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Inspection visit

Health inspection

Wesley Woods Health & RehabilitationCMS #6762111 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0583GeneralS&S Dpotential for harm

    F583 - Privacy and Confidentiality

    Keep residents' personal and medical records private and confidential.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2025 survey of Wesley Woods Health & Rehabilitation?

This was a inspection survey of Wesley Woods Health & Rehabilitation on August 15, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Wesley Woods Health & Rehabilitation on August 15, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Keep residents' personal and medical records private and confidential."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.