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Complaint Investigation

Normandy Terrace Nursing & Rehabilitation Center

Inspection Date: August 15, 2025
Total Violations 1
Facility ID 675823
Location San Antonio, TX
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Inspection Findings

F-Tag F0732

Nursing and Physician Services Deficiencies
Harm Level: Potential for Minimal Harm

F 0732

Post nurse staffing information every day.

Level of Harm - Potential for minimal harm

Based on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 1 of 3 days (08/13/2025) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information on 08/13/2025. This failure could place residents at risk of not having access to information regarding staffing data and the facility census.The findings included: During an observation on 08/13/2025 from 02:24 p.m. to 02:47 p.m. revealed information regarding the current nurse staffing and census information was not found available in a public posting.

During an observation and interview on 08/13/2025 at 02:45 p.m., the DON revealed she also could not locate the daily census and nurse staffing posting. She was observed to ask Receptionist A for the posting location. Receptionist A was observed to reply to the DON, it is not up today. During an interview on 08/14/2025 at 03:48 p.m., CNA A stated she was responsible for the staff scheduling but did not state why

she did not post the daily schedule and census on 08/13/2025. During an interview on 08/15/2025 at 01:13 p.m., the DON revealed it was the responsibility of the staff scheduler to print and post the daily schedule and census for the following day. The DON stated the facility recognized this task not having been done was

an issue. The DON revealed she asked the scheduler on 08/13/2025 (the day the posting was observed not posted at 02:45 p.m.) about the posting and the DON stated the scheduler acted as if she did not know it was one of her tasks. The DON revealed the scheduler knew and completed this task appropriately only a few weeks prior when the facility was going through relicensing certification observations. The DON stated

she could not state why the scheduler stopped performing this task but did state the scheduler said she forgot. The DON stated she had not had a resident or facility guest ask to view the posting, but it should be posted daily for a facility guest or resident to view. During an interview on 08/15/2025 at 04:33 p.m., the DON stated the facility did not have a policy on posting the daily census and nurse staffing, but per the facility compliance nurse, the facility was to follow the regulation. During an interview on 08/15/2025 at 04:43 p.m., the ADMIN stated it was the responsibility of the staffing coordinator (staff scheduler) to post

the daily census and nurse staffing with the ADONs acting as back-up. The ADMIN stated the necessity for posting this information was because there was a regulation that stated the facility had to post this information daily. The ADMIN stated he did not believe the lack of posting the information would impact the residents but stated he referred to the posting when giving prospective residents and facility guests tours to demonstrate the staffing ratios. The ADMIN stated he was not aware until the current day, 08/15/2025, that

the posting was not posted on 08/13/2025, but stated he believed it may have been missed due to the responsibilities of the staff scheduler being transitioned to a different staff member and that the new staff member was not yet fully trained on their new responsibilities.

Residents Affected - Many

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

Normandy Terrace Nursing & Rehabilitation Center in San Antonio, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in San Antonio, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Normandy Terrace Nursing & Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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