Health inspection·June 1, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 3 of 53 residents (Resident #21, Resident #38, and Resident #41) reviewed for discharge MDS assessments. Residents Affected - Some The facility did not ensure Resident #21, #38, and #41's discharge MDS assessment was completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. Finding included: Record review of Resident #21's face sheet, dated 6/01/23, revealed a [AGE] year-old female resident who was admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included: Fibromyalgia (chronic widespread pain), Hypertension, and autoimmune Thyroiditis. Record review of Resident #21's EHR on 6/01/23 revealed, no MDS discharge on record. Record review of Resident #38's face sheet, dated 6/01/23, revealed a [AGE] year-old male resident who was admitted to the facility on [DATE] and discharged [DATE]. His diagnoses included: Unsteadiness on feet and Dementia Record review of Resident #38's EHR on 06/01/2023 revealed, no MDS discharge on record. Record review of Resident #41's face sheet, dated 6/01/2023, revealed a [AGE] year-old female resident who was admitted to the facility on [DATE] and discharged [DATE]. Her diagnoses included: Hallucinations, Muscle Weakness and Altered Mental Status Record review of Resident #41's EHR on 06/01/23 revealed, no MDS discharge on record. In an interview with the MDS Coordinator 06/01/23 at 11:38 AM, the MDS Coordinator stated she was not aware that the MDS discharges were not completed. She stated during the time the residents were discharged there was another person responsible for completing the discharges and she reported that person is no longer employed at the facility. She stated she was now responsible for completing the MDS discharges and stated it should have been completed within 14 days after the resident was Page 1 of 14 676111 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0640 discharged . Level of Harm - Minimal harm or potential for actual harm In an interview with the DON on 06/01/23 at 1:55 PM, she stated the MDS Coordinator was responsible for completing the MDS discharges. She stated the MDS discharges should have been completed when the residents were discharged from the facility. She stated the facility had another MDS Coordinator that was completing the discharges, but she left the facility the week prior, she stated she was not aware that the discharges had not been completed. She stated the risk of it not being completed could affect the residents' benefits. Residents Affected - Some In an interview with the Administrator on 06/01/23 at 2:00 PM, she stated the MDS Coordinator was responsible for completing the MDS discharges. She stated the discharges should have been completed within 14 days after the resident was discharged . She stated she and the DON was responsible for overseeing the MDS Coordinator to ensure the MDS discharges were completed. She stated the risk of it not being completed timely is that is throws off the CMS census. Record review of the facilities MDS Completion and Submission timeframes policy, revised September 676111 Page 2 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 16.67%, based on 5 errors out of 30 opportunities, which involved 4 (Residents #47, #50, #23 and #27) of 10 residents reviewed for medication errors. Residents Affected - Some The facility crushed medications without a physician's order, and administered these medications to Resident #47, #23 and #27. The facility failed to administer Resident #50's antibiotic, Cefpoxidime with food as per pharmacy label instructions. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: Resident #47 Record review of Resident #47's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included fracture to right arm, fracture to right hand, brain bleed, muscle weakness, cognitive communication deficit, glaucoma (eye disease), HTN, long term drug therapy, vitamin deficiency, anemia and pneumonia. Record review of Resident #47's admission MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating intact cognition. She required limited to extensive assistance with ADLs. She did not have any signs and symptoms of swallowing disorder. Record review of Resident #47's physician's order revealed a regular diet order and thin liquids, order date 05/16/2023. Anagrelide 1mg capsules, 4 capsules daily by mouth at 9:00AM, Amlodipine 10mg daily by mouth at 9:00AM, Carvedilol 25mg every 12hours by mouth at 8:00AM and 8:00PM, Aspirin 81mg daily by mouth at 9:00AM, Tylenol 500mg, 2 tabs by mouth every 8 hours at 8:00AM and Multivitamin with minerals one tablet daily by mouth at 9:00AM. Further review revealed there was no order to crush medications. Record review of Resident #47's Speech Therapy Evaluation and Plan of Care dated 05/17/2023 revealed the resident had no swallow disorder. Resident #27 Record review of Resident #27's face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included rhabdomyolysis (rapid muscle breakdown), chronic inflammatory demyelinating polyneuritis (an autoimmune disease of the peripheral nervous system), hyperlipidemia, benign prostatic