Health inspection·August 15, 2025

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 Page 1 of 2 676211 676211 08/15/2025 Wesley Woods Health & Rehabilitation 1700 Woodgate Drive Waco, TX 76712

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 676211 Page 2 of 2