F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, and interviews, the facility failed to ensure a resident has a right to
personal privacy and confidentiality of his or her personal and medical records for 1 of 4 computers.On
08/14/2025 LVN A left the facility's computer open and unattended at the nurse's station with residents'
personal medical information visible to anyone who passed by. The failure could place residents at risk of
having their private information changed, viewed, and not kept secure. Findings include: During an
observation on 08/14/2025 at 12:17pm reflected that LVN left her computer unlocked/opened and
unsupervised, vaguely visible in an open area for resident and other individuals/guest of the facility passing
by the nurse's station. At the time of the observation LVN was passing medication and approximately 35
feet away from the computer at the nurse station. During an interview with LVN A on 08/14/2025 at
12:17pm, the LVN A stated she was told it was ok to leave the computer screen unlocked with the
resident's information displayed. The LVN A stated she did not remember who told her it was ok and then
stated that's how she was trained. The LVN A stated a negative outcome of leaving a computer with
resident information display would be a HIPAA violation or someone could have access to the resident
information. During an interview with ADON on 08/15/2025 at 10:00am, the ADON stated the nurse using
the computer was responsible for ensuring residents' information was not displayed on the unattended
computer. The ADON stated a negative outcome of an unattended computer was resident's information
could be accessed by anyone. The ADON stated her expectations were for staff to ensure resident
information was not displayed on unattended computer screens. During an interview with DON on
08/15/2025 at 10:20am, the DON stated whoever was using the computer would be responsible for ensure
the computer was locked prior to leaving the computer. The DON stated that a negative outcome would be
a HIPAA violation. The DON stated that a family member, visitor, or another resident could have access to
the computer if it was not locked when unattended. The DON stated that the facility immediately begun
inservicing nurses and aides on locking computers and kiosk. The DON stated her expectation were for all
computers to be locked when unattended. During an interview with ADM on 08/15/2025 at 11:10am, the
ADM stated it was the staff who was using the computer was responsible for ensuring the computer screen
was locked when unattended. The ADM stated a negative outcome could be that someone would have
access to a resident's personal information. The ADM's expectation moving forward was for staff to ensure
their computer screens were locked when unattended. The ADM provided this investigator with the HIPAA
Privacy Notice Acknowledgment and Standards of Compliance with Related Policies and Agreements.
Record review of the facility's HIPAA Privacy Notice Acknowledgment, undated reflected, By signing below,
I acknowledge receipt of the facilities NOTICE OF PRIVACY PRACTICES FOR PERSONAL HEALTH
INFORMATION. I understand the content and intent of the Notice and agree to abide by its instructions. I
further understand that as an employee or volunteer of this facility that I am subject to the Articles of the
Employee Handbook I have received. Specifically, I understand the progressive discipline program. By
signing this document acknowledging the Privacy Notice, I am expressly
Residents Affected - Few
(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 2
Event ID:
676211
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
676211
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Woods Health & Rehabilitation
1700 Woodgate Drive
Waco, TX 76712
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 0583
Level of Harm - Minimal harm
or potential for actual harm
acknowledging the modification, by addition of this document, to the Employee Handbook. I also
understand that ANY VIOLATION of the Privacy Notice which results in Protected Information being
released in violation of this policy will result in my termination and reporting of the Employee Misconduct
Registry as a violation of Resident Rights. Please read this carefully as violation of this policy modifies the
progressive discipline program listed in the Employee Handbook .
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676211
If continuation sheet
Page 2 of 2