hyperplasia (enlarged prostate gland), anxiety, depression, anorexia and cognitive communication deficit. Record review of Resident #27's quarterly MDS dated [DATE] revealed a BIMS score of 14 out of 15 676111 Page 3 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicating intact cognition. He required extensive to total assistance with all ADLs. He had no signs or symptoms of possible swallow disorder. Record review of Resident #27's physician's order revealed a regular diet order and thin liquids, order date 09/10/2022. Sertraline 100mg, 1.5 tabs by mouth daily at 9:00AM, liquid protein 30ml by mouth BID at 9:00AM, Vitamin C 500mg tablet by mouth BID daily and Multivitamin 1 tablet by mouth daily at 9:00AM. Further review revealed there was no order to crush medications. Resident #23 Record review of Resident #23's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, HTN, diabetes, vitamin deficiency, depression, hypothyroidism and osteoporosis. Record review of Resident #23's annual MDS dated [DATE] revealed she had short term and long term memory problems. She required total assistance with all ADLs. She had no signs or symptoms of possible swallow disorder. She required mechanically altered diet and therapeutic diet during the last 7 days. Record review of Resident #23's physician's orders revealed an order for mechanical soft/chopped, thin liquid diet order date 04/22/2022. Metformin 500mg 1 tab by mouth BID. Further review revealed there was no order to crush medications. Record review of Resident #23's care plan revealed the resident was at risk for choking/aspiration and was on Mechanical soft diet, start date 04/22/2022. Further review of interventions did not include crushing medications. Resident #50 Record review of Resident #50's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included acute respiratory failure, metabolic encephalopathy (a neurologic disorder characterized by altered mental status) and muscle weakness. Record review of #50's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. He required extensive to total assistance with all ADLs. Record review of Resident #50's physician's orders revealed an order for Cefpodoxime 200mg tablet, 1 tablet by mouth every 12 hours x 7 days for peritonitis/Diverticulitis, start date was 05/31/2023. Record review of Resident #50's Cefpodoxime 200mg blister pack pharmacy label indicated in writing to take with food. During a medication pass observation on 05/30/2023 at 3:00PM, LVN C crushed the Metformin 500mg tablet, mixed with applesauce then administered to Resident #23. During a medication pass observation on 05/31/2023 at 8:30AM, LVN B crushed the Vitamin C 500mg tablet, Multivitamin tablet and Sertraline 150mg tablet. LVN B mixed the crushed oral medications with applesauce then administered to Resident #27. 676111 Page 4 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a medication pass observation on 05/31/2023 at 8:57AM, LVN B crushed Tylenol 500mg tablets, Carvedilol 25mg tablet, Amlodipine 10mg tablet, Aspirin 81 mg tablet, Multivitamin tablet and opened the Anagrelide capsule. LVN B then mixed the medications with applesauce and administered to Resident #47. During a medication pass observation on 06/01/2023 at 7:50AM, LVN D administered Cefpodoxime 200mg tablet to Resident #50, without food. In an interview on06/01/2023 at 11:30AM, LVN B stated she crushed the medications for Resident #27 because the resident requested it. LVN B stated she crushed the medications for Resident #47 because she was following Speech Therapy recommendations and stated it may be posted in her room that medications should be crushed. LVN B stated she also checked Resident #47's diet order and that's where she would find the instructions to crush meds. In an interview on 06/01/2023 at 12:45PM, LVN D stated she forgot and should have given Resident #50's Cefpodoxime with food such as ensure or apple sauce. LVN D stated the risk to the resident would be nausea and some individuals get queasy. During an observation and interview on 06/01/2023 at 2:35PM, Resident #47's Her room did not have postings to crush medications before administering to the resident. The resident stated she had been seen by PT and did not know anything about ST. In an interview on 06/01/2023 at 2:40PM, NP B stated there should always be a physician's order for crushing meds prior to the nurse crushing meds and the orders should always be in the chart. In an interview on 06/01/2023 at 3:05PM DPT stated if ST recommended crushing meds the nurse would address the recommendation by notifying the MD. DPT stated only the MD can write the orders for crushing meds. DPT stated Resident #47 came from the hospital and was screened by ST. DPT stated the resident had no difficulty with swallowing. DPT stated the resident, or the nurses have not reported any swallowing difficulties. In an interview on 06/01/2023 at 3:50PM, the Administrator stated there should be a physician's order in the resident's chart to crush meds before the nurse crushes any medications. In an interview on 06/01/2023 at 5:00PM, the Administrator she did not know about the Cefpodoxime to