 involving Resident #1 and CNA A provided to him by the Administrator. He said he had concluded his investigation, which included assessing for injuries and making pictures of the resident at the facility but was not able to document any injuries from the resident being hit and knocked down. He said based on the video evidence which shows the suspect intentionally and knowingly striking an elderly person over the age of 65 ([AGE] years of age) with a closed fist, causing bodily injury, a warrant for injury to the elderly was requested. The Chief said there was an open warrant for CNA A's arrest, but she had not been apprehended yet. He said that most likely until she had a traffic violation or another issue, it would remain outstanding. Record review of a facility policy titled Abuse and Neglect-Clinical Protocol dated March 2018 indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes deprivation by an individual, including a caretaker or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental, or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 3 of 9 Printed: 05/15/2026 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 676103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facilitated or enabled through the use of technology .willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Treatment/Management 3. The physician will order measures required to address the consequences of an abuse situation. The facility took the following action to correct the non-compliance on 10/05/2023: The facility conducted a physical assessment including skin assessments on all residents in the locked unit, safe surveys were completed on all residents 10/05/2023. In-services included: Retaliation, abuse, preventing resident accidents and incidents, Reporting abuse to the abuse coordinator, Reporting abuse to facility management, Recognizing signs and symptoms of abuse, Abuse investigations, Abuse, neglect, exploitation and misappropriation-reporting and investigating, Investigating resident injuries, Quick safety de-escalation in healthcare, Preventing accidents and incidents, were conducted with all staff on 10/05/2024 then was referred to QAPI (quality assurance performance improvement) committee for efficacy of plan and monitoring frequency. Record Review of a QAPI meeting dated 10/05/2023 indicated the committee meet for discussion of the event involving abuse. A Performance Improvement plan was developed including all reviewed trainings and assessments on 10/05/2023. Record review of an In-service Training report named Retaliation, abuse, preventing resident accidents and incidents, dated 10/05/2023 and conducted by the DON to the facility staff included: Complaints are reported in good faith, it is illegal for the facility or any employee to intimidate or retaliate in any way against the resident or the family reporting. Record review of an In-service Training report named Reporting abuse to the abuse coordinator dated 10/05/2023 and conducted by the DON to the facility staff included: The abuse coordinator is the administrator. Record review on an In-service Training report named Reporting abuse to facility management dated 10/05/23 conducted by the DON to facility staff included: Condemnation of resident abuse, retribution for reporting abuse, responsibility of reporting resident abuse, notifying agencies/individuals of resident abuse, notifying administration of resident abuse, methods of resident abuse, contents of notice of abuse. Record review on an In-service Training report named Recognizing signs and symptoms of abuse/neglect, dated 10/05/23 conducted by the DON to facility staff included: signs and symptoms of abuse, neglect, and psychological abuse and neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 4 of 9 Printed: 05/15/2026 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 676103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review on an In-service Training report named Abuse investigations, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Nursing facility must report no later than two hours after an allegation is made for abuse. The investigation process including all reports of abuse/neglect and injuries will be promptly reported and investigated. Record review on an In-service Training report named Abuse, neglect, exploitation, and misappropriationreporting and investigating, to facility management dated 10/05/23 conducted by the DON to facility staff included: Definitions of Abuse, neglect, exploitation and misappropriation, steps of reporting and investigations. Record review on an In-service Training report named Investigating resident injuries, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Facility policy stating all resident injuries are investigated. Record review on an In-service Training report named Quick safety de-escalation in healthcare, to facility management dated 10/05/23 conducted by the DON to facility staff included: De-escalation is the first line response to prevent potential violence and aggression. Record review on an In-service Training report named Preventing accidents and incidents, to facility staff dated 10/05/23 conducted by the DON to facility staff included: Facility will work to prevent any accident or incident. The facility will change the plan of care in the event of an accident and or incident. All new hires will continue to be required to complete the abuse training on hire as required by regulation. Interviews with staff members, (CNA A, CNA B, CNA C LVN E, LVN F) starting at 11:45 am - 2:00 pm on 03/12/2024, revealed they were in-serviced and verbalized training regarding Abuse. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) could identify understanding of Retaliation, abuse, preventing resident accidents and incidents. