Health inspection·January 7, 2026

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents when they were in the courtyard. She said the maintenance supervisor monitored the locks and changed the codes regularly. She said after Resident #1 eloped there was a camera in the courtyard until the gate was repaired. She said she had been trained in the supervision of residents that wander and are at risk for elopement and it was important to keep all residents safe. During an observation on 01/05/2026 at 10:23 a.m., the male secured unit exit doors were locked by a magnetic lock with a keypad code. The courtyard had a wooden fence around the perimeter, and the gate was locked with a magnetic lock and keypad as well. There was apparent new wood on the gate door, new locking mechanisms and the gate door was secure.During an interview on 01/05/2026 at 10:31 a.m., CNA B said she was working the male unit the day Resident #1 eloped. She said she and CNA A had taken all the residents to the main dining room for the resident Christmas party. She said she was not sure who brought Resident #1 back to the unit, but they had let him out to the courtyard unsupervised, and he left through the courtyard gate. She said that somehow the gate's magnetic lock stopped working and the door was open, and he just walked out. She said the maintenance director had completed a generator test earlier and the gate was secure. She had been told when a generator test happened, she had to check the doors to make sure they relocked. She said she was not sure what time Resident #1 had left and was told about it after he returned. She said afterwards the gate had a camera until it could get repaired and no residents were allowed to go into the courtyard without supervision now. She said that a gate left open for residents that suffer from memory issues could get lost or injured. During an interview on 01/05/2026 at 10:35 a.m., CNA A said that she was in the dining room for the party when the incident with Resident #1 happened. She said she did not know when he left the facility grounds and was later told when he returned. She said the nurse checked him out and a camera was placed in the courtyard until the gate could be repaired. She said since the incident someone came and fixed the lock on the courtyard gate, and they received training on the magnetic locks and checking them to ensure they were locked, and all residents must be accompanied by a staff member when they are in the courtyard. During an interview on 01/05/2026 at 10:50 a.m., the Maintenance Supervisor said that he checked all the locks on the doors almost daily and had checked all the locks the morning of 12/18/2025 on the male secured unit. He said he ran a generator test around noon and had personally gone to each secured unit to reactivate the magnetic locks on the doors and courtyard gate. He said they were all working fine and was not sure what happened after his last check. He said he called the company that repairs the locks and placed an order for repair. In the meantime, he placed a camera at the gate in the courtyard, and no residents were allowed outside in the courtyard without staff assistance. He said when the lock company came to do the repairs, they said the magnetic locks had lost their magnet and were all replaced. He said he continued to check them several times a week, after generator tests and as needed and had educated the staff to always check the gates when they were outside. He said when Resident #1 eloped he had assisted residents back on the secured unit after the party. He said the aide working the hall had asked about residents going outside and he had told her he could go outside but thought she knew he had to be supervised. He said that residents that required a secured unit should be supervised and if left unsupervised they could get hurt.During an observation and interview on 01/05/2026 at 11:30 a.m., Resident #1 was awake and sitting in a recliner in the common area of the men's secured unit. He was calm and pleasant. He was unable to recall leaving the facility and said he liked where he lived but wanted to find his car and go home to his wife soon.During an interview on 01/05/2026 at 12:45 p.m., CNA C said she was working the men's secured unit on 12/18/25 with CNA A. She said all the residents but one had gone to the Christmas party and she stayed on the unit. She said she did not recall letting Resident #1 outside the day he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 2 of 4 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 01/07/2026 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 - Few eloped and thought the Maintenance Supervisor let him outside. She said it was busy with the party and everyone coming back to the unit at the same time. She said she was not aware that Resident #1 had left the facility until the DON came to the unit and told her. She said the Maintenance Supervisor did something to the gate lock and placed a camera in the courtyard. She said she was inserviced that the residents could not go outside alone and how to check the locks to make sure they were working correctly. She said that residents that elope could get hurt. During an observation on 01/05/2026 at 1:00 p.m., there were 3 male residents including Resident #1 outside in the men's unit courtyard smoking. CNA F was present with them. Resident #1 was ambulatory without any assistive devices. During an interview on 01/05/2026 at 2:15 p.m., LVN C said the day of Resident #1's elopement, all the resident's had been in the main dining room for a Christmas party. She said CNA C was on the hall because 1 resident did not come to the party. She said after the party, unsure of the time, all the residents we assisted back to the secured unit. She said sometime after that the SLP called the activity director and told her that Resident #1 was in the parking lot at the library and she was bringing him back to the facility. She said when he returned, he was calm and pleasant but tired. She assessed him, called the doctor and the family and the maintenance supervisor and DON went to see how he had gotten out of the facility. She said they did every 15 minute head counts on the men's unit until a camera was placed the next day. She said the administrator monitored the camera