be taken with food, but Resident #50 could have had food before or after the antibiotic was administered. The Administrator stated the risk of taking the antibiotic without food would be an upset stomach or absorption issues. The Administrator sent a message via text that the breakfast tray came out at 8:30AM. Record review of the facility policy for Crushing Medications, Nursing Services Policy and Procedure Manual for Long-Term Care, 2001 MED-PASS, Inc., revised April 2007 read in part: Policy Statement: Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders 3. The following guidelines shall be followed when crushing a medication: a. The MAR or other documentation must indicate why it was necessary to crush the medication; . Record review of the Cefpodoxime package insert from www.accessdata.fda.gov read in part: .Clinical Pharmacology, Absorption and Excretion: .Effects of Food: The extent of absorption (mean AUC) and the mean peak plasma concentration increased when film-coated tablets were administered with food. 676111 Page 5 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Following a 200mg tablet dose taken with food, the AUC was 21 to 33% higher than under fasting conditions . Record review of the facility policy for Administering Medications, Nursing Services Policy and Procedure Manual for Long-Term Care 2001 MED-PASS, Inc., revised December 2012, read in part: Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .3. Medications must be administered in accordance with the orders .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 676111 Page 6 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 (Resident #47) of 10 residents reviewed for safe administration of medications, in that: Residents Affected - Some -The facility failed to administer the correct number of Anagrelide capsules (a blood thinner to treat elevated blood platelet counts) daily as ordered by the physician to Resident #47 4 days over 14 days. This deficient practice could affect all residents who receive medication from the facility and place them at risk for inadequate therapeutic outcomes, increased negative side effects, decline in health, hospitalization, or death. Record review of Resident #47's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture to right arm, fracture to right hand, brain bleed, muscle weakness, cognitive communication deficit, glaucoma (eye disease), HTN, long term drug therapy, vitamin deficiency, anemia and pneumonia. Record review of Resident #47's admission MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating intact cognition. She required limited to extensive assistance with ADLs. She received anticoagulants (medication that decrease the blood's ability to clot) during the last 5 days. Record review of Resident #47's signed physician's orders revealed an order for Anagrelide 1mg capsule, 4 capsules by mouth once daily for blood thinner, order date 05/18/2023 and start date 05/19/2023. Record review of Resident #47's Medication Record for 05/2023 revealed the resident received Anagrelide 1mg, 4 capsules by mouth once daily at 9:00AM on 05/19/2023 through 05/31/2023. Record review of Resident #47's hospital discharge instructions for visit date 05/09/2023 revealed the medication list to include Anagrelide 1mg oral capsule, take 4 capsules (4mg total) by mouth daily. Record review of Resident #47's interdisciplinary notes dated 05/16/2023 written by LVN A revealed hospital transfer orders and medications had been verified by NP and transcribed. The Physician's orders were faxed to the Pharmacy. Orders were verified by NP A. Record review of the Pharmacy Shipping Manifest dated 05/18/2023 at 1:21PM revealed Resident #47's order for Anagrelide HCL 1mg capsules, quantity 56 each was delivered to the facility. Record review of Resident #47's hospital lab results revealed the following platelet counts (small blood cells that help blood to clot) were: 262 on 05/12/2023, 285 on 05/13/2023, 408 on 5/14/2023, 363 on 5/15/2023 and 382 on 5/16/2023. The hospital lab reference range for platelet count was 133 to 450. Record review of Resident #47's labs drawn at the facility revealed the elevated platelet count was 466 on 5/17/2023. The lab's reference range/cutoff was 182 to 369 thousand cells per microliter. Further review revealed the resident's platelet count was 449 on 06/01/2023. 676111 Page 7 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the medication pass observation on 05/31/2023 at 8:57AM, LVN B administered Anagrelide 1mg oral capsule, one capsule to Resident #47. In an observation and interview on 05/31/2023 at 4:47PM, RN A, stated Resident #47's confirmed the order for Anagrelide was for 4 capsules of 1mg daily, as it read on the pharmacy label. RN A stated the risk to the resident is clots. RN A stated he would notify the unit manager so they can discuss during the morning meeting. The pharmacy label indicated a quantity of 56 tablets. There were 16 broken blister seals and 40 tablets left. During an interview and observation on 05/31/2023 at 5:00PM, Resident #47 was visiting with family. She had a purple/red bruise to the right side of her