Wells LTC Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Wells LTC Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Sep 4, 2025

  Based 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. […]

• Immediate jeopardy, patternF689Sep 4, 2025

  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. […]

• Immediate jeopardy, patternF725Sep 4, 2025

  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. […]

• Immediate jeopardy, isolatedF689Jan 7, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF600Mar 12, 2024

  Based 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. […]