Health inspection·September 4, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 revealed the incident description that Resident #1 was standing over Resident #2 who was sitting on the couch. Resident #1 said something to Resident #2 and resident # 2 shoved Resident #1 causing her to fall. Both residents were assessed for injuries. A skin tear to the left elbow and a raised area was noted to the left side of resident #1's head. An xray revealed age indetermination fifth digit proximal phalanx head fracture (fracture to left fifth toe) for resident #1. Record review of witness statement from CNA F dated 6/25/2025 revealed on the day of 6/25/2025. I saw [Resident #2] push [Resident #1], causing [Resident #1] to fall down. [Resident #2] was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. During an interview on 9/4/2025 at 11:49 AM with RN L she said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and not aggressive and was mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character . 3. Record review of Resident #3's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he was moderately cognitive impaired. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate with walking. Section E of the MDS indicated Resident #3 had not had any behaviors. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related to being hit in the face 2 times by Resident #5 on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 (1 staff member to 1 resident) monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related 7/30/2025 being slapped by Resident #4. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind with interventions that included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed form emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of a progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted, no acute distress and no discomfort noted. The residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by the nurse and all parties were notified by nurse and RN. Record review of a progress note for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 2 of 24 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 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #3 was sitting in the dining room at his table when Resident #4 hit him in the head from behind. Record review of a facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by his roommate Resident #5. An assessment was completed by his nurse and no injuries were noted and no pain or discomfort was noted. Record review of a facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by Resident #4. Redirected other resident away from this resident, placed other resident on 1:1 monitoring. 4. Record review of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Section E of the MDS indicated Resident #4 had not had any behaviors. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring, and Resident #3 was placed on Q15 monitoring. Both residents were assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents were assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident to resident altercations. Record review of a progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated the resident was witnessed hitting other resident on the right side of their head from behind while attempting to come in back door. Psych MD notified and received new order to send to inpatient facility. Record review of a progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated the resident was placed 1 on 1 with housekeeping sitting with the resident at that time. Record review of a progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated the behavioral hospital was at the facility to pick the resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 on the right side of his head from behind while attempting to go out the back door of the dining room to the smoking area. Resident #4 was redirected away from Resident #3 and out onto open floor with nurse so he could be 1 to 1 at that time. During a confidential interview on an undisclosed date and time the interviewee said on 7/30/2025 Resident #4 was trying to go outside, and Resident #3 was fussing at Resident #4 to not go outside and backed his wheelchair up and into Resident #4 and that was when Resident #4 slapped Resident #3 on the right side of the face from behind. During an interview on 9/04/2025 at 1:10 PM the ADON said Resident #4 had a history of physical aggression. She said prior to the incident with Resident #3, Resident #4 had hit his previous roommate because their wheelchairs had got tangled up. She said Resident #4 had gone out to a behavior hospital for that incident and had not had any aggressive behaviors since that time. She said on 7/30/2025 Resident #3 and Resident #4 were by the back door and Resident #3 backed his wheelchair up and into Resident #4's wheelchair and Resident #4 slapped Resident #3 on the right side of his face from behind. She said Resident #3 had not any incidents of verbal aggression prior to the incident. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 3 of 24 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 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking . Section E of the MDS indicated Resident #5 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming). Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Resident #5 hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. Record review of a progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated the nurse was notified by the CNA that the resident hit his roommate twice in the head and then had a shoe and was going to hit another resident but was redirected by the nurse> All parties were notified. The resident was placed on 1:1 and every 15-minute monitoring and separated. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM completed by LVN D indicated: Notified by the CNA Resident #5 hit roommate in the head twice and had a shoe in his hand. The resident was redirected. Resident #5 was assessed by the nurse no and issues were noted. Resident #5 was redirected by the nurse and placed on 1:1 monitoring. During an interview on 9/02/2025 at 10:20 AM CNA B said most days she was on the male secure unit as the only CNA. She said on the day of the incident were Resident #5 hit Resident #3 she was on the male secure unit as the only CNA. She said Resident #3 had wandered into Resident #5's room and Resident #5 hit Resident #3 in the middle of his forehead with a closed fist 2 times. She said she separated Resident #5 and Resident #3 and went and got the nurse. She said Resident #6 had been aggressive to both Resident #3 and Resident #5. She said it had been reported to the ADON and the DON multiple times by nothing had been done. She said the nurse came to the male secured unit while the nurse was making her round or when she was asked to come in by the CNA but that was the only time the nurse was on the male secure unit. She said MA M was on the male secured unit only while MA M was passing out medications. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Section E of the MDS indicated Resident #6 had verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming). Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 4 of 24 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 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. The care plan did not address behaviors prior to the incident. Record review of a progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition: Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of a progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition: Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable, nurse reports that the resident continues to try and hit at a fellow male resident, staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of a facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists, acting like he would hit the resident. The resident was redirected. Record review of a facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated: Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists, acting like he would hit the resident. The resident was redirected and placed 1:1 supervision. During a confidential interview on an undisclosed date and time the interviewee said Resident #6 was a recent admission from the behavioral hospital and said he came to the facility aggressive. She said Resident #6 had been bullying Resident #5 since he admitted 2 days prior to the incident. She said on 8/28/2025 Resident #5 was sitting at the table in the dining room and Resident #6 walked over to Resident #5 and hit him with a balled-up fist to the right side of the face and chin area. She said Resident #5 did not have any redness or bruising where he was hit. She said when the incident occurred, she was trying to keep a fall risk resident from falling. She said she felt like if there was a second CNA in the male secure unit the incident may have been to be prevented. During an interview on 9/2/2025 at 12:20 PM the DON said CNA A facetime called her and showed her how Resident #6 was acting. She said she then ordered Resident #6 to be placed on 1:1 monitoring. She said it was not a video that was sent to her, but it was an actual in real time facetime call. She said she does not allow videos of residents on her phone and said if there was a recorded video then Resident #6 must have attempted to hit Resident #5 more than once. During a confidential interview on an undisclosed date and time the interviewee said she had taken a video of how Resident #6 had been acting and sent the video via text message to the DON. She said she took the video as desperation to get more help on the male secure unit. Observation of a video on 9/02/2025 at 12:32 PM on 9/02/2025 at 12:32 PM taken on 8/28/2025 revealed Resident #5 was sitting at a table in the dining room of the male secure unit, and Resident #6 then walked over to Resident #5 and began attempting to hit Resident #5 multiple times. During an interview on 9/02/2025 at 1:14 PM Housekeeper O said on 8/28/2025 she saw Resident #5 and Resident #6 having a verbal altercation. She said Resident #6 balled up his fists, so she got in between the 2 residents. She said there was only 1 CNA on the male secure unit that day and she was in a room providing care to another resident when the incident she saw occurred. She said she never saw Resident #6 actually make contact with Resident #5 at that time. During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 5 of 24 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 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 9/04/2025 at 1:10 PM the ADON said on 8/27/2025 the CNAs had reported to her that Resident #6 was targeting and taunting Resident #5 by acting like he was angry with Resident #5 and attempting to hit him. She said she notified to psych doctor and received an order to increase his medication. She said on 8/28/2025 she was the nurse working on the male secured unit and said CNA A reported to her that Resident #6 was being physically aggressive to Resident #5. She said she brought Resident #6 outside of the male secured unit to the nurse's station and kept him there until he discharged to the behavior hospital. She said Resident #6 was still at the behavioral hospital at the time of the interview. She said Resident #6 was still at the behavioral hospital at the time of the interview. During an interview on 9/04/2025 at 2:07 PM the DON said on 8/28/2025 CNA A was the only CNA on male secure unit that day. She said the ADON was the nurse for the male secure unit that day and reported to her that Resident #6 was becoming more aggressive and told her she had already notified the psych doctor and received the medication increase order and asked if she could put Resident #6 on 1:1 monitoring. She said it was never reported to her that Resident #6 had hit Resident #5. She said she had questioned herself if Resident #6 was appropriate for their male secure unit due to his aggressive behaviors. She said Resident #6 discharged to the behavior hospital on 8/28/2025. During an interview on 9/04/2025 at 3:07 PM the Administrator said it was never reported to her that Resident #6 had been physically aggressive to Resident #5. She said it was reported to her that Resident #6 had been sent out to the hospital, but she did not know it was a behavior hospital. She said it was after surveyor entrance that she read the 24-hour report that she discovered Resident #6 had been sent out to a behavioral hospital. She said they did normally discuss where residents were sent out to in the morning meetings, but she had taken a day off work and was not in the morning meeting the day after Resident #6 had been sent out. She said after she found out Resident #6 had been sent to a behavior hospital; she did not question anyone as to why he was sent to a behavior hospital. She said on 9/03/2025 after surveyors entrance it was discussed with the DON that she must be notified of any resident-to-resident altercations. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing, toilet use and personal hygiene and did not attempt walking. Section E of the MDS indicated Resident #7 had not had any behavioral symptoms. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behaviors: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 supervision. Record review of a progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: the resident was involved in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 6 of 24 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 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some resident-to-resident incident approximately 2:30 AM. The resident was placed on 1-on-1 monitoring and will be referred to psych services. Record review of a facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found this Resident #7 lying on the right side behind Resident #8 facing the window. Observed Resident #7 having sexual intercourse with Resident #8. Upon entering and discovering Resident #7 removed penis and both residents remained lying quietly. This nurse requested help from CNA K to remove Resident #7 from behind Resident #8 and separate them so assessments and investigation of incident could be performed. Resident #7 verbalized that he knew what he had done and said this incident was the first time. When questioned further Resident #7 began stating he was sad after the recent loss of his son and did not want to discuss any further. Resident #7 requested medication for anxiety and nerves. This nurse medicated Resident #7. 8. Record review of Resident #8's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Section E of the MDS indicated Resident #8 had not had any behavioral symptoms. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Record review of a progress note for Resident #8 dated 9/02/2025 at 1:30 AM written by LVN V indicated: A nurse entered the resident's room and witnessed him being sexually assaulted by his roommate. This resident was immediately cleaned and moved to another room. No injuries or bleeding noticed by assessing nurse at the time. On-call Nurse notified as well as Administrator. [town] Police Department also called and resident is being sent out to ER to be assessed 0230 EMS and Police arrived.)253 Resident leaving facility in route in [Hospital] to be assessed. The resident RP also notified. Record review of hospital paperwork for Resident #8 dated 9/02/2025 at 1:29 PM indicated: Date/Time Patient Seen: 9/02/2025 at 3:42 AM. Chief Complaint: Presents for [Facility] with report of sexual assault by another male patient at the facility. Patient denies memory of incident or pain. Paramedic [name] reports that NH staff told him they cleaned him up before transport. History of Present Illness: The patient was brought in from a nursing home over concerns that the patient had been sexually assaulted. According to the nursing staff the nurse walked into the room and found the patient's roommate sexually assaulting him. At that point the patient was brought to the ER to be evaluated. The patient does not recall the events and has significant dementia. Medical Decision Making: The patient was signed out to the oncoming physician pending a SANE exam. Record review of a facility witness statement dated 9/02/2025 at 1:30 AM written by CNA K indicated: Nurse [LVN J] open door to resident room, she saw resident [#8] in the be with resident [#7], she called for me [CNA K] to come here, from shower room, when I walked in the room, both residents bottoms were off, I asked [Resident #8] why he was in the bed with [Resident #7] he stated he didn't know why, both were facing the window, [Resident #7's] arm was across [Resident #8's] waist, when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 7 of 24 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 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 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 Event ID: Facility ID: 676103 If continuation sheet Page 8 of 24 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 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 8 of 8 residents reviewed for accidents and supervision. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) The facility failed to adequately provide supervision to prevent Resident #2 from abusing Resident #1 on 6/25/2025 when Resident #2 pushed Resident #1 down on the floor causing a fracture to the left 5th toe. The facility failed to adequately provide supervision to prevent Resident #5 from abusing Resident #3 on 7/13/2025 when Resident #5 hit Resident #3 in the head twice. The facility failed to adequately provide supervision to prevent Resident #4 from abusing Resident #3 on 7/30/2025 when Resident #4 slapped Resident #3 on the right side of the face from behind. The facility failed to adequately provide supervision to prevent Resident #6 from abusing Resident #5 on 8/28/2025 when Resident #6 hit Resident #5 in the face. The facility failed to adequately provide supervision to prevent Resident #7 from sexually abusing Resident #8 on 9/02/2025 causing Resident #8 to be admitted to the hospital. The facility failed to adequately supervise residents on the secured unit to maintain safety and to prevent resident to resident altercations. An IJ was identified on 9/03/2025. The IJ template was provided to the facility on 9/03/2025 at 3:36 PM. While the IJ was removed on 9/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents in the secured unit at risk of injury and death. Findings included: 1.Record review of Resident #1's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Alzheimer's Disease with history of psychotic disorder (problem with thinking and delusions), and Hyperlipidemia. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #1's care plan dated 03/14/2025 revealed Resident #1 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured, activities, food, conversation, television, book. 2.Record review of Resident #2's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include dementia with, severe, with other behavioral disturbance, delusional disorders, major depressive, lack of coordination, anxiety disorder and age-related cognitive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 revealed incident description that resident #1 was standing over resident #2 who was sitting on the couch. Resident #1 said something to resident #2 and resident # 2 shoved resident #1 causing her to fall. Both Residents was assessed for injuries, skin tear to left elbow and raised area noted to left side of resident #1's head. Xray revealed age indetermination (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 9 of 24 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 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 fifth digit proximal phalanx head fracture (fracture to left fifth toe) for resident #1. Record review of witness statement dated 6/25/2025 CNA F stated on the day of 6/25/2025. I saw Resident #2 push Resident #1, causing Resident #1 to fall down. Resident #2 was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. During an interview on 9/4/2025 at 11:49 AM with RN L she said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and not aggressive and was mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character. 3. Record review of Resident #3's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he was moderately cognitive impaired. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate with walking. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related to being hit in the face 2 times by Resident #5 on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros x72 hours, moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 9/03/2024 indicated Resident #3 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a psychosocial wellbeing problem potential related 7/30/2025 being slapped by Resident #4. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind with interventions that included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed form emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted no acute distress or discomfort noted. Residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by nurse and all parties were notified by nurse and RN. Record review of progress noted for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated Resident #3 was sitting in dining room at his table when Resident #4 hit him in the head from behind. Record review of facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by roommate Resident #5; assessment completed by his nurse no injuries noted resident denies pain or discomfort. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by another resident. Redirected other resident away from this resident, placed other resident on 1:1 monitoring. 4. Record review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 10 of 24 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 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 of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring, and Resident #3 placed on Q15 monitoring. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs notified. Both residents assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident to resident altercations. Record review of Resident #4's care plan dated 9/30/2024 indicated Resident #4 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Resident #4 was at risk for elopement/wandering as evidenced by a history of attempts to leave facility unattended with interventions that included: Monitor location ever 2 hours and as needed. Document wandering behavior and attempted diversional interventions in behavior log. Record review of progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated resident was witnessed hitting other resident in right side of head from behind while attempting to come in back door. Psych MD notified and received new order to send to inpatient facility. Record review of progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated resident placed 1 on 1 with housekeeping sitting with resident at that time. Record review of progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated behavioral hospital was there to pick resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 in right side of head from behind while attempting to come in back door. Resident #4 redirected away from Resident #3 and out onto open floor with nurse so he could be 1 to 1 at that time. During a confidential interview on 9/02/2025 at 10:54 AM She said on 7/30/2025 Resident #4 was trying to go outside, and Resident #3 was fussing at Resident #4 to not go outside and backed his wheelchair up and into Resident #4 and that was when Resident #4 slapped Resident #3 on the right side of the face from behind. During an interview on 9/04/2025 at 1:10 PM the ADON said Resident #4 had a history of physical aggression. She said prior to the incident with Resident #3, Resident #4 had hit his previous roommate because their wheelchairs had got tangled up. She said Resident #4 had gone out to a behavior hospital for that incident and had not had any aggressive behaviors since that time. She said on 7/30/2025 Resident #3 and Resident #4 were by the back door and Resident #3 backed his wheelchair up and into Resident #4's wheelchair and Resident #4 slapped Resident #3 on the right side of his face from behind. She said Resident #3 had not any incidents of verbal aggression prior to the incident. