Inspection·June 22, 2024

F 0580 note. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2's April TAR revealed: Behavior Monitoring Enter the code - 0. None 1. Panic 2. Agitated 3. Angry 4. Anxiety 5. Biting 6. Compulsive 7. Crying 8. Pacing 9. Screaming/yelling 10. Pull IV line/tubes 11. Poor eye contact 12. Depressed withdrawn 13. Extreme fear 14. False beliefs 15. Fighting 16. Finger painting feces 17. Hallucinations/paranoia/delusion 18. Head banging 19. lnsomnia 20. Jittery 21. Kicking 22. Noisy 23. Pinching 24. Restless 25. Scratching 26. Slapping 27. Suspiciousness 28. Throwing objects 29. Wandering 30. Other see progress notes every shift If any behaviors are noted, document details in a progress note. Further review of this document revealed: Residents Affected - Few [DATE] - [DATE]: 0 (None) [DATE] - [DATE]: 19 (Insomnia) [DATE] and [DATE]: 4 and 13 (Anxiety and Extreme fear) [DATE] and [DATE]: 0 (None) [DATE] and [DATE]: 1 and 4 (Panic and Anxiety) Resident #2's April TAR also revealed: Side Effects - Enter the code - 0. None 1. Dystonia 2. Dry mouth 3. Constipation/urinary retention 4. Hypotension 5. Drowsiness/Sedation 6. Dizziness 7. Arrhythmias 8. Tardive dyskinesia 9. Rash 10. Headache 11. Urine retention 12. Weak 13. Cogwheel rigidity 14. Tremor 15. Appetite change 16. Insomnia 17. Confusion 18. Sore throat 19. Seizure 20. Photo-sensitivity 21. Suicidal Ideations 22.GI disturbance 23. Ataxia every shift If any side effects are noted, document details in a progress note. Further review of this document revealed: [DATE] - [DATE]: 0 (None) [DATE]: 5 (Drowsiness) [DATE]: 14 (Tremor) [DATE] - [DATE]: 0 (None) [DATE]: 8 and 14 (Tardive Dyskinesia and Tremor) [DATE] and [DATE]: 14 (Tremor) [DATE] and [DATE]: 0 (None) [DATE]: 6, 14, and 16 (Dizziness, Tremor, and Insomnia) [DATE]: 14 and 16 (Tremor and Insomnia) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 2 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #2's Progress Notes revealed: Effective Date: [DATE] 13:25 [1:25 pm] .Note Text: This nurse was called to resident room to assist with a transfer back to w/c from the bed. Once resident was in her w/c her eyes became fixated and shallow breathing. Resident then took her last breath and was placed on the floor. Another CNA went to call for help. This resident is a full code. CPR was initiated, with AED, ambu bag with 02 at 15L. 911 was called, family in hallway. Resident now breathing with a strong heartbeat [sic] EMS arrived and placed resident on stretcher, resident still incoherent. Resident was sent to [hospital] with RP at her side.MD, DON, and administrator aware. Author: [LVN B] . Record review of Resident #2's SBAR, dated [DATE], revealed Resident #2 had mental, functional, and neurological status change, with heightened emotional status of anxiety, panic, dizziness, fear, body was shaking, trembling, perspiring, VS were BP 157/80, Pulse 114-140, and respirations 28, symptoms started [DATE]. Record review of Resident #2's SBAR, dated [DATE], revealed Resident #2 had functional status change, needed more assistance with ADLs, falls, weakness, and was diaphoretic (sweating), VS were BP 109/62, Pulse 92, and respirations 20, symptoms started [DATE]. Further review of this documentation revealed the MD or NP were notified on [DATE] and RP was notified on [DATE]. Review of Resident #2's EMR revealed there was no documentation stating the MD/NP was notified of Resident #2's change in condition on [DATE]. Record review of Resident #2's hospital record, dated [DATE], revealed: .brought to the ED via EMS with reports of altered mental status. Per the ED physician the nursing facility reported that the patient was unresponsive, so EMS was called. The nurse at the outside facility started CPR .Upon arrival to the ED of EMS the patient was found to be hypotensive [low blood pressure] and tachycardic [elevated heart rate] .Initially on arrival the patient was unresponsive .ASSESSMENT/PLAN: 1. Sepsis .2. Acute encephalopathy .3. Dehydration .4. AKI . During interview on [DATE] at 9:38 am, RN A said, on [DATE] at approximately 10:00 am, Resident #2 was sitting in the dining room holding on very tightly to the table and the pillar and said she did not want to be left alone. RN A obtained VS and said the abnormal VS (BP 157/80, Pulse 114-140, and respirations 28) on [DATE] triggered the SBAR. RN A further stated she notified the MD about Resident #2's change in condition after completing the SBAR on [DATE] and did not receive any new orders from the MD. RN A said she must have documented the communication with the MD in a progress note. During interview on [DATE] at 11:57 am, the MD, she was not notified of the change in condition for Resident #2 on [DATE]. The MD said had she been notified; she would have sent Resident #2 to the hospital. The MD further stated there was a