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of when to report abuse to the abuse coordinator, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized when Reporting abuse to facility management, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized when Recognizing signs and symptoms of abuse, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Abuse investigations, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding Abuse, neglect, exploitation, and misappropriation-reporting and investigating. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Investigating resident injuries. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Quick safety de-escalation in healthcare. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Preventing accidents and incidents. During an interview on 03/12/2024 at 3:00 pm the Administrator stated she expected her staff to report any abuse, neglect or exploitation. She said that retaliation was not tolerated. She stated that the monitoring would continue with the facility QAPI meetings. During an interview on 3/12/2024 at 3:15 pm the DON said she expected all staff to treat the residents with dignity and respect. The DON said that abuse will not be tolerated in the facility and any staff members that is accused of abuse will be immediately placed on suspension and terminated pending the investigation. The DON said her focus is now on her hiring process to ensure that quality (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 5 of 9 Printed: 05/15/2026 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 676103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 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 0600 staff members are brought into the facility. Level of Harm - Immediate jeopardy to resident health or safety The noncompliance was identified as PNC. The IJ began on 10/04/2023 and ended 10/05/2023. The facility had corrected the noncompliance before the survey began. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 6 of 9 Printed: 05/15/2026 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 676103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of resident property for 1 of 5 residents (Resident #2) reviewed for misappropriation. Residents Affected - Few The facility failed to prevent misappropriation of property when NA H took money via bank card in the amount of $202.50. The noncompliance was identified as PNC (past non-compliance) The noncompliance was began on 02/29/2024 and ended 03/04/2024. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of misappropriation which could lead to further exploitation of other residents. Findings included: Record review of Resident #2's electronic face sheet, dated 03/03/2024, indicated that he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dysphagia, (difficulty swallowing), Atrial Fibrillation (an abnormal heart rhythm), Abnormalities of gait and mobility, Morbid obesity, hypertension (high blood pressure), and acute and chronic respiratory failure. Record review of MDS dated [DATE], indicated that Resident #2 was understood by others and understood others. Resident #2 had a BIMS of 11, which indicates moderate cognitive impairment. Record review of comprehensive care plan, dated 9/14/2023, indicated resident #2 had an ADL self-care performance deficit related to leg amputation and requires extensive assistance with bed mobility, dressing, and bathing. Resident #2 is care planed for dependence on staff for activities, cognitive stimulation and social interaction related to immobility and physical limitations. Care plan dated 3/03/2024 for Resident #2 indicated that he had a potential psychosocial well-being problem related to Resident #2 gave employee money for her light bill. During an interview on 3/11/2024 at 10:30 AM, the administrator said that on 3/3/2024 Resident #2 reported he had paid for NA H's electric bill and that she had agreed to pay him back the next day on payday . The administrator reported the incident to local law enforcement and the Ombudsman Record review of witness statement, dated 3/3/2024, by Resident #2 indicated that he had paid $309.00 on 2/28/2024 on NA H's electric bill, she had withdrawn $200.00 from his account at an ATM, bought 3 packs of cigarettes using his money and that he had given her $20.00 and $10.00. His statement indicated that NA H was to pay him back on 2/29/2024. Record review of witness statement, dated 3/3/2024, by NA H indicated that Resident #2 would request that NA H would provide personal care and that he had asked her to kiss his penis while providing incontinent care. She said that Resident #2 offered her $100.00 to allow him to touch her breast on 3/1/2024. NA H denied any inappropriate touching and denied receiving any money from Resident #2. Record review of local Police Department Incident report dated 3/3/2024 showed the incident that was reported to facility on 3/3/2024 was reported to police and that event was under investigation at that time. Law enforcement obtained a photo from electronic monitoring device of local store dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 7 of 9 Printed: 05/15/2026 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 676103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2/27/2024 with time stamp that had NA H using the ATM. Resident #2 provided electronic bank statement that had a $202.50 withdrawal that occurred on 2/27/2024 at the same time and location. Resident #2 also provided proof of a $309.92 transaction to a local electric company. Record review of safe survey performed on 3/3/2024 on 10 residents by social worker revealed initially all residents denied giving money to staff members or recalled being asked for money. During an interview on 3/12/2024 at 1:00 PM, the Business Office Manager said that she was responsible for residents' money. She said that if a resident wants to access cash, she completes a form and the resident signs for any money given. She said that residents are limited to $60.00 a day but can come in multiple times a week if they wish to withdraw more money. She said that any items purchased for the residents require a receipt and that the resident signs the receipt as