footage until the gate was repaired a few days later. She said they were all inserviced in supervision, wandering and elopement and the residents were no longer allowed in the courtyard without supervision. During an interview on 01/05/2026 at 2:45 p.m., CNA E said she was working the day Resident #1 eloped. She said she had not known about the elopement until the DON inserviced her and all the staff on elopements, wandering and supervision at all times when in the courtyard. She said that it was important to keep all residents safe because they could get hurt. During an interview on 01/05/2026 at 2:48 p.m., the DON said the day of Resident #1's elopement he had been at the Christmas party and sometime after he returned to the hall an aide let him out in the courtyard unsupervised. She said at that time, he exited the courtyard through the gate that had somehow become unlocked. She said the activity director told her the SLP had called about Resident #1 being at the library and she was bringing him back to the facility. She said he was immediately assessed, the MD was called, and the family was notified. She said the Maintenance Supervisor and herself started looking to see how he got out and discovered the courtyard gate was unlocked. She said she started inservices on wandering, elopement and supervision in the courtyard and every 15 minute head counts were initiated on the male secured unit as well. She said the next day a camera was placed outside in the courtyard, and the video was monitored 24/7 by the administrator until the gate was repaired. She said she was responsible for oversight in the facility and training on safety of residents at risk for elopement. She said that elopements were taken seriously because residents could be injured if they elope.During an interview on 01/05/2026 at 3:13 p.m., the SLP said she had worked on 12/18/2025 and attended the Christmas party. She said she had left for the day and on her way down the street she saw Resident #1 walking in the library parking lot near the main highway. She said she pulled over and addressed him, and he said he was looking for his car. She said he was pleasant and got in her car without any issues and she drove him back to the facility. She said she had called the activity director from her car to let her know she had found him and was bringing him back. She said when they arrived back at the facility the nurses assisted him inside and started assessing him for any injuries. She said she was glad she drove that way because he could have gotten hurt if he wasn't found so quickly. She said afterwards the DON did inservices on supervision of residents at all times in the courtyard and the maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676103 If continuation sheet Page 3 of 4 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 01/07/2026 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete supervisor did repairs to the gate.During an interview on 01/05/2026 at 4:15 p.m., the Administrator said that as soon as they were notified of Resident #1's elopement they started their interventions. She said they discovered the gate lock was no longer working, put every 15 minute resident counts into effect until a camera was installed on 12/19/2025. At that time, she monitored the camera for activity 24/7 and kept a log of any activity. The staff were inserviced and the gate was repaired on 12/23/25. Resident #1 was assessed, and he had no injuries or negative outcomes. They started an action plan and contacted the doctor and family. She said the residents on the secured unit can no longer go into the courtyard unsupervised.Record review of the facilities Wandering and Elopements policy dated March 2019 indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.On 01/06/2026 at 12:26 p.m., the Administrator was informed of the IJ. The non-compliance was identified as past non-compliance. The IJ began on 12/18/2025 and ended on 12/23/2025. The facility had corrected the noncompliance before the investigation began. The interventions and plan for correction included:Record review of Resident #1's comprehensive care plan dated 12/18/2025 revealed Resident #1's care plan was updated for his elopement with new interventions to include: monitor for emotional distress times 72 hours, complete head to toe assessment to assess for any injuries or abnormalities, notify physician and family of incident, provide additional training to all staff regarding elopement and review elopement policy and procedure, resident to be supervised while out in courtyard and not to be left unattended and update elopement assessment. Record review of Resident #1's medical record revealed an incident report was completed on 12/18/2025 with physician and family notifications, comprehensive assessment was completed on 12/18/2025, emotional distress assessment was completed on 12/18/2025, 12/19/2025, and 12/20/2025 and a new elopement risk assessment was completed 12/18/2025.Record review of an in-service titled Secured unit outside supervision dated 12/18/2025 with 47 employee signatures. Record review of in-service titled Elopement and Wandering Residents dated 12/18/2025 with 47 employee signatures.Record review of a Every 15 Minute Head Count dated 12/18/2025 to 12/19/2025 revealed all residents on the male secured unit were accounted for starting 12/18/2025 at 3:00 pm until 12/19/2025 at 4:45 pm. Record review of a log titled Ring Camera revealed the camera was installed on 12/19/2025 and was monitored from 12/19/2025 until 12/23/2025 when the gate was repaired. Record review of elopement drills for day and night shifts dated 12/22/2025 with 27 employee signatures.Record review of an invoice from the repair company dated 12/23/2025 revealed the exterior gates magnetic lock and z bracket were replaced and working. During observations from 01/05/2026 to 1/07/2026 Resident #1 as well as all the residents on the male secure unit was supervised when outside in the courtyard. On 01/06/2026 at 12:26 p.m., the Administrator was informed of the IJ. The non-compliance was identified as past non-compliance. The IJ began on 12/18/2025 and ended on 12/23/2025. The facility had corrected the noncompliance before the investigation began. Event ID: Facility ID: 676103 If continuation sheet Page 4 of 4