possibility the change in condition Resident #2 experienced on [DATE] may have led to the hospitalization on [DATE]. During interview on [DATE] at 4:09 pm, the DON said she was aware of the SBAR for [DATE] and had briefly read it. She further stated RN A reported that on [DATE] Resident #2 had gripped the table and was shaking, and RN A notified the MD. She further stated she was not aware of the symptoms listed on the SBAR for Resident #2 or the lack of documentation regarding notification or follow up to the MD/NP on [DATE] regarding Resident #2. The DON said she expected nurses to contact the MD once the resident was stabilized if there was a change in condition and document on the SBAR what the MD said. The DON further stated she audited resident records at least once a week, reviewed all the nurses notes every morning on Tuesday - Friday, and the 72-hour report on Monday mornings. The DON said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 3 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0580 Level of Harm - Immediate jeopardy to resident health or safety was not aware there were no progress notes for [DATE]. The DON said during her observations Resident #2 was fine but did not remember the exact date of the observation. During interview on [DATE] at 10:27 am, LVN D said Resident #2 had some neurological changes, excessive shaking, and trembling between [DATE] and [DATE]. LVN D further stated Resident #2 was more incontinent and needed more help with ADLs during this time, and on [DATE]. Residents Affected - Few During interview on [DATE] at 10:30 am, CNA C said between [DATE] and [DATE], Resident #2 was shaking a lot, holding on to the table thinking she was going to fall, and was saying the police were coming. CNA C further stated Resident #2 was having delusions and kept saying I'm falling, I'm falling. During interview on [DATE] at 1:30 pm, the NP said she was not notified of the change in condition for Resident #2 on [DATE]. The NP further stated the facility was responsible for notifying the MD/NP of changes in resident condition so that they could intervene if needed. The NP further stated, had she been notified, she would have sent Resident #2 to the hospital. Record review of facility policy, titled Notifying the Physician of Changes in Status and revised [DATE], stated: The nurse will notify the physician immediately with significant changes in status . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:26 pm. The ADO and the DON were notified. The ADO and the DON were provided with the IJ template on [DATE] at 4:30 pm. The following POR submitted by the facility was accepted on [DATE] at 1:06 pm and reflected the following: [Facility] [DATE] Quality Assurance Problem: Facility failed to notify Physician/NP of resident change in condition. Interventions: The following in-services were initiated by the DON and the ADON on [DATE]. Any staff member not present or in-serviced on [DATE] will not be allowed to assume their duties until in-serviced. - In-service completed with the DON and the ADONs by the ADO and the RCN on [DATE] regarding reviewing and monitoring documentation in PCC to include review of the SBAR, and PCC clinical alerts. Licensed Nurses Certified Nurse Aides In-service licensed nursing staff to the following in the event of a resident change in condition: - Promptly and correctly assessing a resident when a change of condition has been identified / (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 4 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0580 reported. Level of Harm - Immediate jeopardy to resident health or safety - Unless it was an emergency situation, assessing a resident's change in condition and document change using a SBAR, so that all necessary information was communicated to the physician or nurse practitioner. The completion of the SBAR included documentation of the notification to the physician and any new orders, if any, the physician provided. Residents Affected - Few - If an emergency situation, stabilize the resident as much as possible and notify 911. Notify the physician after transfer. - Initiate any orders provided. - Promptly and correctly assessing a resident when a change of condition has been [sic] identified. Communication of change in condition to other nurses, med aides, and nurse aides will occur during shift-to-shift change report. Documentation of change in condition will occur on the 24-hour report in PCC. In-service initiated for Certified Nurse Aides on [DATE] by the DON on the following: Any non-licensed nursing staff not present or in-serviced on [DATE] will not be allowed to assume their duties until in-serviced. - CNAS will verbally communicate any resident change of condition as well as document the change under point of care in PCC. - An adhoc QAPI meeting was conducted on [DATE] regarding this plan