proof of how money is spent. The BOM stated that Resident #2 manages his own money. She said that he has his own banking account and that she goes to his room every third week of the month to have him sign a paper to allow the facility to draft his monthly payment from his account. During an interview on 3/12/2024 at 1:20 PM LVN G said that she was on duty the date that the incident on 3/3/2024 was reported. She was the nurse that took the statement from Resident #2. She said that the resident was upset that NA H did not want to take care of him and was uncomfortable being in his room. She said that Resident #2 told her that he had paid for NA H's electricity and that she was going to pay him back, but she had not given the money back on the day she stated she would. LVN G said that no other residents had reported to her that money was taken or that any employee had asked them for money. During an interview on 3/12/2024 at 2:00 PM the DON said that NA H had been hired as a housekeeper and had recently transferred to a hospitality aide position. She said that NA H had a CNA certification in the past and did not renew her certification but was interested in restoring her certification. The DON said that NA H had only worked as a hospitality aide for a week prior to the incident that was reported. She was not aware of any complaints prior to the one on 3/3/2024. She said that all staff must complete training on abuse, neglect, and exploitation upon hire, which includes housekeeping staff. Training includes definitions of Abuse, neglect, exploitation and misappropriation, steps of reporting and investigations. Record review of NA H's Personnel File indicated a hire date of 01/14/2024. Preventing, Recognizing, and Reporting Abuse training was completed on 1/14/2024. A change in status from housekeeping to hospitality aide was 2/27/2024. Record review of Associate Separation Report dated 3/4/2024 and signed 3/8/2024 indicated that NA H was terminated as a result of the investigation of the incident reported on 3/3/2024 . The facility took the following actions to correct the non-compliance on 03/03/2024: Records review of staff training dated 3/3/2024 conducted by DON included Abuse, Neglect, Exploitation and Misappropriation of Residents, Abuse Neglect, Exploitation and Misappropriation Prevention Program, Compliance and Ethics- Risk Areas for Fraud and Abuse, Coordinating/Implementing Abuse, Neglect, and Exploitation Policies and Procedures and Recognizing Signs and Symptoms of Abuse/Neglect. Record review on an In-service Training report named Abuse, neglect, exploitation, and misappropriationreporting and investigating, to facility management dated 3/3/2024 conducted by the DON to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 8 of 9 Printed: 05/15/2026 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 676103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility staff included: Definitions of Abuse, neglect, exploitation and misappropriation, steps of reporting and investigations. Condemnation of resident abuse, retribution for reporting abuse, responsibility of reporting resident abuse, notifying agencies/individuals of resident abuse, notifying administration of resident abuse, methods of resident abuse, contents of notice of abuse. Record review of QAPI meeting dated 3/3/2024 indicated the committee met for discussion of the event involving misappropriation. A performance approval plan was developed including ongoing monitoring of trainings and assessments of residents involved in the incident. Interviews with staff members, (CNA A, CNA B, CNA C LVN E, LVN F) starting at 11:45 am - 2:00 pm on 03/12/2024, revealed they were in-serviced and verbalized training regarding Abuse. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) could identify understanding of Retaliation, abuse, preventing resident accidents and incidents. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of when to report abuse to the abuse coordinator, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized when Reporting abuse to facility management, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized when Recognizing signs and symptoms of abuse, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Abuse investigations, All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding Abuse, neglect, exploitation, and misappropriation-reporting and investigating. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Investigating resident injuries. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Quick safety de-escalation in healthcare. All 5 staff members (CNA A, CNA B, CNA C LVN E, LVN F) verbalized understanding of Preventing accidents and incidents. During an interview on 03/12/2024 at 3:00 pm the Administrator stated she expected her staff to report any abuse, neglect or exploitation. She said that retaliation was not tolerated. She stated that the monitoring would continue with the facility QAPI meetings. During an interview on 3/12/2024 at 3:15 pm the DON said she expected all staff to treat the residents with dignity and respect. The DON said that abuse will not be tolerated in the facility and any staff members that is accused of abuse will be immediately placed on suspension and terminated pending the investigation. The DON said her focus is now on her hiring process to ensure that quality staff members are brought into the facility. Record review of a policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, stated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.protect residents from misappropriation of property by anyone including facility staff develop and implement policies and protocols to prevent and identify .theft, exploitation or misappropriation of resident property. The noncompliance was identified as PNC (past non-compliance) The noncompliance was began on 02/29/2024 and ended 03/04/2024. The facility had corrected the noncompliance before survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 9 of 9