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 11 of 24 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 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 quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, Moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. Record review of Resident #5's care plan dated 8/27/2025 indicated Resident #5 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated notified by CNA to floor nurse that resident hit roommate twice in the head and then had a shoe and was going to hit another resident but was redirected by nurse, all parties notified, resident placed on 1:1 and every 15-minute monitoring and separated. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM indicated: Notified by CNA Resident #5 hit roommate in the head twice and had a shoe in his hand, resident was redirected. Resident assessed by nurse no issues noted, resident redirected by nurse and placed on 1:1 monitoring. During an interview on 9/02/2025 at 10:20 AM CNA B said most days she was on the male secure unit as the only CNA. She said on the day of the incident with were Resident #5 hit Resident #3 she was on the male secure unit as the only CNA. She said Resident #3 had wandered into Resident #5's room and Resident #5 hit Resident #3 in the middle of his forehead with a closed fist 2 times. She said she separated Resident #5 and Resident #3 and went and got the nurse. She said Resident #6 had been aggressive to both Resident #3 and Resident #5. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.etc) and document per facility protocol. Record review of progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition. Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Phone note change of condition. Nursing staff request to address a documented psychiatric issue of concern that requires a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 12 of 24 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 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 timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable, nurse reports that the resident continues to try and hit at a fellow male resident, staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fist acting like he would hit this resident, resident redirected. Record review of facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fist acting like he would hit this resident, resident redirected, resident placed 1:1 supervision. During a confidential interview on 9/02/2025 at 10:54 AM She said Resident #6 was a recent admission from the behavioral hospital and said he came to the facility aggressive. She said Resident #6 had been bullying Resident #5 since he admitted 2 days prior to the incident. She said on 8/28/2025 Resident #5 was sitting at the table in the dining room and Resident #6 walked over to Resident #5 and hit him with a balled-up fist to the right side of the face and chin area. She said Resident #5 did not have any redness or bruising where he was hit. She said when the incident occurred, she was trying to keep a fall risk resident from falling. She said she felt like if there was a second CNA in the male secure unit the incident may have been to be prevented. During an interview on 9/2/2025 at 12:20 PM the DON said CNA A facetime called her and showed her how Resident #6 was acting. She said she then ordered Resident #6 to be placed on 1:1 monitoring. She said it was not a video that was sent to her, but it was an actual in real time facetime call. She said she does not allow videos of residents on her phone and said if there was a recorded video then Resident #6 must have attempted to hit Resident #5 more than once. During a confidential interview on 9/02/2025 at 12:32 PM She said she had taken a video of how Resident #6 had been acting and sent the video via text message to the DON. She said she took the video is desperation to get more help on the male secure unit. Observation of a video taken on 8/28/2025 showed Resident #5 sitting at a table in the dining room of the male secure unit, Resident #6 then walked over to Resident #5 and began attempting to hit Resident #5 multiple times. During an interview on 9/02/2025 at 1:14 PM Housekeeper O said on 8/28/2025 she saw Resident #5 and Resident #6 having a verbal altercation, she said Resident #6 balled up his fists, so she got in between the 2 residents. She said there was only 1 CNA on the male secure unit that day and she was in a room providing care to another resident when the incident she saw occurred. She said she never saw Resident #6 actually make contact with Resident #5 at that time. During an interview on 9/04/2025 at 1:10 PM the ADON said on 8/27/2025 the CNA's had reported to her that Resident #6 was targeting and taunting Resident #5 by acting like he was angry with Resident #5 and attempting to hit him. She said she notified to psych doctor and received an order to increase his medication. She said on 8/28/2025 she was the nurse working on the male secured unit and said CNA A reported to her that Resident #6 was being physically aggressive to Resident #5. She said she brought Resident #6 outside of the male secured unit to the nurse's station and kept him there until he discharged to the behavior hospital. During an interview on 9/04/2025 at 2:07 PM the DON said on 8/28/2025 CNA A was the only CNA on male secure unit that day. She said the ADON was the nurse for the male secure unit that day and reported to her that Resident #6 was becoming more aggressive and told her she had already notified the psych doctor and received the medication increase order and asked if she could put Resident #6 on 1:1 monitoring. She said it was never reported to her that Resident #6 had hit Resident #5. She said she had questioned herself if Resident #6 was appropriate for their male secure unit due to his aggressive behaviors. She said Resident #6 discharged to the behavior hospital on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 13 of 24 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 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 8/28/2025. During an interview on 9/04/2025 at 3:07 PM the Administrator said it was never reported to her that Resident #6 had been physically aggressive to Resident #5. She said it was reported to her that Resident #6 had been sent out to the hospital, but she did not know it was a behavior hospital. She said it was not until after she read the 24-hour report that she discovered Resident #6 had been sent out to a behavioral hospital. She said they did normally discuss where residents were sent out to in the morning meetings, but she had taken a day off work and was not in the morning meeting the day after Resident #6 had been sent out. She said after she found out Resident #6 had been sent to a behavior hospital; she did not question anyone as to why he was sent to a behavior hospital. She said on 9/03/2025 after surveyors entrance it was discussed with the DON that she must be notified of any resident-to-resident altercations. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing, toilet use and personal hygiene and did not attempt walking. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behavior: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in-serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 supervision. Record review of Resident #7's care plan dated 7/22/2025 indicated Resident #7 had impaired cognitive function/dementia or impaired thought processes related to dementia with interventions that included: Monitor/document/report to MD any changes in cognition function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: this resident involved in resident-to-resident incident approximately 2:30 AM resident placed on 1-on-1 monitoring and will be referred to psych services. Record review of facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found this resident lying on right side behind other resident facing the window. Observed this resident having sexual intercourse with resident. Upon entering and discovering this resident removed penis and both residents remained laying quietly, this nurse request help from CNA K to remove resident from behind resident and separate them so assessments and investigation of incident could be performed. This resident verbalized that he know what he done and said this incident was the first time, when questioned further this resident began stating he is sad after the recent loss of his son and doesn't want to discuss any further, this resident request he as needed medication for anxiety and nerves, this nurse medicated this resident. 8. Record review of Resident #8's facility's electronic face sheet revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 14 of 24 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 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 a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Record review of Resident #8's care plan dated 7/31/2025 indicated Resident #8 required medications for behavior management with interventions that included: Monitor/record occurrence for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of hospital paperwork dated 9/02/2025 at 1:29 PM indicated: Date/Time Patient Seen: 9/02/2025 at 3:42 AM. Chief Complaint: Presents for [Facility] with report of sexual assault by another male patient at the facility. Patient denies memory of incident or pain. Paramedic [name] reports that NH staff told him they cleaned him up before transport. History of Present Illness: The patient was brought in from a nursing home over concerns that the patient had been sexually assaulted. According to the nursing staff the nurse walked into the room and found the patient's roommate sexually assaulting him. At that point the patient was brought to the ER to be evaluated. The patient does not recall the events and has significant dementia. Medical Decision Making: The patient was signed out to the oncoming physician pending a SANE exam. Record review of facility witness statement dated 9/02/2025 at 1:30 AM written by CNA K indicated: Nurse [LVN J] open door to resident room, she saw resident [#8] in the be with resident [#7], she called for me [CNA K] to come here, from shower room, when I walked in the room, both residents bottoms were off, I asked [Resident #8] why he was in the bed with [Resident #7] he stated he didn't know why, both were facing the window, [Resident #7] arm was across [Resident #8] waist, when [Resident #7] went to turn over on his back, we could clearly see his penis was in [Resident #8] buttocks, [Resident #7] had BMon 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. During an interview on 9/02/2025 at 10:40 AM Resident #7 said he had been sexually inappropriate with another resident here at the facility. He said it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 15 of 24 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 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: 676103 If continuation sheet Page 16 of 24 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 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 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, when reviewing the facility for sufficient staffing for 2 of 4 hallways (Hallways A and B). The facility failed to adequately staff the A and B hallway (secured units) to prevent resident to resident abuse.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #2 from abusing Resident #1 on 6/25/2025 when Resident #2 pushed Resident #1 down on the floor causing a fracture to the left 5th toe. The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #5 from abusing Resident #3 on 7/13/2025 when Resident #5 hit Resident #3 in the head twice.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #4 from abusing Resident #3 on 7/30/2025 when Resident #4 slapped Resident #3 on the right side of the face from behind.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #6 from abusing Resident #5 on 8/28/2025 when Resident #6 hit Resident #5 in the face.The facility failed to ensure A Hall (male secured unit) had sufficient staffing to prevent Resident #7 from sexually abusing Resident #8 on 9/02/2025 causing Resident #8 to be admitted to the hospital.An IJ was identified on 9/03/2025. The IJ template was provided to the facility on 9/03/2025 at 3:36 PM. While the IJ was removed on 9/04/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injuries, abuse, severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included:Record review of Resident #1's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include Alzheimer's Disease with history of psychotic disorder (problem with thinking and delusions), and Hyperlipidemia (high cholesterol). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #1's care plan dated 03/14/2025 revealed Resident #1 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #2's facility's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis include dementia with, severe, with other behavioral disturbance, delusional disorders, major depressive, lack of coordination, anxiety disorder and age-related cognitive disorder. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 (Resident is rarely to never understood), indicating she was severely cognitive impaired. She required supervision to limited assistance with one person assist for dressing, toilet use, personal hygiene and required supervision with ambulation. Record review of Resident #2's care plan dated 01/03/2025 revealed Resident #2 is an elopement risk/wanderer as evidenced by Impaired safety awareness, with interventions that included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1 and #2's incident report dated 06/25/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 17 of 24 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 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 revealed that Resident #1 was standing over Resident #2 who was sitting on the couch. Resident #1 said something to resident #2 and resident # 2 shoved resident #1 causing her to fall. Both Residents were assessed for injuries. A skin tear to left elbow and raised area noted to the left side of Resident #1's head. An x-ray revealed age indeterminate fifth digit proximal phalanx head fracture (fracture to left fifth toe but unable to determine the age of the fracture) for Resident #1. A Record review of a witness statement from CNA F dated 6/25/2025 stated, on the day of 6/25/2025. I saw Resident #2 push Resident #1, causing Resident #1 to fall down. Resident #2 was brought to the nurse's station and sat there during the process of notifying the psych doctor and then was placed on Q15 monitoring. 