and monitoring. - The medical director [Medical Director] was notified of this plan and monitoring on [DATE]. Monitoring: The DON / designee will monitor PCC Dashboard alert documentation for all residents at least 5 times per week to ensure any potential change of condition has been addressed and the physician was notified timely. The DON / designee will ask 10 nursing staff (including at least 6 nurses) per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change in condition. All monitoring noted above will continue for at least 4 weeks. The QAPI Committee will review the findings and make changes to this plan as needed. The DON/designee will review all SBARs 5 times a week for 4 weeks and periodically there after to ensure all resident change in condition have been addressed. Verification of POR: Record review of facility's sign-in sheets on of [DATE] revealed 65 out of 65 nursing staff (100%) were in-serviced in-person, via text, and via telephone. Record review of facility's in-service Training Attendance Roster, Topic: Reviewing and Monitoring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 5 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Documentation in PCC, dated [DATE], revealed it was completed by the ADO; Attendees: the DON, LVN D, and LVN H. In interviews between [DATE] at 5:13 pm and [DATE] at 11:34 am, with 4 nursing staff on the 6 am - 6 pm shift (2 RNs and 2 LVNs), 4 nursing staff on the 6 pm - 6 am shift (2 RNs and 2 LVNs), 6 CNAs on the 7 am - 3 pm shift, 4 CNAs on the 3 pm - 11 pm shift, and 5 CNAs on the 11 pm - 7 am shift, staff said they had been in-serviced regarding communication of changes of condition between shifts and to the charge nurse, documentation of SBAR, and notification of changes in resident condition to the MD. During interview on [DATE] at 5:13 pm, LVN A said she received an in-service on [DATE] that included when to complete an SBAR, what it entails (documentation, calling the MD), when to report changes in condition, documenting changes and notifying the MD, and documenting new orders. During interview on [DATE] at 5:16 pm, RN D said she received in-service on [DATE] that included SBAR, changes in condition, identifying changes and need for SBAR, full documentation of the SBAR and notification to the MD, family, and the DON. Communicating with our peers, and shift report. During interview on [DATE] at 5:22 pm, CNA E said she received an in-service on [DATE] that included changes for the residents, reporting changes, such as bruises or wounds, to the nurse and documentation of any changes in POC. During interview on [DATE] at 5:24 pm, CNA F said she received an in-service on [DATE] that included telling the nurse, the DON, or Administrator if we see anything like skin tears or bruising and documentation of changes in POC. During interview on [DATE] at 5:25 pm, LVN F said she received an in-service on [DATE] that included SBAR, changes in condition, calling the MD, documentation, notifying family, calling 911 for emergencies and contacting the RP. Documentation of the SBAR, such as what was going on, the change in condition, notifying the MD and documenting what the MD said regarding orders or what they want us to do, sometimes its medication or monitoring. During interview on [DATE] at 5:29 pm, CNA G said she received an in-service on [DATE] that included notifying the nurse if we see any signs of decline and documenting those changes in POC. During interview on [DATE] at 5:30 pm, CNA H said she received an in-service on [DATE] that included reporting any changes in condition or declines to the nurse and documentation in POC. During interview on [DATE] at 5:34 pm, RN B said she received in-service on [DATE] that included SBAR, calling the MD, the family, and contacting the Medical Director. She stated if the MD did not answer the medical director should be notify, and to notify the resident, family, and the medical director, if needed of new orders. CNAs were supposed to let us know if there were changes in condition, such as: loose stools, pain, fever, bruises, falls, decreases in appetite, and they document those changes in PCC. For emergencies, assess the resident, complete an SBAR, document any new orders, and make notifications. If we need to call 911, call them, document, and notify everyone. It also included the 24-report, which was a communication sheet used during shift change. During an interview on [DATE] at 2:01 am, LVN G said she received an in-service on [DATE] that included recording changes in condition, who to call if there were changes, what to do, notifying the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 6 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0580 MD, family, and stabilizing the resident. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 2:03 am, CNA I said she received an in-service on [DATE] that included reporting any changes in resident condition to the nurse and documenting in POC. Residents Affected - Few During an interview on [DATE] at 2:04 am, CNA J said she received an in-service on [DATE] that included reporting of abuse/neglect, reporting any changes in condition to the nurse, and documenting changes in POC. During an interview on [DATE] at 2:06 am, RN F said she received an in-service on [DATE] that included contacting the MD when there were changes in condition, documentation of the changes, and completing the SBAR. During an interview on [DATE] at 2:07 am, CNA K said she received an in-service on [DATE] that included reporting any changes in condition to the nurse and documenting them in POC. During an interview on [DATE] at 2:10 am, RN G said she received an in-service on [DATE] that included how to complete an SBAR and notifying the MD. During an interview on [DATE] at 2:13 am, LVN H said she received an in-service on [DATE] that included SBAR, assessing the resident with changes in condition, notifying the MD, initiating new orders, communication of changes to nurses, Mas, and CNAs during shift report and documentation. During an interview on [DATE] at 2:14 am, CNA L said she received an in-service on [DATE] that included abuse, documentation of changes in condition, reporting to the nurse, and documenting in the POC. During an interview on [DATE] at 2:16 am, CNA M said she received an in-service on [DATE] that included abuse/neglect, documenting changes in condition, and communicating changes to the nurse. During an interview on [DATE] at 11:30 am, CNA N said she received an in-service on [DATE] that included if she saw something, such as skin tears, or if someone was hurt it should be reported to the nurse and documented. During an interview on [DATE] at 11:31 am, CNA O said she received an in-service on [DATE] that included if something happened to the residents or if there was a change in their condition, it should be reported to the nurses and then documented in the POC kiosk. When they shower the residents, if they saw anything, like a bruise, document it and report it to the nurse. During an interview on [DATE] at 11:34 am, CNA R said she received an in-service on [DATE] that included reporting changes in resident condition, such as bruising or changes in health, to the nurse, and documented in POC. During an interview on [DATE] at 11:36 am, CNA S said she received an in-service on [DATE] that included patient care, reporting changes in condition, skin, or health, to the nurses. During an interview on [DATE] at 11:40 am, the DON said she provided an in-service starting on [DATE] that included all nurses and CNAs. Topics included proper documentation and notification of SBARs regarding changes in resident condition and CNAs reporting changes to the nurses and documenting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 7 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few changes in POC. The DON further stated she completed a review of all resident SBARs for the months of April, May, and [DATE] and no concerns were identified. During an interview on [DATE] at 11:46 am, CNA B said she received an in-service on [DATE] that included reporting changes in resident condition to the nurse and documentation of changes in POC. During an interview on [DATE] at 11:47 am, CNA Q said she received an in-service on [DATE] that included a text message to receive an in-service before she started her shift on [DATE] at 7:00 am. She further stated on [DATE] she was told to report any changes that she had not seen before while caring for a resident to the nurse and document the change in Care Tracker/POC. Record review of facility policy, titled Notifying the Physician of Changes in Status and revised [DATE], revealed on was present and in effect. The ADO and the DON were informed the Immediate Jeopardy (IJ) was removed on [DATE] at 1:06 pm. The facility remained out of compliance at a severity of potential for more than minimal harm that was not an 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) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 8 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary care and services to a resident who [NAME] unable to carry out activities of daily living for 1 of 7 residents (Resident #2), reviewed for activities of daily living in the area of incontinent care. Residents Affected - Few Resident #2 was not provided with incontinent care by a nursing staff member on 6/7/24 in a timely manner. This failure could result in residents experiencing a diminished quality of life. Findings included: Record review of Resident #2's admission Record, dated 6/11/24, revealed Resident #2 the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. , Resident #2 hadwith diagnoses that included: Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors) , acute