face, large purple/red bruises to left forearm and both hands. Her skin was very thin, and her right arm was in a sling. She stated it was her Hematologist who first ordered the Anagrelide d/t to her high platelet count. She stated she had been on this medication for over a year. The family stated Resident #47 dose of Anagrelide was 4mg at home. In an interview on 05/31/2023 at 5:15PM, the DON stated the risk to Resident #47 of not getting the correct dose of Anagrelide was bleeding. The DON stated the nurses were responsible to make sure meds are administered properly as ordered. The DON stated she did not know what happened and will have to investigate. She stated she would be talking to LVN B tonight. The DON stated she planned to conduct medication inservices to all nursing staff and stated the NP B was ordering labs for Resident #47 and had a call out to the physician via text to notify of the medication error. During a telephone interview on 05/31/2023 a 6:00PM, NP B stated the Anagrelide was part of Resident #47's hospital discharge meds. NP B stated the resident had been on 4mg daily and NP B confirmed the order for Anagrelide 1mg capsules x 4 capsules for total of 4mg every day was correct. NP B stated the risks to Resident #47 is clotting d/t she had thrombocytosis (platelet count above normal range). NP B stated labs will need to be ordered again and will need to monitor Resident #47's vital signs more regularly so she does not develop deep vein thrombosis (formation of blood clot in a blood vessel). During a telephone interview on 06/01/2023 at 11:00AM, the pharmacy said that delivery of Resident #47's Anagrelide 1mg capsules was on 05/18/23 for 56 capsules and that this was the first time pharmacy had ever filled this order. During an interview on 06/01/2023 at 11:30AM, LVN B, stated the DON had spoken with her about the Anagrelide med error for Resident #47. LVN B, stated she did not give any more capsules of Anagrelide to Resident #47. She stated that she just didn't read the order properly and that next time she will read orders more carefully. LVN B confirmed that it was her initials on the MAR dates of administration on May 19, 23, and 27 of 2023 and stated that honestly, she did not know how many capsules she gave to Resident #47 on those days. Record review of Resident #47's Medication Record for 05/2023 revealed the DON administered Anagrelide 1mg capsule, give 3 tablets one time at this time, for blood thinner, 3 tablets PO x 1 on 05/31/2023 at 8:00PM. Record review of the facility policy for Administering Medications, Nursing Services Policy and Procedure Manual for Long-Term Care 2001 MED-PASS, Inc., revised December 2012, read in part: Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. Policy 676111 Page 8 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interpretation and Implementation .3. Medications must be administered in accordance with the orders .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of the fda.gov label for Anagrelide revised on 3/2018, read in part: .Indications and Usage, Anagrelide is a platelet reducing agent for the treatment of thrombocythemia, secondary to myeloproliferative neoplasm, to reduce the elevated platelet count and the risk of thrombosis and to ameliorate associated symptoms including thrombo-hemorrhagic events . 676111 Page 9 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for three (Nurse Cart 2B Hall, Med Aide Cart 1A Hall, Nurse cart 2A Hall) of four medication carts reviewed for storage of medications. Nurse Cart 2B Hall, Med Aide Cart 1A Hall and Nurse cart 2A Hall had punctured protective seals on the back of multiple narcotic medication blister pill cards. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings included: Nurse Cart 2B Hall: Observation on 05/31/2023 at 10:00am revealed the narcotic storage of Lorazepam 0.5mg tablets #5 and #6 of 9 tablets had torn protective seals. A second blister card of Lorazepam 0.5mg, tablet #3 of 4 tablets had a torn protective seal. A third blister card of Lorazepam, tablet #6 of 30 tablets had a torn protective seal. In an interview on 05/31/2023 at 10:00AM, LVN E stated if the resident needed a dose of Lorazepam, he would use the tablets with the broken seal first. LVN E stated if the seal was broken there would be an infection control issue, or someone could remove the pills. LVN E stated he will waste the tablets with another nurse. Med Aide Cart 1A Hall: Observation on 05/31/2023 at 10:43AM revealed the narcotic storage of Lorazepam 0.5mg, tablet #10 of 10 tablets had a torn seal that was taped over with paper tape. In an interview with RN B and DON on 05/31/2023 at 10:43AM, RN B stated the Lorazepam tablet may fall out, get lost and the resident will not have any pills available when needed. RN B stated it should not have been taped, it should be wasted. The DON stated it should not have tape and will be wasted. Nurse Med Cart 2A Hall: Observation on 06/01/2023 at 12:45PM revealed the narcotic storage of Tramadol 50mg (1/2tabs), tablets #2, #3, #5 of 6 tablets had torn protective seals. A blister card of Lorazepam 0.5mg, had 16 tablets; blister