3. Record review of Resident #3's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), Alzheimer's disease (memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, indicating he had moderate cognitive impairment. He required partial to substantial assist for dressing, toilet use and personal hygiene and required partial/moderate assistance with walking. Record review of Resident #3's care plan dated 7/13/2025 indicated Resident #3 had a potential psychosocial wellbeing problem related to being hit in the face 2 times by Resident #5 on 7/13/2025. Interventions that included: residents separated and both placed on 1:1 monitoring (a staff member is assigned to stay with the resident at all times), assessed both residents for injury, emotional distress, and neuros for 72 hours (neurological assessment for 72 hours), moved other resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and Resident to resident altercations. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #3's care plan dated 7/30/2025 indicated Resident #3 had a potential psychosocial wellbeing problem related to being slapped by Resident #4 on 7/30/2025. Resident #3 backed his wheelchair into Resident #4 and when he moved his wheelchair forward Resident #4 slapped him from behind. Interventions included: Resident #4 placed on 1:1 monitoring, Resident #3 referred to Psych services. Both residents assessed for injuries and will be monitored for delayed injuries, none found in initial assessment. Psych MD and both RPs were notified. Both residents assessed for emotional distress for 72 hours. In-services provided on Abuse/Neglect and resident to resident altercation. Record review of a progress note for Resident #3 dated 7/13/2025 at 4:50 PM written by LVN D indicated Resident #3's nurse was notified by staff that roommate Resident #5 had hit him twice in the head. He reported no injuries noted, no acute distress and no discomfort noted. The residents were separated, 1:1 monitoring initiated and every 15-minute monitoring, neuros initiated by the nurse and all responsible parties were notified by the RN. Record review of a progress noted for Resident #3 dated 7/30/2025 at 5:53 PM written by LVN E indicated Resident #3 was sitting in the dining room at his table when Resident #4 hit him in the head from behind. Record review of a facility incident report dated 7/13/2025 at 4:25 PM indicated Resident #3 was physically hit twice in the head by his roommate Resident #5. An assessment was completed by his nurse. No injuries were noted and the resident denied pain and discomfort. Record review of a facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #3 was hit in the head from behind by Resident #5. Redirected Resident #5 away from Resident #3 and placed Resident #5 on 1:1 monitoring. 4. Record review of Resident #4's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 18 of 24 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 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 such as memory, thinking, reasoning, and judgment), cognitive communication deficit (difficulty communicating), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 06, indicating he was severely cognitively impaired. He was dependent or required substantial to maximal assist for dressing, toilet use and personal hygiene. Record review of Resident #4's care plan dated 5/01/2025 and revised on 8/14/2025 indicated Resident #4 had demonstrated physical behaviors and hit another male resident in the face. Interventions included: Residents separated, Resident #4 placed on 1:1 monitoring and Resident #3 placed on Q15 monitoring. Both residents were assessed for injuries and will be monitored for delayed injuries. None found on initial assessment. Psych MD and both RPs notified. Both residents were assessed for emotional distress for 72 hours. Witness statements gathered from staff. In-services provided on Abuse/Neglect and resident-to-resident altercations. Record review of a progress note for Resident #4 dated 7/30/2025 at 5:21 PM written by LVN E indicated resident was witnessed hitting other resident on the right side of their head from behind while attempting to come in the back door. Psych MD notified and received new order to send to inpatient facility. Record review of progress note for Resident #4 dated 7/30/2025 at 6:00 PM written by LVN E indicated the resident was placed 1 on 1 with housekeeping sitting with the resident at that time. Record review of a progress note for Resident #4 dated 7/31/2025 at 11:07 AM written by LVN E indicated a behavioral hospital was at the facility to pick the resident up. Record review of facility incident report dated 7/30/2025 at 5:00 PM indicated Resident #4 was witnessed hitting Resident #3 on the right side of his head from behind while attempting to come in the back door. Resident #4 was redirected away from Resident #3 with the nurse so he could be 1 to 1 at that time. 5. Record review of Resident #5's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), bipolar disorder (mood swings ranging from depressive lows to manic highs). Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score was not completed due to Resident #5 was rarely/never understood. He required partial to moderate assist for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #5's care plan dated 7/13/2025 indicated Resident #5 had potential to demonstrate physical behaviors related to dementia, poor impulse control. Resident #5 hit another resident 2 times in the face on 7/13/2025 with interventions that included: residents separated and both placed on 1:1 monitoring, assessed both residents for injury, emotional distress, and neuros for 72 hours, moved this resident to a room on another hall with continued 1:1 monitoring, Psych MD and both RPs notified, gathered witness statements from staff and both residents, BIMS done on both residents, started in-services on Abuse/Neglect and resident to resident altercations. Record review of a progress note for Resident #5 dated 7/13/2025 at 4:35 PM written by LVN D indicated the nurse was notified by the CNA that the resident hit his roommate twice in the head and then had a shoe and was going to hit another resident, but the resident was redirected by nurse. All parties were notified. The resident was placed on 1:1 and separated from other residents. Record review of facility incident report for Resident #5 dated 7/13/2025 at 4:25 PM indicated: Notified by the CNA Resident #5 hit roommate in the head twice and had a shoe in his hand. The resident was redirected. The resident was assessed by the nurse and no issues were noted. The resident was redirected by the nurse and placed on 1:1 monitoring. 6. Record review of Resident #6's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 19 of 24 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 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 included: schizoaffective disorder (hallucinations and delusions and mood disorder symptoms), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety (excessive and persistent worry, fear, and nervousness that can interfere with daily life). Record review of Resident #6's admission MDS assessment dated [DATE] revealed a BIMS 06 score which indicated severe cognitive impairment. He was independent for dressing, toilet use and personal hygiene and was independent with walking. Record review of Resident #6's care plan dated 8/27/2025 indicated Resident #6 required psychotropic medications with interventions that included: Monitor/record occurrence of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc.) and document per facility protocol. Record review of a progress note for Resident #6 dated 8/27/2025 at 12:00 AM written by FNP G indicated: Change of condition. Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: verbal disruptions, threatening, yelling, hostility towards others, impulsive behavior, initiation of fights, highly irritable, physical aggression towards others, socially inappropriate behavior, verbal aggression, patient is targeting 2 specific male residents, trying to hit them, starting fights, unable to redirect. Record review of a progress note for Resident #6 dated 8/28/2025 at 12:00 AM written by FNP G indicated: Change of condition. Nursing staff requested to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Symptoms included: Hostility towards others, impulsive behavior, highly irritable. Nurse reports that the resident continues to try and hit at a fellow male resident. Staff is concerned that the resident may harm others and or himself, staff requesting the resident be sent out to an inpatient psych hospital. Record review of a facility behavior nurses note dated 8/27/2025 at 4:45 PM written by the ADON indicated Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists acting like he would hit the resident. The resident was redirected. Record review of a facility behavior nurses note dated 8/28/2025 at 11:55 AM written by the ADON indicated: Resident #6 had been verbally aggressive and targeting a specific resident, balling up fists acting like he would hit the resident. The resident was redirected and resident placed 1:1 supervision. 7. Record review of Resident #7's facility's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), major depressive disorder (feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and seizures. Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS 09 score which indicated moderate cognitive impairment. He was dependent for dressing; toilet use and personal hygiene and did not attempt walking. Record review of Resident #7's care plan dated 7/15/2025 indicated Resident #7 had behavior: Sexually inappropriate as evidenced by previous inappropriate behaviors. On 8/11/2025 vulgar, inappropriate comments to nurse during care. On 8/14/2025 sexually inappropriate comments to nurse. Interventions included: Male secure unit, listen/talk to the resident-see if they will tell you why they do the behavior, psychiatric services consult as needed, staff to be in serviced on behavioral approaches designed to effectively manage unacceptable sexual advances, staff will be trained to respond, but not react to resident's behavior. Record review of Resident #7's care plan dated 9/02/2025 indicated Resident #7 had engaged in physical touch of a sexual nature toward another resident with interventions that included: Avoid leaving resident unsupervised in situations where inappropriate contact may occur, identify and document triggers or patterns leading to inappropriate behaviors, immediately intervene report and document inappropriate sexual contact, resident immediately placed on 1:1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 20 of 24 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 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 supervision. Record review of a progress note for Resident #7 dated 9/02/2025 at 2:45 AM written by the Administrator indicated: the resident was involved in resident-to-resident incident at approximately 2:30 AM. The resident was placed on 1-on-1 monitoring and will be referred to psych services. Record review of a facility incident report for Resident #7 dated 9/02/2025 at 1:30 AM completed by LVN J indicated: this nurse entered residents' room at approximately 1:30 AM and found the resident lying on his right side behind another resident facing the window. The nurse observed the resident having sexual intercourse with the other resident. Upon entering the room, the resident removed his penis from the other resident and both residents remained lying quietly. This nurse requested help from CNA K to separate the residents so assessments and investigation of incident could be performed. This resident verbalized that he knew what he had done and said this incident was the first time. When questioned further this resident stated he was sad after the recent loss of his son and doesn't want to discuss any further. This resident requested medication for anxiety and nerves. This nurse medicated this resident. 8. Record review of Resident #8's facility's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included: Dementia (progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), psychotic disorder with delusions due to known physiological condition (false beliefs), cognitive communication deficit (difficulties with communication due to underlying cognitive impairments). Record review of Resident #8's admission MDS assessment dated [DATE] revealed a BIMS 08 score which indicated moderate cognitive impairment. He required supervision or touching assistance for dressing, toilet use and personal hygiene and set up or clean up assistance with walking. Record review of Resident #8's care plan dated 7/25/2025 indicated Resident #8 had impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors with interventions that included: communication: use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. During an observation on 9/2/2025 at 10:42am of the female unit, there was one CNA providing care for 7 residents. 4 female residents were sitting in the common area watching TV, 2 female residents were sitting at the table doing activities (coloring) and one female resident was sitting outside alone smoking (in an enclosed sitting/smoking area and could be seen by staff through a large window). During an interview on 09/02/2025 at 11:40am the MA said staffing had been an issue due to people calling in or not showing up for work. She said there were times other staff had come in for extra shifts and times they could not get coverage for the workers who did not show up. She said the facility was staffed with only four CNAs and two nurses. One nurse worked the A & B halls (secured units), one nurse works C&D halls and one CNA staffed on each hall. She said she felt the facility would benefit from having more available CNAs and nurses. She said she felt the residents would receive a better quality of care with an increase of staff. During an interview on 9/4/2023 at 9:15am CNA-F said on most days more help was needed. She said she had worked up to 16 hours straight but had heard of other workers working 18 to 24 hours straight and going home for a 6-hour break and coming back for their regular 12-hour shift. She said staff volunteered to work the hours if the facility was short staffed. She said they had been provided walkie talkies on 9/04/2025 to call for help when needed, such as when giving a resident a shower, other resident needs or if they needed a break. She said she felt that more staff would be a plus to resident care. She said instead of doing the basic care staff would be able to provide a better quality of care and prevent things such as resident to resident altercation, falls, toileting and any negative incidents. During an interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 21 of 24 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 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 on 9/4/2023 at 9:40am the Housekeeping Supervisor said she helped in the kitchen, housekeeping and monitored on the halls. She said she did not provide direct care for residents but did monitor the residents (kept residents separated) on the unit (A & B halls) when the CNA needed to take a break or leave the unit for short periods. She said staffing was an issue some days and more staff would be a plus when caring for residents. She said on the unit most days there were behaviors to address, and one person could not see that all needs were being addressed at all times. She said the female unit had 7 residents that wanted constant interactions of some kind. She said most of them just wanted continual attention from staff as if they felt lonely and it was hard for one staff to assure all needs were met. She said on the male unit there were 15 residents, most with aggressive behaviors or wanted constant attention and it was impossible for one staff to ensure all needs were addressed for all residents on any shift. She said she had not witnessed anyone working more than 12 hours per shift. She said she mainly did housekeeping and did not have to stay over. During an interview on 9/4/2025 at 11:49AM RN-L said she had worked