Normandy Nursing Center: Hepatitis C Follow-up Failed - MO
The resident's February 2024 lab work showed hepatitis C virus antibodies and elevated RNA levels indicating an active infection. Provider notes from that date documented a clear plan: "Resident to follow up at clinic in regard to see about medication regime to start."
Six weeks passed.
By March 15, 2024, the resident was complaining of vision problems during a provider visit. The doctor's notes again referenced the hepatitis C diagnosis and stated: "Will follow up on referral for hepatitis clinic." But no follow-up occurred before the resident transferred to another facility.
When federal inspectors arrived in August 2025 to investigate a complaint, they found a troubling gap in care coordination. The Assistant Director of Nursing, who worked at the facility during the resident's stay, told inspectors she remembered only the resident's schizophrenia diagnosis.
"She does not remember any diagnosis except schizophrenia," the inspection report states. "She does not remember a hepatitis diagnosis but the resident left on his/her and family's own choice."
The Director of Nursing, hired after the resident's departure, was equally unclear about what happened. She told inspectors she wasn't sure if an appointment was ever scheduled with the hepatitis clinic or if the provider followed up on the lab results.
Both nursing directors acknowledged they would expect staff to arrange follow-up care for reactive hepatitis C results. "When they transferred the resident, the information should have been sent to the new facility," they told inspectors.
It wasn't.
The facility administrator provided inspectors with copies of all transfer documents sent to the receiving facility. The order sheet contained no hepatitis C follow-up instructions. Transfer summaries made no mention of the lab results or the recommended infectious disease consultation.
The provider's progress notes were included in the transfer packet, but buried among other documentation rather than highlighted as an active medical concern requiring immediate attention.
The administrator offered explanations for the oversight. The medical director who had treated the resident at Normandy also worked at the receiving facility and had been the resident's physician since 2016. She suggested this continuity of care might have ensured proper follow-up despite the incomplete transfer documentation.
But key staff members who might have arranged the hepatitis clinic referral were no longer available to verify what happened. The social worker and transportation coordinator involved in the resident's case had both left the facility.
The administrator told inspectors she had tried reaching out to the hospital to clarify whether follow-up arrangements were made with the infectious disease clinic. No one had called her back.
Hepatitis C is a viral infection that attacks the liver and can cause serious long-term health problems if left untreated. Modern antiviral medications can cure most cases, but treatment requires specialized monitoring and follow-up care.
The February 2024 lab results showing elevated RNA levels indicated the resident had an active, ongoing infection rather than past exposure that had cleared naturally. The provider's documentation of "acute hepatitis C without hepatic coma" reinforced the need for prompt treatment.
Federal inspectors found the facility failed to ensure the resident received the recommended follow-up care before transfer. The violation was classified as causing minimal harm to few residents, but highlighted broader concerns about care coordination during facility transitions.
The resident's case illustrates how critical medical information can fall through cracks during nursing home transfers. Despite two separate provider visits documenting the need for hepatitis clinic follow-up, no evidence exists that appointments were scheduled or that receiving facility staff were alerted to the urgent medical need.
The inspection occurred more than a year after the resident's transfer, making it impossible to determine whether appropriate care was eventually provided or if treatment delays caused additional health complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Normandy Nursing Center from 2025-08-21 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 21, 2026 · Our methodology
NORMANDY NURSING CENTER in SAINT LOUIS, MO was cited for violations during a health inspection on August 21, 2025.
The resident's February 2024 lab work showed hepatitis C virus antibodies and elevated RNA levels indicating an active infection.
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.