THOMAS HOSPITALS SKILLED NURSING UNIT

333 LAIDLEY STREET, CHARLESTON, WV 25322 (304) 347-6500
Non profit - Corporation 29 Beds WVU MEDICINE Data: November 2025
Trust Grade
85/100
#9 of 122 in WV
Last Inspection: July 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Thomas Hospitals Skilled Nursing Unit in Charleston, West Virginia has received a Trust Grade of B+, indicating it is recommended and above average. It ranks #9 out of 122 facilities in the state and #1 out of 11 in Kanawha County, placing it in the top tier of local options. The facility is improving, with the number of issues decreasing from 7 in 2022 to 4 in 2025. Staffing is a strong point with a perfect 5-star rating and a turnover rate of 32%, which is better than the state average. However, there are concerns regarding resident activities, as nine out of sixteen residents were found to lack individualized activity plans, which could impact their mental and psychosocial well-being. Overall, while there are notable strengths in staffing and compliance history, the facility needs to enhance its engagement activities for residents.

Trust Score
B+
85/100
In West Virginia
#9/122
Top 7%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
7 → 4 violations
Staff Stability
○ Average
32% turnover. Near West Virginia's 48% average. Typical for the industry.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most West Virginia facilities.
Skilled Nurses
✓ Good
Each resident gets 203 minutes of Registered Nurse (RN) attention daily — more than 97% of West Virginia nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations
⚠ Watch
14 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★★
5.0
Inspection Score
Stable
2022: 7 issues
2025: 4 issues

The Good

  • 5-Star Staffing Rating · Excellent nurse staffing levels
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (32%)

    16 points below West Virginia average of 48%

Facility shows strength in staffing levels, fire safety.

The Bad

Staff Turnover: 32%

14pts below West Virginia avg (46%)

Typical for the industry

Chain: WVU MEDICINE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 14 deficiencies on record

Jul 2025 4 deficiencies
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Based on record review, staff interviews, and observation, the facility failed to develop and implement person-centered, comprehensive care plans that included individualized activities for 9 of 16 re...

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Based on record review, staff interviews, and observation, the facility failed to develop and implement person-centered, comprehensive care plans that included individualized activities for 9 of 16 residents reviewed (Residents #30, #29, #6, #1, #32, #27, #37, #38, and #23). This failure resulted in residents, including those with low BIMS scores and those who remained in their rooms, lacking documented activity interventions tailored to their needs and preferences. Resident Identifier: #30, #29, #6, #1, #32, #27, #38, and #23 Facility Census: 16a) On 07/30/2025 at 12:00 PM, a review of 16 resident records revealed that nine (9) lacked individualized activity care plans or interventions, despite cognitive or physical limitations requiring modified or room-based activities.Resident #30 had a low BIMS score and remained in their room and had no documented activity plan or evidence of room-based engagement effort.On 07/30/25 at 12:30 PM, during an interview with the Activities Director (AD) revealed she was unaware of how to create or update activity care plans in the facility's current electronic medical records system. She stated: I don't have an option to create care plans in this system that I know of. If there is, I have not been shown yet. I have been out due to health issues.On 07/30/25 at 3:00 PM, the Director of Nursing (DON) acknowledged she was not aware that residents were not care planned for activities, stating: All residents should be care planned for activities. I will get with the AD now.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0675 (Tag F0675)

Could have caused harm · This affected multiple residents

Based on interviews, observations, and record reviews, the facility failed to ensure residents maintained the highest practicable mental and psychosocial well-being. The facility did not provide indiv...

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Based on interviews, observations, and record reviews, the facility failed to ensure residents maintained the highest practicable mental and psychosocial well-being. The facility did not provide individualized activities and meaningful engagement for residents who remain in their rooms, failing to implement sensory stimulation or one-on-one interventions. In addiiton they failed to offer weekend activity programming for all residents. Facility Census: 16. a) On 07/30/25 The facility reported that it does not provide outings or opportunities for community involvement.On 07/31/25 The facility was unable to provide specific programming for one-on-one or sensory stimulation residents who are either unable or unwilling to leave their rooms.During record review on 07/30/25 at 12:00 PM a review of 16 resident care plans for activities revealed nine (9)lacked individualized activity care plans/interventions, particularly for residents who remain in their rooms or have low BIMS scores.An Interview on 07/30/25 with the Activities Director (AD) revealed that she was unaware of how to create or update activity care plans in the current new system. She stated, I don't have an option to create care plans in this system that I know of. If there is, I have not been shown yet. I have been out due to health issues.On 07/30/25 at 3:00 PM an Interview with the Director of Nursing (DON) revealed that she was unaware of the lack of activity care plans and stated, All residents should be care planned for activities, I will get with the AD now. Further Record review on 07/30/25 Review of facility activity calendars for May, June, and July showed no weekend activities were offered during those months.Various observations during the survey process revealed residents with a low Brief Interview for Mental Status (BIMS) score were noted to remain in their room without any documented one-on-one engagement or sensory-based activity plan.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