with Resident #1 and Resident #2, in the past and was not at work during the time of the incident between Resident #1 and Resident #2. She said Resident #1 was on hospice and was not aggressive and mostly bedridden. She said Resident #2 was normally not aggressive and to push someone was out of her normal character. She said the incident may have been prevented if there were at least two staff working together on all halls especially the halls A&B (secured units) due to the residents with behavior issues were housed on those halls. She said daily staffing included 2 nurses, one for A&B hall and 1 for C&D hall, 1 med aid, 1 CNA on A hall, 2 CNAs on B hall, one CNA on C hall and one CNA on D hall. She said she felt like there should be sufficient staffing at all times, but not all employees showed up for work as scheduled. She said when staff did not show up to work the on-call person was notified, and they were responsible for getting someone to come in and cover that shift. She said she had not worked more than 12 hours at a time. She said the least amount of CNAs she worked with in the facility was 2 nurses and 2 CNAs. She said when there were only 4 workers in the building at night it left them one worker short. She said one CNA floated from hall to hall helping the other CNAs. She said she had witnessed staff working 6A to 10P due to short staffing. She said she had not seen anyone working close to 24 hours at a time and but did hear that it had happened. She said if there were more staff to cover shifts it would make a difference in the quality of care provided to residents. During an interview on 9/4/2025 at 4:00pm CNA-B said she had not worked 24 hours straight but knew that some of the other staff worked 20-24 hours at a time. She said she volunteered to work extra hours but no more than 12-16 hours straight. She said she was not asked to or felt forced to work the extra hours by the administrative staff. She said she they had been short staffed due to a Covid outbreak and some people quitting, calling in or just not showing up. During an interview on 9/4/2025 at 1:24PM the ADON said the staffing pattern was usually two CNAs on halls C and D, one CNA on hall A, 1 CNA on hall B, one MA and two nurses (1 on hall A&B and 1 on hall C&D) during the day. She said the only staffing changes for the night shifts was one aide on the B hall and no MA was scheduled for the night shift. She said when someone called in, she would come in and cover the shift or another staff was called in to work. If they could not find someone to work, the person on call would cover the shift. She said they had worked with only 4 workers for the entire building in the past. She said it was not ideal but when staff did not come to work, they did the best they could to ensure all of the residents' needs were met. She said they would pull a CNA from A hall, leaving one CNA on the male unit (hall A) occasionally to make sure every hall had at least one CNA. She said sometimes they were fully staffed and other times they were short staffed. She said due to Covid and staff quitting they were short staffed and needed to hire 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 22 of 24 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 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 CNAs before the facility would be fully staffed. She said they were trying to hire workers at that time. She said they did allow their staff to work 20 plus hours. She said they never asked staff to work 20 plus hours and knew it was not safe for staff or residents if staff worked exhausted. She said the facility was short staffed and some staff volunteered to work extra hours, and they were allowed to work such long hours due to being short staffed and the facility needing coverage. During an interview on 9/4/2025 at 1:24PM the Administrator said she had been notified of low staffing issues. She said the facility was in the process of hiring at least 3 more CNAs. She said the staff especially the CNAs had issues with calling in and not coming for their scheduled shift. She said they tried to staff 1 CNA on hall C and one CNA on hall D for daytime, 2 CNAs on Hall A (Male Unit) and 1 CNA on hall B (Female Unit). She said for the male secure unit there should always be at least 2 CNAs. She said she did not know that staff was working 20-24 hours straight and did not feel it was safe for the staff or the residents to work that many hours. She said she did not feel it was safe for the residents to have resident to resident altercations as someone could get hurt. She said there could be a decline in care if there was not enough staff to sufficiently always address the needs of all residents. Record review of the Facility assessment dated [DATE] indicated Staffing will be based upon the needs and acuity of the residents in-house. If acuity increases so will the staffing departments. This also goes for an overall increase in total census. The administrator will identify needs based on each admission and discharge and will make corrective action in staffing needs. Record review of the payroll detail indicated CNA-H worked 22.72 hours in a 24-hour time frame beginning on 8/25/25 at 5:46am through 8/26/2025 at 5:46am. Record review of the payroll detail report indicated CNA-B worked 23.67 hours in a 24-hour time frame beginning on 8/30/2025 at 1:25pm thru 8/31/2025 at 1:25pm. Record review of facility policy, dated September 2022, titled Resident to Resident Altercations indicated, .1. Facility staff monitor residents for aggressive/inappropriate behaviors toward other resident, family members, visitors, or to the staff.Record review of facility policy, Inservice: Redirecting Dementia Patients dated 06/25/2025 indicated, Objective: To equip staff with effective techniques for safely and respectfully redirecting residents with dementia during episodes of confusion, agitation, or repetitive behavior. Record Review of facility policy titled Hours of Work, Indicated, Our facility has established hours of work in accordance with resident needs and current regulations governing our facility's staffing requirements. *Employees take 8 hours break after working 16 hours. This was determined to be an Immediate Jeopardy (IJ) on 9/03/2025 at 3:36 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 9/03/2025 at 3:36 p.m. and a plan of removal was requested. The facility's plan of removal was accepted on 9/04/2025 at 12:18 PM and included: The following is a plan of removal, which has been immediately implemented at [Facility], to remedy the immediate jeopardy which was imposed 9/3/25 at 3:32pm.All items listed will be completed by 9/4/25 at 2:00 pm with continued follow up for scheduled staff. 1. Resident #2 was placed on 1:1 while contact was made for psych services on 6/25/25. Psych services reviewed the information and initiated a medication review with change of medication order regarding the resident-to-resident altercation. Resident #1 was moved to Q15 minute checks on 6/25/25 and a telehealth visit was completed on 6/26/25. Resident #1 was monitored for emotional distress for 72 hours post the incident. 2. Resident #1 was assessed for pain and injuries on 6/25/25. Resident #1 was administered a medication for pain (OTC medication) following the event. Facility obtained orders for X ray per hospice regarding a fracture that resulted in age indeterminate fracture of the 5th digital proximal phalanx. Neuros were initiated per protocol for Resident #1 as well as injury monitoring for 72 hours. Resident #1 was monitored for emotional distress for 72 hours post the incident and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 23 of 24 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 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. 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 Event ID: Facility ID: 676103 If continuation sheet Page 24 of 24