seal #3 was torn, #15 had a puncture, #6 and #8 were torn and taped over with paper tape. A second blister card of Lorazepam 0.5mg tabs had 14 tablets and seal #8 was torn. A third Lorazepam 0.5mg blister card had 34 tablets and blister seal #6 was torn. In an interview on 06/01/2023 at 12:45PM, LVN D stated it was not correct to tape up the seals that were broken. LVN D stated the risk would be infection, loss of the drug, depletion of the resident's supply and the tablet may not be the same that was originally in the package. LVN D stated she 676111 Page 10 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0761 would notify the ADON, waste the meds with another nurse and place reorders. Level of Harm - Minimal harm or potential for actual harm In an interview on 06/01/2023 at 12:50PM, LVN E said all nurses in charge of medication carts were responsible for checking the integrity of blister seals on all packaging. Residents Affected - Some In an interview on 06/01/2023 at 4:40PM, the Administrator stated she expected the nurses to be responsible for checking the integrity of the packaging since they are the ones who count it daily. The Administrator stated she expected nurses to waste the meds if the seals are broken as the tablets could fall out and picked up by anyone. The Administrator then stated, I don't know, I would probably tape it if the seal was broken only slightly then label it, do not use, or waste it later. Record review of the facility policy for storage of medications, revised April 2007 read in part: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe and sanitary manner. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing Record review of the facility policy for Controlled Substances, revised December 2012 read in part: Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances Record review of the undated facility policy for Drug Diversion revealed in part: .Goal, to support the health and safety of its employees, patients and visitors. Policy: Drug diversion (theft) is prohibited. Suspected drug diversion will be investigated . 676111 Page 11 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and/or serve food in accordance with professional standards for food service safety in 1 of 3 kitchens reviewed for food procurement in that: Facility failed to maintain proper storage, label and/or date. These failures could place residents at risk of foodborne illnesses and disease. Findings included: Observation on 05/30/23 at 08:30 AM, 1 of 1 walk in refrigerators in the facility's main kitchen revealed: 1-red top container of white sauce unlabeled and/or dated, 1-red top container of red sauce unlabeled and/or dated. 1-24 oz container opened and used Ricotta cheese unlabeled and/or dated. 1-2 lb. bag loosely folded over Mild cheddar cheese block unsealed/opened and unlabeled and/or dated. 1-2 lb. bag of American cheese slices unsealed/opened. Observation on 05/30/23 at 08:49 AM, 1 of 1 walk in pantries in the facility's main kitchen revealed: unsealed and unlabeled and/or undated 20lb bag of cornstarch sitting in a large bin with a scooper inside bag. Observation on 05/30/23 at 09:11 AM, 1 of 4 food preparation stations in the facility's main kitchen revealed: food thickening Thick & Easy unsealed/opened with small scooper inside. Observation on 05/30/23 at 09:12 AM, 1 of 4 standalone freezers in the facility's main kitchen revealed: plain beget bread unlabeled/undated. 2lb bag of Sysco breaded catfish unlabeled and/or undated. 1 small bag of poppy seed bagels that appeared to be covered in freezer burnt ice unlabeled and/or undated. 1 half full 6lb bag of platanos maruros unlabeled and/or dated. 6 bags of assorted Bakery Solutions Royal Danish Pastry unsealed/opened and unlabeled and or undated inside a box. 1-metal tin pan of cake prepared by date of 04/30/23 at 5:25 PM and an expired must use by date of 05/07/23 at 5:25 PM. 1-small bag of pasta that appeared to be covered in freezer burnt ice with a prepared date of 05/01/23 at 01:56 PM with no used by date, 1-apple pie prepared date of 05/02/23 at 04:02 PM and an expired must use by date of 05/09/23 at 4:02 PM. Observation on 05/31/23 at 11:30 AM, revealed: unsealed/opened, unlabeled/undated and outdated foods previously observed in 1 of 1 main kitchen had been removed, sealed, and/or labeled in 1 of 4 standalone freezers reviewed during the initial kitchen tour. Interview on 05/30/23 at 08:30 AM, [NAME] stated that the red top container of white sauce and red top container of red sauce and 1-24 oz container opened and used Ricotta cheese were used in last night's meal. [NAME] could not provide what dish was made last night that called for the red and white sauces. [NAME] stated he would label the red and white sauce and discard the Ricotta cheese container. Interview on 05/30/23 at 08:49 AM, Dining Services Director (DSD) stated the 2 lb. block of mild cheddar cheese was used that morning for breakfast and needed to be resealed and labeled. DSD stated that the large bag of course starch had come in that morning on the Tuesday food shipment order and 676111 Page 12 