Based on record review, interviews, and observations, the facility failed to provide an ongoing activities program that met the individual needs, interests, and abilities of residents in accordance wi...

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Based on record review, interviews, and observations, the facility failed to provide an ongoing activities program that met the individual needs, interests, and abilities of residents in accordance with their comprehensive assessments and care plans. Specifically, the facility failed to offer room-based or sensory stimulation activities for residents who did not leave their rooms, failed to develop individualized care plans for activities for most sampled residents, and did not offer weekend activities. These systemic failures had the potential to negatively impact the residents' quality of life and psychosocial well-being. Facility census: 16.a) During the survey on 07/30/25, the following concerns were identified:Facility staff reported that there were no community outings or external engagement opportunities offered to residents.Staff stated they did not provide one-on-one or sensory stimulation activities for residents who are room-bound or chose not to leave their rooms.14 of 16 resident care plans reviewed showed no individualized activities interventions for residents, especially those with low BIMS (Brief Interview for Mental Status) scores or cognitive decline.The interview with the Activities Director (AD) revealed she did not know how to create or update activity care plans in the current system. She stated: I don't have an option to create care plans in this system that I know of. If there is, I haven't been shown yet. I've been out due to health issues.The interview with the Director of Nursing (DON) revealed she was unaware of the absence of activity care plans. She acknowledged all residents should be care planned for activities.Review of the facility's activity calendars for May, June, and July showed no weekend activities were provided during those months.Observation and record review confirmed that residents with low BIMS scores who remained in their rooms had no documented individualized activity interventions, and staff were unable to describe any in-person, sensory, or alternate engagement methods being used.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, and staff interviews, the facility failed to date and safely store open and prepared food items in multiple refrigeration units; maintain cleanliness of kitchen equipment and sur...

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Based on observation, and staff interviews, the facility failed to date and safely store open and prepared food items in multiple refrigeration units; maintain cleanliness of kitchen equipment and surfaces; and implement effective systems to prevent contamination or spoilage of food, including food that may be consumed by residents. These practices created a risk of foodborne illness. Facility Census: 16.On 07/30/2025 at 11:48 AM, the following was observed in the kitchen areas:Walk-In Cooler:A canister of chopped garlic was observed with no open or discard date.Walk-In Freezer:A bag of chicken tenders was stored outside of the original box, open and without a date.An open box of fish filets was observed without an open date and not sealed, exposing contents to possible contamination.Reach-In Cooler:The following perishable food items were observed undated and unsealed:OnionsCheeseLettuceSliced tomatoesSalad mixDishwashing Area:The floor under the dishwasher was visibly soiled with build-up.Racks and surrounding walls were observed to be unclean, indicating a lack of proper sanitation in an area critical to cleaning and storing eating utensils.Kitchen Equipment:Deep fryers were found to have grease accumulation behind the vats. The oil appeared dark and foamed at the edges, indicating potential overuse or contamination.The front of the fryer was coated in dried grease.Exhaust hoods above cooking equipment were visibly covered in grease.All ovens, reach-in coolers, and prep stations had build-up on the metal surfaces and visible debris and grease under the units.Reach-In Freezer:The following frozen food items were found open and without dates:Five (5) bags of French friesPre-made frozen omeletsFrozen biscuitsFrozen carrots, which were brown and discolored, indicating possible spoilageDuring the tour of the Kitchen the Dietary Manager (DM) was present and confirmed all findings as we completed the tour of the kitchen.
Oct 2022 7 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, record review, and staff interview, the facility failed to ensure one (1) of nine (9...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, record review, and staff interview, the facility failed to ensure one (1) of nine (9) residents reviewed during the long - term care survey process had a chair in the room to accommodate her needs and personal preferences. This was a random opportunity for discovery. Resident identifier: #62. Facility census: 17. Findings included: a) Resident #62 On 10/10/22 at 12:18 PM, the resident said she needs a chair so she can get up out of bed. She said, it needs to be a chair that would allow me to prop up my right leg. The residents' husband was visiting in the room and occupying the only chair in the room which was a hard back chair with arms. The residents' husband added, it could even be a wheelchair with an extension because she has a fractured leg. When asked if she had asked staff for a chair, the resident replied, I did but they told me all the reclining chairs are in use. Observation revealed no other chairs or wheelchairs were present in the residents' room. Review of the medical record found the resident was admitted to the facility on [DATE] with a right lateral plateau fracture. At approximately 11:00 AM on 10/11/22, the resident was observed to be up in a wheelchair with her right leg resting on a trash can turned upside down on the floor with a pillow on top of the can. At 1:24 PM on 10/11/22, the unit manager, Registered Nurse (RN) #15 observed the resident in her room with her right leg propped up on a trash can. She said, that's not good, I will get her a reclining chair, we have plenty of those. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

