Health inspection·February 24, 2026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interviews and record review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 7 residents (Resident #1), reviewed for drug diversion.The facility failed to prevent the misappropriation of Resident #1's hydrocodone-acetaminophen 5-325 mg (formerly known under the brand name Norco, this combination medication containing 5 mg of hydrocodone [an opioid analgesic] and 325 mg of acetaminophen [also known as Tylenol] is used to treat pain).This failure could place residents at risk for not receiving their prescribed medications, unrelieved pain, and decreased quality of life.Findings include:1.Record review of Resident #1's face sheet dated [DATE] indicated he was [AGE] years old, admitted to the facility on [DATE] and expired in the facility on [DATE] with diagnoses including: obstructive hydrocephalus (buildup of cerebrospinal fluid inside the brains ventricles), malignant neoplasm of brain (brain cancer), dementia (decline in memory, thinking and behaviors).Record review of the MDS dated [DATE] indicated Resident #1 was rarely/never understood. The MDS indicated Resident #1 BIMS was not assessed. The MDS indicated Resident #1 was dependent on staff with bed mobility, transfers, and toilet use.Record review of the care plan dated [DATE] indicated Resident #1 had complaints of pain. The care plan interventions included monitor/document for side effects of pain medication.Record review of the active physician order with a start date of [DATE] detailed Resident #1 was to be administered hydrocodone-acetaminophen 5-325 mg 1 tablet two times a day related to malignant neoplasm of brain.Record review of the provider investigation report (PIR) dated [DATE] detailed that the medication hydrocodone/acetaminophen 5/325mg for Resident #1 went missing between [DATE]-[DATE]. The medication was given to the ADON after Resident #1's discharge/death on [DATE]. The ADON logged the medication on her destruction list, paired the count sheet and medication together using a rubber band and placed it in the locked closet. On [DATE] the Pharmacist and DON pulled medications to destroy them and the hydrocodone/acetaminophen 5/325mg for Resident #1 that was listed on the destruction log was not located with the rest of the narcotics. During an interview on [DATE] at 10:10 am, the ADON said drug destruction was her responsibility and she was the only person who had a key to the closet. She said Resident #1 expired in the facility on [DATE], she said she had taken Resident #1's 43 tablets of hydrocodone/acetaminophen 5/325mg and logged it on the drug destruction log then placed the count sheet with the medication in the closet in her office. She said she did not place the medication in the safe in the closet, she said she locked the 1 door handle on the outside of the closet door. She said on [DATE] she was out that day and the DON did the drug destruction with the Pharmacist and that was when it was discovered that the medication was missing. She said at the time of the drug diversion the nurses would bring her discontinued narcotic medications, she would log them and place them in the closet not in the safe. She said she was trained to put the medications in the closet not in the safe. She said the door to her office could be bumped and would (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 676103 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 02/24/2026 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)