Wells LTC Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 4 residents (Resident #4) reviewed for smoking. The facility failed to ensure Resident #4 did not have a lighter in his possession on 6/23/2026 that was not allowed. This failure could place residents at risk of injuries and burns.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 3 smoking areas (smoking area for halls C/D) reviewed for smoking safety. The facility failed to ensure paper and plastic trash were not discarded into the fire safety can in the smoking area for halls C/D that was to be used for cigarette butts only on 6/23/2026. This failure could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to 1 of 1 medication destruction storage closet reviewed for medication storage. The facility failed to ensure the medication destruction closet was secured and was unable to be accessed by unauthorized personnel between 12/04/2025 through 1/15/2026. This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 15 (Resident #1) residents reviewed for supervision. The facility failed to protect Resident #1, who had a history of exit seeking, from eloping from the secured unit courtyard on 12/18/2025. Resident #1 was left unsupervised in the male unit's courtyard and the courtyard's exterior gate was unlocked. Resident #1 exited the courtyard and was located 2 blocks away in the local library parking lot. Resident #1 was located by a staff member who was leaving the facility from their shift. The facility was unaware Resident #1 was missing during this time. The non-compliance was identified as past non-compliance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that:The facility failed to ensure the dish machine reached recommended minimal 50-100 parts-per-million, (PPM), of hypochlorite (chlorine) and water temperature of 120 degrees Fahrenheit (F) during the final rinse cycle of the facility dish machine. The facility failed to keep the freezer surfaces clean and free of ice buildup. This failure could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for one of one facility reviewed for pest control. The facility failed to ensure an effective pest control program was in place to keep roaches, rats and flies out of the kitchen and the remainder of the facility. This failure could place residents at risk of exposure to ineffective pest control at the facility and food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals identified with MI, DD, or ID were evaluated for services for 1 of 5 residents (Residents #48) reviewed for PASARR.The facility failed to ensure Resident #48 had a PASARR evaluation after being readmitted to the facility on [DATE] with a mental illness diagnoses of bipolar disorder. This failure could place residents who had a mental illness at risk of not receiving individualized specialized services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with a mental disorder received the appropriate treatment and services to correct the assessed problem and/or attain the highest practicable mental and psychosocial well-being, for 1 of 6 residents (Resident #39) reviewed for behavioral health services. The facility failed to document an episode of resident behaviors in the clinical record for Resident #39 on 12/1/25. The facility failed to offer a prn medication for anxiety to Resident #39 when she was exhibiting signs of anxiety on 12/1/25. These failures could place residents at risk of additional stress, feelings of hopelessness and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 6 resident's personal refrigerators reviewed for food safety (Resident #42). The facility failed to ensure the refrigerator for Resident #42 did not contain expired melon, unidentified substance in white Styrofoam cup with glove over it, and open, unlabeled, undated bean dip. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #8) reviewed for infection control. The facility failed to ensure CNA A and the DON followed enhanced barrier precautions and wore a gown and gloves when providing direct care to Resident #8 on 12/02/2025. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the appropriate temperature range for resident-use hot water for 2 of 4 Halls (Halls C and D) observed for the residents' environment. The facility failed to ensure the resident rooms and shower room for halls C and D had sufficient water pressure and hot water on 10/20/2025 and 10/21/2025. This failure could place residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 9 residents (Resident #3) reviewed for accident hazards. The facility failed to ensure two cans of air freshener were not left in Resident #3's room on 10/20/2025 and 10/21/2025. This failure could place residents at risk of injuries due to environmental hazards.

Inspectors wroteBased on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 2 of 9 residents (Residents #8 and #9) reviewed for medical records. The facility failed to ensure Resident #8 and Resident #9's medical records were accurate when CNA C documented both residents received a bath on 10/20/2025 when they did not. This deficient practice could place residents at risk of improper care due to inaccurate medical records.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 9 residents (Resident #4) and 1 of 4 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A changed gloves and washed or sanitized her hands when providing care to Resident #4 on 10/20/2025. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents the right to be free from abuse and neglect for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8) of 8 residents reviewed for abuse and neglect. The facility neglected to ensure enough staff to monitor the residents in the male secure unit which lead to the resident-to-resident abuse. The facility failed 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 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 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to be free from abuse was provided for 2 of 12 residents reviewed for abuse. (Resident #1 and Resident #3) in that: The facility failed to protect Resident #1 from Abuse on [DATE] when Resident #2 stuck his hand into Resident #1's shirt and groped her breast. The facility failed to protect Resident #3 from Abuse on [DATE] when Resident #4 pushed Resident #3's wheelchair over and hit him in the face. The noncompliance was identified as PNC. The past noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 5 of 5 residents (Residents #13, #25, #26, #36, and #42) reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Residents #13, #25, #26, #36, and #42 on 9/4/24. This failure could place residents who received pureed foods at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 20 residents (Residents #16, 20, and 39) reviewed for call lights. 1. The facility failed to ensure the call light in Resident #16's bathroom located on the men's secured unit were not wrapped around the support bar and were reachable from the floor on 9/03/2024. 2. The facility failed to ensure the call light in Resident #20's bathroom and rooms [ROOM NUMBER] located on the women's secured unit were not wrapped around the support bar and were reachable from the floor on 9/03/2024. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 3 of 16 residents reviewed for ADLs (Residents #3, Resident #19, and Resident #9). 1. The facility failed to ensure Resident #19's face and bed linens were clean when her eyes had drainage present to the corners of both of her eyes and when her bed linens were visibly dirty with brown stains and the comforter had dark brown stained substances on 9/3/2024. 2. The facility failed to ensure Resident #3 received timely incontinent care on 9/4/2024 when the resident was observed walking throughout the facility with wet pants. 3. The facility failed to clean or groom Resident #9 fingernails on 9/3/2024-9/4/2024. [...]