. Based on record review and staff interview, the facility failed to update the resident's care plan after the resident experienced a fall. This was true for one (1) of one (1) resident reviewed for t...

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. Based on record review and staff interview, the facility failed to update the resident's care plan after the resident experienced a fall. This was true for one (1) of one (1) resident reviewed for the care area of accidents during the long - term care survey process. Resident identifier: #55. Facility census: 17. Finding included: a) Resident #55 Review of the medical record revealed the resident fell at 4:30 AM on 10/05/22. At 0430 Nursing Assistant entered patient's room. Patient was found on the floor. Notified nursing supervisor and (name of physician.) (Name of physician was apprised of patient hitting her head and the presence of a hematoma. Doctor's order was to continue to monitor patient Patient complained of hitting her head and shoulder on the right side. Placed patient back in bed; applied ice pack to forehead; noted bruise to left arm. Will continue to follow. At 8:12 AM on 10/05/22 the physician documented the resident had a traumatic hematoma of the forehead. On 10/05/22 at 1:20 PM, an x-ray report noted the resident had a minimally displaced fracture of the right humerus. At 11:14 AM, on 10/11/22 the Director of Nursing (DON) confirmed the nurse did not start neurological checks after the fall as the facility policy directs. The DON provided a copy of the policy entitled: Fall prevention/entrapment plan, revised on August, 2020. H. Patient fall in spite of precautions: Reassess the patient, including the patient's vital signs, patient complaint of pain and obvious injury. If there is a change in LOC, loss of consciousness or head injury, the RN is to add neurological checks to plan of care and document results. At 11:30 AM on 10/11/22, the unit manager (UM) #15 said the nurse in charge received a disciplinary action because the nurse did not complete a nursing assessment following the fall and did not follow through with obtaining the orders from the physician for neurological checks and did not place the intervention for neurological checks on the care plan. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

. Based on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of accidents during the long - term care survey process received trea...

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. Based on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of accidents during the long - term care survey process received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Neurological checks were not started after the resident had a fall, hit her head, resulting in a hematoma. Resident identifier: #55. Facility census: 17. Finding included: a) Resident #55 Review of the medical record revealed the resident fell at 4:30 AM on 10/05/22. At 0430 Nursing Assistant entered patient's room. Patient was found on the floor. Notified nursing supervisor and (name of physician.) (Name of physician was apprised of patient hitting her head and the presence of a hematoma. Doctor's order was to continue to monitor patient Patient complained of hitting her head and shoulder on the right side. Placed patient back in bed; applied ice pack to forehead; noted bruise to left arm. Will continue to follow. At 8:12 AM on 10/05/22 the physician documented the resident had a traumatic hematoma of the forehead. On 10/05/22 at 1:20 PM, an x-ray report noted the resident had a minimally displaced fracture of the right humerus. At 11:14 AM, on 10/11/22 the Director of Nursing (DON) confirmed the nurse did not start neurological checks after the fall as the facility policy directs. The DON provided a copy of the policy entitled: Fall prevention/entrapment plan, revised on August, 2020. H. Patient fall in spite of precautions: Reassess the patient, including the patient's vital signs, patient complaint of pain and obvious injury. If there is a change in LOC, loss of consciousness or head injury, the RN is to add neurological checks to plan of care and document results. At 11:30 AM on 10/11/22, the unit manager (UM) #15 said the nurse in charge received a disciplinary action because the nurse did not complete a nursing assessment following the fall and did not follow through with obtaining the orders from the physician for neurological checks after the fall. The nurse on duty did not complete her assessment until 10/10/22. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