kidney failure (condition in which kidneys suddenly are unable to filter waste from blood) , schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) , and dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's Quarterly MDS assessment, dated 5/3/24, revealed Resident #2 had a BIMS score of 6 (suggesting severe impairment). Further review of this record revealed Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's Care Plan, dated 5/6/24, read: . incontinent of bowel and bladder . INCONTINENT care at least q 2 hrs. Record review of Resident #2's Care Task Record for June 2024 revealed Toilet Use was initialed at 12:31 am on 6/7/24. Record review of Resident #2's [NAME] revealed .TOILET USE: the resident is totally dependent on staff for toilet use . Record review of Resident #2's Progress Notes for 6/7/24 revealed no progress note reflecting that Resident #2 refused incontinent care. Record review of Provider Investigation Report, dated 6/7/24, read: On 6/7/2024 at approximately 4:00pm the resident's daughter reported to the Administrator that she was requesting to transfer to another long-term care facility. Administrator inquired as to the reason for the request to transfer, the daughter replied that she found her mom with a wet brief, wet bed, and the Nurse had to assist because there was only one C.N.A. working on this date. The DON reported to the resident's room and did find the resident with a wet brief and wet bed.; The resident was being changed by the Charge Nurse and new linens provided to the bed. Staffing on this unit on this date was 2 Charge Nurses and 2 C.N.A.s for 33 residents. Record review of the facility's schedule, dated 6/7/24, revealed there were two CNAs scheduled, CNA A and CNA C. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 9 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of staff statement, undated and signed by the DON, read: When I entered the room [LVN A] the floor nurse was providing perineal care. The brief was very wet, and the sheets were wet. It was obvious to this nurse that it was fresh urine. We are encouraging fluids, due to her having a UTI. On dayshift we had two cna's working and one has been requested not to care for [Resident #2]. Record review of staff statement, undated, read: CNA A statement on the phone I checked her at 1 pm and she was dry. She is resistant to care but I changed her during the day. Record review of staff statement, dated 6/7/24 and signed by the CNA C, read: I [CNA C] was not [Resident #2's] aid on Friday June 7. 2024 . During observation and interview on 6/12/24 at 10:36 am, Resident #2 was sitting up in bed. The resident was alert, there were no visible injuries on Resident #2. The resident's bed and brief were dry and there was no odor of urine. Resident #2 said her needs were met and that she was able to press the call light button when she required assistance. During a telephone interview on 6/11/24 at 9:38 am, Resident #2's family member said when she arrived at the facility on 6/7/24 at approximately 3:15 pm, she saw the resident trying to reach for the covers and the resident was shaking like a leave., The family member said Resident #2 had Parkinson's, but she did not shake that bad. Resident #2's family member further stated when she pulled the covers back, the bed was wet with urine. The family member said the call light was on when she arrived. Resident #2's family member said she reported to LVN A that Resident #2 was soaked in urine., LVN A said CNA A wereas assigned to Resident #2 but had left for the day and the 3:00 pm - 11:00 pm shift had not arrived. Resident #2's family member said the resident did not have skin breakdown. During an interview on 6/12/24 at 11:14 am, LVN A said on 6/7/24 she was asked by Resident#2's family member if she would ask the CNA to change the resident because she was wet. LVN A further stated Resident #2's family member asked to show LVN A the condition Resident #2 was found in. LVN A said Resident #2 was wet, the brief was saturated to the point where it was very heavy, and the resident and the bed were wet from the resident's neck to about her mid-thigh. LVN A said there was a brown ring around the wet area on the bedding. LVN A said check and change was supposed to be every two hours but did not know when Resident #2 was last checked by the CNA. LVN A said she asked CNA A to check on Resident #2 after she was put in bed at 7:00 am and CNA A said he checked Resident #2, and she was dry. LVN A said CNAs were expected to document whether residents were wet or dry in POC, adding the CNAs were responsible for ensuring residents were checked every 2 hours. LVN A said when residents were left wet, they were at risk for UTIs, sepsis, skin breakdown, or yeast infection. During an interview on 6/12/24 at 12:36 pm, CNA A said on 6/7/24 left at 3pm and