Inspection·August 18, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm hospital setting. During an interview on 8/18/25 at 8:45 am the RN Compliance Nurse stated she thought the facility reporting time frame requirement for missing residents to the Complaint and Incident Intake Department was 24 hours. Record review of the Nursing Policy and Procedure Manual Section TG 03-1.0 titled, Abuse/Neglect that was undated, reflected, If the allegation involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 2 of 6 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 08/18/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision in that: The facility failed to supervise Resident #1 who eloped from the facility on 08/16/25 and was gone from the facility for more than nine hours and found in a closed car and had sustained a heat stroke. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 08/16/2025 and ended on 08/16/2025. The facility had corrected the non-compliance before the survey began on 08/17/2025. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Review of Resident's #1 face sheet, dated 8/17/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: multiple sclerosis (a condition in which nerve damage affects the communication between the brain and body), type 2 diabetes mellitus (a condition in which the body's blood sugar was not controlled), and unspecified dementia (a condition in which there is a decline in cognition). Record review of Resident #1's quarterly MDS assessment, dated 7/29/25, revealed a blank BIMS score, indicating the resident could not complete the interview. The MDS revealed that Resident #1 was ambulatory and had wandering behavior. Record review of Resident #1's elopement assessment, dated 1/16/25, revealed Resident #1 had the potential for wandering behavior and was at risk for elopement. Record review of Resident #1's care plan, initiated on 1/16/25, revealed Resident #1 had an identified risk for elopement behavior. The interventions for elopement behavior included close supervision, reporting of risk factor such as wandering behavior and requests to leave the facility to the MD, and increased monitoring. The care plan for Resident #1 was updated on 8/16/25 to include the elopement incident. Record review of Physician Order Summary, dated 8/16/25, revealed Resident #1 was taking Depakote Sprinkles 125 mg for (General Anxiety Disorder), Humalog SQ 100 unit/ML for (Diabetes Mellitus), Metformin HCI 500 MG for (Diabetes Mellitus) and Lantus SQ 300 unit for (Diabetes Mellitus). Record review of the facility incident report, dated 8/16/25, revealed Resident #1 eloped from the facility at 5:10 am and that staff first learned of the incident at 7:30 am and a search on the secure unit was initiated with a Code Orange being called at 9:00 am. Record review of the National Weather Service weather data (https://www.weather.gov/wrh/Climate?wfo=ewx) for 8/16/2025 revealed a high temperature that day of 98 degrees Fahrenheit. Record review of the employee statement from CNA P, dated 8/16/25, revealed she said she took out the trash on the secure unit side door shortly after 11:10 pm on 8/15/25 and made sure the door was locked. Record review of the employee statement from LVN B, dated 8/16/25, revealed he said he took out the trash on the morning of 8/16/25 thru the gate in the courtyard and made sure the courtyard gate was closed. The actual time in the morning was not specified on the statement. Observation of the facility's camera footage revealed Resident #1 exiting the secure unit thru the side door on 8/16/25 at 5:04 am and thru the courtyard gate at 5:10 am. Record review of the facility's actual elopement exercise for Resident #1 revealed the drill was initiated on 8/16/25 at 7:30 am and cleared at 2:55 pm. During an interview with Family Member A on 8/17/25 at 8:00 am, Family Member A stated Resident #1 had gotten out of the facility's secure unit door shortly after 5:00 am on 8/16/25 and was not located until 2:30 pm on 8/16/25. Family Member A stated Resident #1 was found by family members inside of a closed car on a private residence that was one block from the facility. Family Member A stated Resident #1 was then transported to the hospital from this location. Family Member A stated Resident #1 would be returned to the same nursing home facility. During an interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 3 of 6 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 08/18/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with hospital RN B on 8/17/25 at 9:00 am, hospital RN B stated Resident #1 was admitted to the hospital with a diagnosis of heat stroke. Hospital RN B stated Resident #1 would be given IV fluids along with Magnesium, Potassium, and Electrolytes. During an interview with Resident #1 on 8/17/25 at 9:10 am at her hospital room she stated she did not know where she was currently at or what had happened to her on 8/16/25. During an interview with Family Member C on 8/17/25 at 9:15 am, Family Member C stated she was told by the facility administrator that the side door on the secure unit apparently had a malfunction in its locking mechanism which allowed for Resident #1 to be able to leave the facility. Family Member C stated she was told by the Administrator the cameras on the secure unit were not fully operational at the time of Resident #1's elopement on 08/16/25. Family Member C stated Resident #1 would be returning to the same nursing facility upon hospital discharge. Record review of the facility's staff checklist in-service log dated 8/16/25 revealed that 100 percent of the staff had received the in-service on abuse/neglect, elopement protocol, and ensuring exit doors and gates were locked. Record review of the facility's secure unit resident head count form dated 8/17/25 revealed the protocol for the charge nurse on the secure unit conducting the resident head count. Record review of the facility's secure unit resident rounding form completed by Nurses and CNA staff revealed that the form is completed at the end of the shift. Record review of the facility's care plan listing report revealed that all of the residents on the secure unit had their care plan updated on 8/16/25 for elopement status. Record review of the facility's elopement policy in the Nursing Policy and Procedure Manual WA-03-2.0 revealed the intervention steps for staff to take in conducting an internal and external search for a missing resident as well as the need for staff to manually check all exit doors and outside gates for closure and alarm viability. Record review of the facility's Code Orange Drill Elopement Guide that was undated revealed the steps and notifications that staff are to follow when searching for a missing resident. Record review of the facility's process change form dated 8/16/25 revealed the following updates:a. The side door on the secure unit used by Resident #1 to exit the facility is now permanently secured and closed.b. All secure unit door codes were changed.c. Nurse will conduct hourly resident head counts on the unit.d. CNA and Nursing