Cycle 1
Health 2025-12-03 · Fire 2025-12-03
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Wells, TX
Wells LTC Nursing & Rehabilitation
1-star overall rating with 1-star inspections with abuse icon flag with $179,538 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
46 May Street, Wells, TX
(936) 867-4707
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gulf Coast Ltc Partners
Operator or chain grouping
Approved since
2006-01-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,568
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.99
Baseline 57.63% · Performance 59.65% · Measure score 0.99 · Achievement 0.99 · Improvement 0
Adjusted total nurse staffing
4.28
Baseline 4.20 hours · Performance 4.29 hours · Measure score 4.28 · Achievement 4.28 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 6.27% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 23 · Denominator 23 |
| Falls with major injury | 8.7% |
0.77%
7.9 pts worse
|
Numerator 2 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 71 |
| Staff flu vaccination coverage | 13.73% |
42%
28.3 pts worse
|
Numerator 14 · Denominator 102 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.1%
2.3 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.8% |
3.3%
4.5 pts worse
|
3.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.7% · Q3 8.9% · Q4 4.8% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
2.7%
1.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
3.3%
4.1 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 3.1% · Q3 6.2% · Q4 10.8% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
18.9%
0.4 pts better
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 16.7% · Q3 10.8% · Q4 21.6% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.2% |
10.8%
17.4 pts worse
|
16.7%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 32.1% · Q3 30.0% · Q4 21.7% · 4Q avg 28.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.8% |
15.4%
2.4 pts worse
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.9% |
16.1%
3.8 pts worse
|
14.9%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 22.9% · Q3 22.2% · Q4 8.6% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
0.8%
2.8 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.4% · Q3 5.0% · Q4 4.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
15.0%
7.1 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 18.3% · Q3 19.6% · Q4 22.5% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.2%
About the same
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.2% · Q3 4.6% · Q4 4.1% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
89.7%
5.7 pts worse
|
81.7%
2.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 85.7% · Q3 87.5% · Q4 89.3% · 4Q avg 84.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
12.0%
6.7 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 6.5% · Expected 13.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 9.1% |
1.5%
7.6 pts worse
|
1.6%
7.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.6% |
88.0%
5.4 pts worse
|
79.7%
2.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 42.2% |
25.9%
16.3 pts worse
|
23.9%
18.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 42.2% · Observed 32.3% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-05 · Fire 2024-09-05
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-10 · Fire 2023-08-10
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-12-06
E · Potential for more than minimal harm
2024-09-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-09-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-15
E · Potential for more than minimal harm
2023-08-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-06
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
F · Potential for more than minimal harm
2025-12-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-12-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-03
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-03
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-03
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-11-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-26
K · Immediate jeopardy
2025-09-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-05
K · Immediate jeopardy
2025-09-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-05
K · Immediate jeopardy
2025-09-04
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-04-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-29
F · Potential for more than minimal harm
2024-09-05
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
J · Immediate jeopardy
2024-03-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-05
D · Potential for more than minimal harm
2024-03-12
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-03-04
J · Immediate jeopardy
2023-08-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-09
J · Immediate jeopardy
2023-08-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-09
J · Immediate jeopardy
2023-08-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-23
F · Potential for more than minimal harm
2023-08-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-08-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-08
C · Minimal harm
2023-08-10
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-09-08
J · Immediate jeopardy
2023-06-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-04-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-04
Penalties and ownership
What sits behind the stars
$19,120
2026-01-07
Fine
Fine · fine $19,120
Fine
$81,250
2025-09-04
Fine
Fine · fine $81,250
Fine
$10,049
2024-03-12
Fine
Fine · fine $10,049
Fine
$16,801
2024-03-12
Fine
Fine · fine $16,801
Fine
$17,986
2023-08-10
Fine
Fine · fine $17,986
Fine
$21,727
2023-08-10
Fine
Fine · fine $21,727
Fine
$12,605
2023-06-19
Fine
Fine · fine $12,605
Fine
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bergeron, Bobby
Operational/Managerial Control · Individual
Murrell, Edward
Corporate Officer · Individual
Nicholson, Louis
Operational/Managerial Control · Individual
Wells Ltc Partners Inc
Operational/Managerial Control · Organization
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#3
Castle Pines Health And Rehabilitation
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