later received a call from LVN H, who said Resident #2 was found wet at 3:00 pm on 6/7/24. CNA A further stated he changed Resident #2's brief on 6/7/24 at approximately 9:00 am and checked her at approximately 1:30 pm and she her brief was dry. CNA A said he worked the 7:00 am to 3:00 pm shift. CNA A said he was expected to check the resident and change the briefs as needed every 2 hours unless he was too busy. CNA A further stated staff were not expected to document when residents were changed. CNA said he would be expected to check if Resident #2 was wet before he left for the day and he checked her at approximately 1:30 pm, adding the following shift arrived at approximately 2:45 pm -3:00 pm and they would check the residents . During an interview on 6/20/24 at 2:30 pm, the DON said CNAs were expected to check and change resident about every two hours and were also expected to document episodes incontinence but was not sure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 10 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0677 Level of Harm - Minimal harm or potential for actual harm if they were expected to document when the residents were dry. The DON further stated she expected residents to be checked 3-4 times within every 8 hours shift. The DON said if Resident #2 was only checked twice 6/7/24, that was not acceptable. The DON further stated on changing resident when they [NAME] wet put them at risk for skin breakdown. The DON said the floor nurses, the ADONs, and the DON were responsible for ensuring residents were checked approximately every 2 hours. Residents Affected - Few Record review of the facility's policy, titled Perineal Care dated 4/27/22, read: . It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 11 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 7 residents (Resident #2) reviewed for clinical records. The facility failed to ensure Resident #2's vital signs were documented in the EMR on [DATE] and [DATE]. This deficient practice could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #2's admission Record, dated [DATE], revealed Resident #2 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included: Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), acute kidney failure (condition in which kidneys suddenly are unable to filter waste from blood), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed Resident #2 had a BIMS score of 6 (suggesting severe impairment). Record review of Resident #2's Progress Notes revealed: Effective Date: [DATE] [12:03 pm] . Note Text: .vs stable. Author: [LVN B] Record review of Resident #2's Progress Notes revealed: Effective Date: [DATE] [10:12 pm] . Note Text: .VS WNL. Author: [RN C] Record review of Resident #2's Progress Notes revealed: Effective Date: [DATE] [1:25 pm] . Note Text: This nurse was called to resident room to assist with a transfer back to w/c from the bed. Once resident was in her w/c her eyes became fixated and shallow breathing. Resident then took her last breath and was placed on the floor. Another CNA went to call for help. This resident is a full code. CPR was initiated, with AED, ambu bag with 02 at 15L. 911 was called, family in hallway. Resident now breathing with a strong heartbeat EMS arrived and placed resident on stretcher, resident still incoherent. Resident was sent to [Hospital] with RP . at her side. [MD], DON, and administrator aware. Author: [LVN B] During a telephone interview on [DATE] at 1:10 pm, LVN B said on [DATE] she checked Resident #2's breathing and pulse before initiating CPR but said she did not document that she checked before initiating CPR. LVN B further stated she thought it needed to be documented but thought it was a given if she was doing CPR. LVN B said she did not know if not documenting VS negatively affected the resident. During a telephone interview on [DATE] at 3:02 pm, LVN B said she usually obtained residents' VS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 12 of 13 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 675823 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Terrace Nursing & Rehabilitation Center 841 Rice Rd San Antonio, TX 78220 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 0842 for her knowledge, not to be documented in PCC. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 4:09 pm, the DON said where nurses documented VS stable and WNL they should have documented a full set of VS, adding if VS were taken they were expected to be documented. The DON further stated the ADONs, and the DON were responsible for ensuring documentation was completed accurately. Residents Affected - Few Record review of the facility's policy, titled Cardiopulmonary Resuscitation , revised [DATE], revealed: . 22. Document all care given and the resident's response to treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 13 of 13