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some used during breakfast preparation. He stated that the scooper inside the cornstarch should be stored outside of the container. He stated it is every one of the kitchen staff's responsibilities to ensure the foods are properly stored and labeled. Interview on 05/30/23 at 09:15 AM, DSD stated that the Danish pastries had been used that morning for breakfast and should have been securely sealed and labeled with opened and use by dates. He stated that he would have the staff go through the 1 of 4 standalone freezers in the facility's main kitchen to discard any outdated food items. Interview on 05-30-23 at 02:28 PM, Dietary Manager (DM) stated that she is over the staff in the two small serving kitchens on each floor of the facility and Clinical/Minimal Data Set charting. She stated that DSD is over the Executive Chef (EC) and the EC is over all the staff in the main kitchen. She stated that the EC had performed in-services on food storage had copies of the storage and labeling policies. Interview on 05/31/23 at 11:38 AM, Sous Chef stated that staff in the main kitchen have removed all outdated and freezer burn foods and insured all other foods in the refrigerators, freezers and pantries are properly sealed and labeled. Interview on 06/01/23 at 09:34 AM, DSD stated that all the kitchen staff had been in serviced on the proper food storage and labeling. Interview on 06/01/23 at 02:17 PM, Administrator stated that DSD and EC performed a complete walk through of the kitchen the evening of 5/31/23 and the early morning of 06/01/23 to ensure all food items were property labeled, stored, dated, and not outdated. DSD and EC also performed in-services on proper food storage with all the kitchen staff. She stated the risk of unlabeled/undated, unsealed and/or outdated food would be foods could lose nutritional value and taste, develop bacteria, freezer burn, and open foods could cross contaminate to other foods causing bacteria. These failures could place residents at risk for stomach problems and other diseases and illnesses and cause the residents to not enjoy the food. Interview on 06/01/23 at 03:17 PM, DSD stated that the foods that are not sealed could attract bugs and other airborne diseases that could cause the residents to get sick. Failure to property date foods could result in the facility serving foods to the residents that are expired and could make the residents sick. He stated that EC in-serviced all the staff on proper food storage and he and the EC made sure that all the items in the kitchen were properly sealed, labeled and within date range for consumption. Interview on 6/01/23 at 01:28 PM, EC stated that it is every kitchen staff's responsibility to ensure that the foods in the kitchen are properly stored, labeled, and used within date range. He stated he does not handle food he only manages the food handling staff. He stated he is responsible for ensuring all staff are trained on food handling in the kitchen. He stated that the staff that handle food in the kitchen have food handling certifications. The CMS 672 dated 06/01/23 indicated a census of 53. Record Review of the facility's Food Storage policy (undated). Frozen Meat/Poultry and Foods: 3. Storage . Foods should be stored in their original container if designed for freezing. Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special 676111 Page 13 of 14 676111 06/01/2023 The Buckingham 8580 Woodway Drive Houston, TX 77063

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some laminated papers. Label and date all food items. Dry Storage: 7. Any opened products should be placed in seamless plastic or glass container with tight fitting lids and labeled and dated. 8. Label and date all storage containers or bins. Keep free of scoops. Lids need to be tight fitting and in good condition. Record Review of the facility's Standard Storage Procedure Policy. It is a standard operating procedure of this facility to properly store food in the manner that emphasizes food safety, food rotation, checking and observing expiration dates, and practicing proper date marking to ensure product quality and safety. Policy Interpretation and Implementation. 2. Proper storage practices help to ensure food is rotated and being used before expiration date. All items should be dated upon delivery to ensure older items are being used before newer ones. Expiration dates should be checked when putting away deliveries to ensure items closest to expiration date are at the front while items furthest from the expiration date are at the back. If any items found to have expired when rotating stock, those items should be properly researched if received recently and discarded. All refrigeration's, freezers and Storage areas need to be Safe and in Sanitized conditions at all times. Inspect daily. Date code genie - is the tool for proper labeling - it's the company, it's your standard. 3. Best practices should include the date of preparation, with the expiration date following 6 days later all prepared food items. If only one date is present, it must be assumed and treated as the expiration date. 676111 Page 14 of 14