The Buckingham

F-F580 (Physician Notification/Residents Rights) involving failure to immediately notify the physician after a significant change

in condition.

Resident #1 was readmitted back to the facility on [DATE REDACTED] from a local area hospital.

Residents that can be affected are those who reside in the community. All facility residents were assessed for any Change in Condition. Completion date: 03/27/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 18 676111 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676111 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Buckingham 8580 Woodway Drive Houston, TX 77063

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 0684 1:1 education was immediately provided to RN A on 03/27/2025 by the Director of Nursing and Administrator. Education has been extended on 03/28/2025 to all licensed nursing staff and CNAs. Level of Harm - Immediate Instructor: DON and ADON jeopardy to resident health or safety Direct care staff (PRNs, new hires, from vacation) will not be allowed to render care until in-service is

Residents Affected - Few completed.

Test questions were given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures.

The topics covered were the following:

1. Policy & Procedure on Notification - Physician Notification

2. Policy & Procedure on Quality of Care - Change in a Resident's Condition

o A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by the staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument.

o Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form in MatrixCare. Licenses nurse will follow physician order to call 911(emergency services), if applicable.

3. Updated Physician and Nurse Practitioner Notification Call Tree

The updated call tree was completed on 03/27/2025. The appropriate action is to call 911 if the situation is emergent. The Physician and Nurse Practitioner Notification Call Tree is posted in all Nurses stations. All direct care staff were educated on the location and use during the in-service conducted by the Director of Nursing and the Administrator. Completion Date: 03/27/2025

Systematic Approach:

Audit tools/checklists were developed to monitor timely provider notification and change-in-condition documentation. Registered and licensed nurses were educated on these audit tools. Completion date: 03/28/2025.

A Notification Report audit on Change in Condition for residents in the last 30 days was reviewed and completed.

These tools will be reviewed weekly for compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 676111 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676111 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Buckingham 8580 Woodway Drive Houston, TX 77063

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 0684 Reviewed by: Director of Nursing and Administrator

Level of Harm - Immediate The Administrator notified the Medical Director of the Immediate Jeopardy on 03/27/2025 at 3:11 p.m. jeopardy to resident health or safety An emergency QAPI meeting was held on 03/27/2025, which was inclusive of a review of our policies/protocols for Change in Condition and Physician Notification, the policies were found to be sufficient. Residents Affected - Few Attendees were the following: Administrator, Medical Director, and Assistant Directors of Nursing.

The Director of Nursing and the ADON were in-serviced by the Medical Director, PCP A on Change in Condition and Physician Notification on 03/27/2025.

Staff in-services, to include all registered nurses, licensed clinical staff, were started on Physician Notification and all clinical staff on Changes in condition; this in-servicing will continue until all clinical staff have been trained. Staff will not be allowed to start on the floor or give care until this training has been completed. All new clinical staff will receive the in-services as part of the onboarding orientation process prior to being assigned and providing care to residents. All licensed clinical staff, will be in-serviced on Physician Notification and all clinical staff will be in-serviced on Changes in Condition.

Post tests were conducted and completed to ensure understanding and competency. Completion Date: 03/27/2025 Verified by: -DON

All current residents were assessed to determine if there is any change in status and/or condition. The assessments were noted in the individual residents' EMR's. The physician will be made aware of any noted changes from the resident's normal baseline. This will be completed by the registered/licensed nurses and nursing leadership.

Completion Date: 03/27/2025

After completion of the residents' audits, no other residents were found to be at imminent risk of having a change in condition and at their normal baseline completed 03/27/2025.

Who will be responsible: Director of Nursing and ADONs

Who will monitor: Administrator

\

Monitoring of the plan of removal included the following (3/28/2025 - 3/29/2025):

Record review of facility 1:1 education on change in condition, falls, physician notification provided to RN A

on 03/27/2025 by the ADMIN and DON. Further review of education on change in condition, falls, physician notification to all licensed nursing staff and cnas provided by the DON and ADON on 3/28/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 676111 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676111 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Buckingham 8580 Woodway Drive Houston, TX 77063

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 0684 Record review of facility in-services on notification to physician using the Call Tree System dated 3/27/2025 revealed the following: The Physician and Nurse Practitioner Notification Call Tree is posted in all Nurses Level of Harm - Immediate stations. All direct care staff were educated on the location and use during the in-service conducted by the jeopardy to resident health or ADMIN and DON. safety

Observation on 3/28/2025 revealed the Call Tree system posted at both nursing stations. 1. Call 911 if Residents Affected - Few patient needs emergency services. If not, call: 1. NP A, [NP A phone number], 2. MD A [MD A phone number], 3. On-Call Physician Answering Service [phone number], If no answer, please call Management Team - AMDIN, DON, ADON.

Record review of the facility audit for monitoring timely provider notifications and change in condition dated 2/28/2025 - 3/28/2025 revealed timely physician notifications. The tool is reviewed weekly.

Record review of the facility QAPI meeting dated 3/27/2025 revealed a review of policies/protocols for Change in Condition and Physician Notification, the policies were found to be sufficient. Attendees were the following: ADMIN, MD, and ADON.

Record review of the facility in-service on Change in condition and Physician Notification dated 3/27/2025 revealed the MD and PCP in-serviced DON and ADON.

Record review of the facility in-service on Physician Notification and Changes in condition dated 3/27/2025 - 3/28/2029 revealed the DON in-serviced all clinical staff. Post test were conducted and completed to ensure understanding and competency.

Record review of facility test, given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures.

The topics covered were the following:

1. Policy & Procedure on Notification - Physician Notification

2. Policy & Procedure on Quality of Care - Change in a Resident's Condition

o A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by the staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; requires interdisciplinary review and/or revision to the care plan ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument.

o Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form in MatrixCare. Licenses nurse will follow physician order to call 911(emergency services), if applicable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 676111 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676111 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Buckingham 8580 Woodway Drive Houston, TX 77063

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 0684 Interviews were conducted on 3/28/2025 - 3/29/2025 with staff (via phone and in person) on all shifts (6:00 a. m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., 6:00 a.m. - 2:00 p.m Level of Harm - Immediate (nurses and cnas) included the MD, PCP A, ADMIN, DON, ADON, RN A, RN B, RN C, RN D, RN E, LVN A, jeopardy to resident health or LVN B, LVN C, LVN D, CNA A , CNA B, CNA C, Dietary A, and HK A (8:30 a.m. - 5:00 p.m.), to verify the safety in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related Residents Affected - Few the Call Tree system - to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the Call Tree system. All were instructed to make a phone call and not to text.

Interviews were conducted on 3/28/2025 - 3/29/2025 with staff (via phone and in person) on all shifts (6:00 a. m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., 6:00 a.m. - 2:00 p.m (nurses and cnas) included the MD, PCP A, ADMIN, DON, ADON, RN A, RN B, RN C, RN D, RN E, LVN A, LVN B, LVN C, LVN D, CNA A , CNA B, CNA C, Dietary A, and HK A (8:30 a.m. - 5:00 p.m.), to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related

the Physician Notification and Changes in condition - to verify the in-services were conducted and to validate

the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related the how and when to make physician notification and changes in condition.]

The Administrator was informed the Immediate Jeopardy was removed on 3/29/2025 at 2:52 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 676111