Normandy Terrace: Resident Elopement Immediate Jeopardy - TX
SAN ANTONIO, TX. The last time anyone at Normandy Terrace Nursing & Rehabilitation Center could say with certainty that they had seen Resident #1 was possibly 4:00 in the morning, when she received incontinence care in her room. After that, she was gone.
The resident walked out of the facility sometime during the overnight hours of August 16, 2025. She eloped, in the clinical language inspectors use, a word that means a vulnerable person in a locked and monitored care facility made it through a secured exit without anyone stopping her or, apparently, noticing she had left.
Federal inspectors cited Normandy Terrace for immediate jeopardy, the most serious level of violation the Centers for Medicare and Medicaid Services issues, reserved for situations where a facility's failures have placed residents in a condition that is likely to cause serious injury, harm, or death.
The nursing assistant who was working that night shift was interviewed by inspectors on August 17, the day after the elopement. CNA O told inspectors she did not remember when she had last seen Resident #1. She said it could have been at 4:00 a.m., during incontinence care. She could not say what happened between that moment and whenever it was that someone realized the resident was missing.
That gap is the story.
Elopement in a nursing home is not a paperwork failure. It is the breakdown of the most fundamental obligation a facility accepts when it takes in a resident who cannot safely be on her own: the obligation to know where she is. Residents who elope are, by definition, residents who need monitoring. They wander because of dementia, cognitive impairment, or other conditions that make independent navigation of the outside world dangerous. When a facility loses track of one of them in the dark, the consequences can be permanent.
CNA O had been re-in-serviced on elopement protocol, she told inspectors. She knew the steps for conducting an internal and external search for a missing resident. She knew that staff were supposed to manually check all exit doors and outside gates to confirm they were closed and alarmed. So did CNA N, another nursing assistant interviewed at 2:40 p.m. on August 17, who told inspectors she too had received the same re-in-service training on abuse, neglect, and elopement protocol, including the manual door and gate checks. The re-in-servicing had happened. The knowledge, apparently, was there.
What the inspection report does not say is whether anyone performed those checks on the night of August 16. It does not say how long Resident #1 was missing before staff noticed. It does not say where she was found, or what condition she was in when she was. The inspection report, six pages long and ending mid-paragraph before the narrative breaks off, contains the outline of what went wrong without filling in the worst of it.
What it does say is that the facility's own policy defines neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Inspectors cited that definition. They applied it to what happened on August 16.
On the morning of August 18, inspectors walked the building with the administrator and the maintenance director, checking every exit door and outside gate from 8:05 a.m. until 8:30 a.m. Everything was in working order. The alarms functioned. The gates closed. The administrator and maintenance director told inspectors that all exit doors and outside gates would be checked twice a day, seven days a week, going forward.
Twice a day, seven days a week, is the kind of corrective measure that gets written into a plan of correction after something has already gone wrong. It is not a measure that appears to have been in place on August 16.
The inspection that produced these findings was a complaint investigation. Someone filed a complaint. Inspectors came. They interviewed staff, reviewed records, walked the perimeter. The facility's elopement policy, pulled from a document called the Nursing Policy and Procedure Manual, was undated. The manual had no date on it.
Immediate jeopardy citations carry weight beyond the inspection itself. They trigger an accelerated timeline for correction. A facility that fails to remove the immediate jeopardy condition faces the termination of its Medicare and Medicaid provider agreements, which for most nursing homes means closure. The citation also becomes part of the facility's public record on the CMS Care Compare website, where families researching placement can see it.
But the record that matters most here is not a regulatory one. It is whatever record exists of where Resident #1 was between 4:00 a.m. and the moment she was reported missing, and what happened to her between the time she walked through that exit door and the time someone found her.
The inspection report does not provide those details. It describes the aftermath: the re-in-servicing, the door checks, the administrator's promises, the policy language about neglect. It describes a facility moving quickly to demonstrate that the problem had been addressed, that the doors were working, that the staff had been retrained, that the checks would happen twice daily now.
CNA O worked the night shift when Resident #1 eloped. She was re-in-serviced the next day. She told inspectors she did not remember when she had last seen the resident. It could have been 4:00 a.m.
That is the last specific moment anyone placed Resident #1 inside the building. After that, the inspection record goes quiet, and what happened to her in the hours between that incontinence check and whenever she was found remains outside the frame of what inspectors chose to document, or what this report was permitted to show.
Normandy Terrace is still operating.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 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 resident walked out of the facility sometime during the overnight hours of August 16, 2025.
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.