Inspectors wroteBased on interviews and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 12 months (January 2024) reviewed for pharmacy services. The facility failed to document the required number of 2 witness signatures for drug destruction on 1/5/2024. This failure could put residents at risk for misappropriation and drug diversion.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 12 residents (Resident #15) and 1 of 5 staff (NA C) reviewed for infection control. NA C did not sanitize or wash her hands between glove changes when providing incontinent care to Resident #15 on 9/3/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident #1 was free from abuse when CNA A pushed and struck Resident #1 on his face causing him to fall. The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on 10/04/2023 and ended 10/05/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of resident property for 1 of 5 residents (Resident #2) reviewed for misappropriation. The facility failed to prevent misappropriation of property when NA H took money via bank card in the amount of $202.50. The noncompliance was identified as PNC (past non-compliance) The noncompliance was began on 02/29/2024 and ended 03/04/2024. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of misappropriation which could lead to further exploitation of other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 1 resident reviewed for accidents/supervision (Resident #28) in that: Facility failed to ensure a resident environment as free of accidents/hazards as possible due to not ensuring the locks were engaged on the secure unit and not ensuring that the alarm was functioning on the emergency door on secure unit. Resident #28 eloped from the facility on 6/23/23 and was discovered by a local citizen approximately 2 blocks from the facility. The non-compliance was identified as past non-compliance. The IJ began on 6/23/23 and ended on 6/23/23. The facility had corrected the noncompliance before survey began. This failure could place all residents at risk of eloping which could lead to severe injuries or death.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 2 of 3 months reviewed. (January 2023 and February 2023) The facility did not have RN coverage for 2 days in February 2023. The facility did not have RN coverage for 1 day in January 2023. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. Two of six gas stove burners did not light automatically, when the knob was turned. (Rear, middle, and right side). The pilot lights on the burners would not stay lit. The oven door was missing the spring in the door which kept it from falling open heavily when you open it. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 residents (Resident #9) reviewed for pharmacy services in that: MA A administered Resident #9's eye drops in the incorrect eye. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that: The temperature gage on the dish machine was not working. The dish machine did not reach manufacturer's recommend water temperature of 120 degrees F during rinse cycle, required for a low temperature, chemical sanitation dish machine. The staff did not have the proper test strips (Chlorine Test Strip) to test the sanitation level of the dish machine. These failures could place the residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 (Residents #9 and #16) residents reviewed for infection control in that: MA A failed to follow infection control measures when instilling eye drops into Resident #9's eye. Agency CNA I did not wash or sanitize her hands or change her gloves while performing incontinent care to Resident #16. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 2 residents reviewed for resident rights (Resident # 46 and Resident #54) in that: On 6/19/23 CNA A took a video of Resident # 46 on the secured unit of him kicking the door and posted the video on social media. On 6/19/23 CNA A took a video of Resident # 54 on the secured unit of him making inappropriate sexual advances and posted the video on social media. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents the right to be free from abuse for 2 of 2 residents reviewed for abuse (Resident # 46 and Resident #54) in that: On 6/19/23 CNA A took a video of Residents # 46 on the secured unit of facility and posted the video on social media of him kicking the door. On 6/19/23 CNA A took a video of Resident # 54 on the secured unit of facility making inappropriate sexual advances and posted the video on social media. The non-compliance was identified as past non-compliance. The IJ began on 6/19/23 and ended on 6/19/23. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate MDS was completed for 2 of 24 residents reviewed for MDS assessment accuracy. (Resident #38 and Resident #43) The facility incorrectly coded Resident #38 as being on dialysis and not on hospice services. The facility incorrectly coded Resident #43's antiplatelet as an anticoagulant on her MDS. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 5 Residents (Resident #43) reviewed for PASSAR (Preadmission Screening and Resident Review Services) in that: Resident #43 did not have a PASSR level II evaluation with diagnosis of agoraphobia (avoiding situations or places that may cause fear or embarrassment, not being able to escape or get help if a panic attack occurs). The MDS Coordinator failed to refer Resident #43 for a resident review after being diagnosed with agoraphobia with onset of diagnoses on 12/30/2022 and psychotic disorder with delusions on 2/2/2023. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and the expiration date when applicable for 1 of 2 medication carts (medication aide cart on D hall) reviewed for labeling and storage. The facility failed to properly label eye drops for Resident # 9. This failure could place residents who receive medications at risk for receiving outdated medications and could result in residents not receiving the intended therapeutic effects of their medications and health decline.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2023 for the second quarter (January 1, 2023 to March 31, 2023) reviewed for administration. The facility failed to submit accurate RN hours for 01/21/2023, 01/31/2023, 02/18/2023, 02/19/2023, 02/25/2023, 02/26/2023, 3/06/2023, and 3/31/2023. This failure could place residents at risk for personal needs not being identified and met.