New Martinsville Health & Rehab: Death Notice Failures - WV
The legal representative for Resident 97 told state inspectors she never received a phone call from the facility about the death. She had caller ID and voicemail, she said, and neither showed a missed call from the nursing home nor contained any message from staff.
She had been home all evening and all night when her loved one passed away.
Instead, the funeral home called at approximately 9:30 AM saying they had her loved one's body and wanted to discuss funeral arrangements. That was the first time she learned the resident had died at the facility.
"She reported she was devastated to get the news in that manner," inspectors wrote in their August 27 report.
The legal representative waited the entire day for the nursing home to call. Staff never did.
When inspectors interviewed the facility administrator the next morning at 11:40 AM, he acknowledged the legal representative had been actively involved in the resident's care through both telephone calls and visits to the facility.
The administrator also acknowledged nursing staff could not produce evidence they had successfully notified the legal representative of Resident 97's death.
He called it "a terrible oversight" and said it had been addressed with the staff involved.
The failure to notify families of deaths represents one of two communication breakdowns inspectors found during their complaint investigation at the 225 Russell Avenue facility.
In a second case, staff added anxiety medication for Resident 76 without notifying the resident's Medical Power of Attorney, as required by facility policy.
The resident had participated in a MindCare Psychiatric Evaluation via video call. A progress note dated at 8:50 AM stated the psychiatrist had prescribed Vistaril 25 milligrams by mouth every eight hours as needed for 14 days for anxiety.
However, inspectors found no record that staff had notified the resident's Medical Power of Attorney about the new medication. There was also no change-in-condition notice completed, as facility policy requires.
When inspectors interviewed the Medical Power of Attorney at approximately 4:15 PM, they asked whether the resident seemed anxious or was having problems with anxiety.
"No, I don't," the representative replied.
The administrator acknowledged to inspectors that there should have been a change-in-condition notice and documentation showing the Medical Power of Attorney was notified about the new medication.
Both violations fell under federal regulations requiring nursing homes to immediately notify residents' representatives of changes in condition, treatment, or other significant events.
The legal representative in the death notification case had maintained regular contact with the facility about her loved one's care. Her involvement made the communication failure particularly egregious, inspectors noted.
Federal regulations require nursing homes to notify families or legal representatives immediately when residents experience accidents, injuries, significant changes in condition, or death. The notification must be made to the resident's physician and a family member or legal representative.
Facilities must also document these notifications in the resident's medical record.
The failure to notify the legal representative of Resident 97's death meant family members could not be present during the resident's final moments or make immediate decisions about care or arrangements.
For Resident 76, the lack of notification about new psychiatric medication meant the Medical Power of Attorney could not provide input about the treatment or monitor for potential side effects.
Vistaril, the medication prescribed for anxiety, can cause drowsiness, confusion, and increased fall risk in elderly patients. Family involvement in medication decisions helps ensure treatments align with residents' values and that representatives can watch for adverse reactions.
The administrator's acknowledgment that both situations represented policy failures suggests systemic problems with the facility's communication protocols rather than isolated incidents.
In the death notification case, multiple staff members would typically be involved in the process. Nursing staff who discover a death, supervisors who coordinate with funeral homes, and administrators who handle family communications all have roles in ensuring proper notification.
The fact that none of these staff members successfully contacted the legal representative, despite her active involvement in the resident's care, points to broader communication breakdowns.
The facility's inability to produce any evidence of attempted contact raises questions about whether staff followed any notification protocols or simply failed to document their efforts.
For families of nursing home residents, these communication failures represent some of the most traumatic experiences possible. Learning of a loved one's death from a funeral home rather than caring staff compounds grief with feelings of abandonment and institutional indifference.
The legal representative's devastation at receiving news of the death through funeral home staff rather than nursing home personnel she had worked with throughout her loved one's care illustrates the human cost of administrative failures.
Similarly, medication decisions made without family input can undermine trust between families and facilities, particularly when the family questions whether the treatment was necessary.
State inspectors classified both violations as causing minimal harm or potential for actual harm, affecting few residents. However, the emotional impact on families dealing with death notification failures or excluded from medication decisions can be profound and lasting.
The administrator's admission that the death notification was "a terrible oversight" and his acknowledgment that proper procedures were not followed for the medication case suggest the facility recognizes the severity of these communication breakdowns.
Whether the facility's corrective actions will prevent similar failures remains to be seen. The inspection report does not detail what specific steps were taken to address the problems with staff involved in either case.
The legal representative who learned of her loved one's death from the funeral home spent an entire day waiting for a call from nursing home staff that never came, adding unnecessary anguish to an already difficult time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Martinsville Health & Rehab from 2025-08-27 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
NEW MARTINSVILLE HEALTH & REHAB in NEW MARTINSVILLE, WV was cited for immediate jeopardy violations during a health inspection on August 27, 2025.
The legal representative for Resident 97 told state inspectors she never received a phone call from the facility about the death.
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.