staff will complete resident head counts at the end of their respective 8 hour and 12-hour shifts.e. The Maintenance Director or designated person (Manager on Duty for the weekends) will check all exit doors and outside gates for alarm viability twice a day).f. Nursing staff completed elopement assessments on all residents.g. Care plans were updated for all residents on elopement risks.h. A spring was added on the outside court- yard gate to increase the automatic closure ability of the gate.i. The elopement policy, abuse/neglect policy, and door/gate closure protocol were reviewed with 100 percent of the staff. Record review of the facility's maintenance log exit door check completed on 8/18/25 at 8:30 am revealed all facility exit doors were alarmed. During an interview with the DON on 8/17/25 at 10:15 am, the DON stated that she believed Resident #1 was able to exit the secure unit thru a side door that had a malfunction on the locking mechanism. The DON stated Resident #1 was last seen on the secure unit at 4:00 am and the resident had a habit of wandering into other resident rooms. The DON stated the facility staff began an internal search of the facility for Resident #1 on 08/16/25 at 7:30 am and the official Code Orange was called at 9:00 am. The DON stated 100 percent of the facility's staff had been in-serviced on 8/16/25 on the elopement protocol which included the steps to undertake to complete an internal and external search for missing resident. The DON stated that the in-service also included the need to staff to manually check all facility exit doors and outside gate to ensure that they were closed and alarmed. During an interview with the Administrator on 8/17/25 at 8/17/25 at 11:20 am, the Administrator stated he felt the locking mechanism on the side door on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 4 of 6 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 08/18/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few secure unit malfunctioned which allowed Resident #1 to exit the building. The Administrator stated that courtyard gate was not properly secured which allowed Resident #1 to go thru that gate to the outside. The Administrator stated that he believed a nurse working on a different unit had left the courtyard gate open and that nurse was suspended. The Administrator stated that Resident #1 was last seen on the secure unit at 4:00am and had a habit of wandering into other resident rooms. The Administrator stated that the facility staff began an internal search for Resident #1 on 8/16/25 at 7:30 am and the official Code Orange was called at 9:00 am. The Administrator stated the facility had new cameras installed and the cameras on the secure unit were recording but the playback from the cameras was not fully operational until 8/17/25. The Administrator stated 100 percent of the facility's staff had been in-serviced on 8/16/25 on the elopement protocol which included the steps to undertake to complete an internal and external search for missing resident. The Administrator stated that the in-service also included the need to staff to manually check all facility exit doors and outside gate to ensure that they were closed and alarmed. During an interview with the Maintenance Director on 8/17/25 at 12:20 pm, the Maintenance Director stated he was not sure how Resident #1 had exited the building thru the side door on the secure unit. He stated that he had checked that exit door on 8/15/25 and the alarm was functioning properly. The Maintenance Director stated during the elopement search on 8/16/25 he checked both the side door of the secure unit in which Resident #1 had exited the building as well as the courtyard gate and both were closed and alarmed. During an interview with CNA D on 8/17/25 at 1:15 pm, CNA D stated she had assisted in the elopement search for Resident #1. CNA D stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with LVN E on 8/17/25 at 1:20 pm, LVN E stated she had assisted in the elopement search for Resident #1. LVN E stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with ADON F on 8/17/25 at 1:35 pm, ADON F stated she had assisted in the elopement search for Resident #1. ADON F stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. ADON F stated during the elopement search she had gone to the side door on the secure unit, and it was properly locked. During an interview with CNA G on 8/17/25 at 1:40 pm, CNA G stated she had assisted in the elopement search for Resident #1. CNA G stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with Housekeeper H on 8/17/25 at 1:50 pm, Housekeeper H stated she had assisted in the elopement search for Resident #1. Housekeeper H stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with LVN I on 8/17/25 at 2:00 pm, LVN I stated she had worked as the Charge Nurse during the night shift on 8/16/25 and did not observe Resident #1 leave the unit. LVN I stated she had not participated in the elopement search but had been re-in-serviced on abuse/neglect, elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675823 If continuation sheet Page 5 of 6 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 08/18/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete gates to be sure they were closed and alarmed. During an interview with RN J on 8/17/25 at 2:20 pm, RN J stated she had assisted in the elopement search for Resident #1. RN J stated that she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA K on 8/17/25 at 2:25 pm, CNA K stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with RN L on 8/17/25 at 2:30 pm, RN L stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA M on 8/17/25 at 2:35 pm, CNA M stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA N on 8/17/25 at 2:40 pm, CNA N stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. During an interview with CNA O on 8/17/25 at 2:45 pm, CNA O stated she had been re-in-serviced on abuse/neglect and elopement protocol including the steps to take to conduct an internal and external search for a missing resident as well as manually checking all exit doors and outside gates to be sure they were closed and alarmed. CNA O stated she had worked on the night shift in which Resident #1 had eloped on 8/16/25. CNA O stated she did not remember when she had last seen Resident #1 but that it could have been at 4:00 am, whenever Resident #1 received incontinent care in her room. During an observation with the Administrator and Maintenance Director on 8/18/25 from 8:05 am until 8:30 am all of the facility's exit doors and outside gates were checked for closure and alarm viability and found to be in good working order. The Administrator and Maintenance Director stated that all facility exit doors and outside gates would be checked twice a day seven days a week for closure function and alarm viability. Record review of the facility's policy titled, Nursing Policy and Procedure Manual TG 03-1.0, undated, revealed that Neglect; is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Event ID: Facility ID: 675823 If continuation sheet Page 6 of 6