Normandy Terrace: Resident Elopement Immediate Jeopardy - TX
The elopement occurred sometime after 4:00 am when Resident #1 was last seen receiving incontinence care in her room, according to CNA O, who worked the night shift but could not remember exactly when she had last checked on the resident.
Federal inspectors arrived within days of the incident and discovered systemic failures in the facility's ability to prevent residents from wandering off the premises undetected. The citation carries the most serious level of harm designation under federal nursing home regulations.
CNA O told inspectors on August 17 that 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." The aide's uncertainty about basic resident monitoring highlighted gaps in the facility's overnight supervision.
The escape exposed broader problems with staff training and security awareness. Multiple employees interviewed by inspectors had recently completed retraining on elopement protocols, yet a resident still managed to leave the building unnoticed.
During interviews conducted on August 17, six different staff members told inspectors they 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."
RN J participated in the search for the missing resident and confirmed she had received the emergency retraining. The nurse spoke with inspectors at 2:20 pm on August 17, describing her involvement in looking for Resident #1 after the elopement was discovered.
Four other staff members gave nearly identical responses about their recent training. CNA K spoke with inspectors at 2:25 pm, followed by RN L at 2:30 pm, CNA M at 2:35 pm, and CNA N at 2:40 pm. Each confirmed they had been retrained on proper search procedures and door monitoring protocols.
The rapid succession of staff interviews suggested facility management had conducted emergency training sessions immediately after the incident, attempting to address obvious gaps in security awareness among employees.
CNA O, the night shift aide who last saw the resident, completed her interview at 2:45 pm. Her inability to pinpoint when she had last checked on Resident #1 raised questions about the adequacy of overnight monitoring procedures.
The morning after the interviews, inspectors conducted a comprehensive security assessment with facility leadership. On August 18 from 8:05 am until 8:30 am, the Administrator and Maintenance Director walked through the entire facility checking every exit door and outside gate.
All security systems tested properly during the inspection. Doors closed correctly and alarms functioned as designed, indicating the elopement did not result from equipment failure but from procedural breakdowns.
The Administrator and Maintenance Director committed to enhanced monitoring protocols, telling inspectors that "all facility exit doors and outside gates would be checked twice a day seven days a week for closure function and alarm viability."
The promise of twice-daily security checks represented a significant increase from previous protocols, though inspectors did not document what the prior checking schedule had been or why it proved inadequate.
Federal regulations require nursing homes to prevent residents from wandering off premises, particularly those with cognitive impairments who may become confused or disoriented outside familiar surroundings. Elopements can result in serious injuries or death when residents become lost or exposed to weather conditions.
The facility's own policy manual defines neglect as "the failure of the facility, its 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." The undated policy, titled "Nursing Policy and Procedure Manual TG 03-1.0," establishes standards that the elopement incident appeared to violate.
Immediate jeopardy citations require nursing homes to submit detailed correction plans and demonstrate they have eliminated the conditions that put residents at risk. Facilities typically have 23 days to achieve compliance and avoid potential termination from Medicare and Medicaid programs.
The inspection report does not indicate whether Resident #1 was found safely or what happened during the time she remained missing from the facility. It also does not specify her cognitive condition or whether she had a history of wandering behavior that should have triggered enhanced monitoring.
The timing of the incident during overnight hours, when staffing levels are typically lowest, raises questions about whether Normandy Terrace maintained adequate supervision to prevent elopements. Night shift personnel often cover larger numbers of residents with fewer staff members available to conduct regular room checks.
The facility's response of immediately retraining multiple staff members suggests management recognized significant deficiencies in elopement prevention procedures. However, the fact that six different employees required emergency training indicates the problems extended beyond a single individual's oversight.
Normandy Terrace's commitment to twice-daily security checks may help prevent future incidents, but the inspection report provides no details about what additional measures the facility implemented to address the underlying supervision gaps that allowed the elopement to occur undetected.
The immediate jeopardy finding means inspectors determined the facility's failures created a situation where residents faced the likelihood of serious injury, harm, impairment, or death. Such citations are reserved for the most serious violations that require immediate correction to protect resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Normandy Terrace Nursing & Rehabilitation Center from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Normandy Terrace Nursing & Rehabilitation Center in San Antonio, TX was cited for immediate jeopardy violations during a health inspection on August 18, 2025.
The citation carries the most serious level of harm designation under federal nursing home regulations.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.