. Based on observation and staff interview, the facility failed to ensure medications were properly stored for Resident #57. This was a random opportunity for discovery. Resident identifier: #57. Faci...

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. Based on observation and staff interview, the facility failed to ensure medications were properly stored for Resident #57. This was a random opportunity for discovery. Resident identifier: #57. Facility census: 17. Findings included: a) Resident #57 On 10/12/22 at 10:34 AM during medication pass, observed Registered Nurse (RN) #1 remove a cup of medications from the back pocket of her uniform. When asked why the prepoured medications were stored in her uniform, RN #1 explained the medications were poured and found Resident #57 was not available to take the medications. An interview with the Unit Manager (UM) #15 on 10/12/22 at 10:34 AM regarding RN #1 putting poured medications in uniform pocket stated that the medications should have been placed in the locked box outside Resident #57's room and not in RN #1's uniform. .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

. Based on observation, resident interview, and staff interview, the facility failed to have an ongoing activity program that included group activities. This was true for six (6) of six (6) anonymous ...

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. Based on observation, resident interview, and staff interview, the facility failed to have an ongoing activity program that included group activities. This was true for six (6) of six (6) anonymous residents reviewed for the care area of activities during the long - term care survey process. This had the potential to affect more than a limited number of residents. Facility census: 17. Findings included: a) Resident interviews Anonymous interviews with residents during the initial phase of the survey on 10/10/22 found the unit has no group activities scheduled. One resident said, If they ever had any bingo, I would probably go. At 12:20 PM on 10/11/22, the activities coordinator (AC) #14 said, We have not had any group activities since COVID started, we have not been released to have group activities. Review of the August, September, and October activities calendar with AC #14 confirmed the unit has no group activities listed on the calendar. The AC was asked if residents who were not in isolation and did not have COVID could attend group activities with masks and social distancing? The AC again replied, We have not been cleared to have any group activities. Review of five (5) care plans for various Residents found the following activity intervention listed for all five (5) Residents: (Typed as written) Due to COVID - 19 the skilled nursing unit is restricted and is in effect until further notice. All residents are to stay in there rooms no group activities. On 10/11/22 at approximately 12:30 PM, the Registered Nurse (RN) unit manager #15 confirmed the unit has not had any group activities since COVID-19 started approximately 3 years ago. Observation of the activity room at 7:20 AM on 10/12/22 with the Minimum Data Set Coordinator (MDSC) #2 found a large activity room measuring at least 34 feet by 18 feet. Observations on 10/10/22, 10/11/22, and 10/12/22, found no group activities were occurring. At approximately 3:00 PM on 10/12/22, RN #15 was advised the above memo is available for guidance for facility group activities. RN #15 confirmed none of the 17 residents at the facility have COVID-19. Only two (2) of the 17 in the unit are in contact isolation for infections unrelated to COVID - 19. .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

. Based on observation and staff interview, the facility failed to ensure food items were stored, prepared, distributed and served in accordance with professional standards for food service safety. Me...

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. Based on observation and staff interview, the facility failed to ensure food items were stored, prepared, distributed and served in accordance with professional standards for food service safety. Meats were stored above vegetables and fruit in kitchen refrigeration's. The cook in the kitchen did not have a hair restraint. In addition, the facility failed to ensure residents personal snacks in the pantry refrigerator on the unit were labeled and dated as to when they were prepared and when to discard. This had the potential to affect more than a limited number of residents. Resident identifier: #66. Facility census: 17. Findings included: a) Tour of the kitchen The initial tour of the kitchen with the Dietary Operations Manager (DOM) #6 began at 11:25 AM on 10/10/22 and ended at 11:40 AM on 10/10/22 found the following: --Observation of 1 refrigerator found an unsliced section of roast beef which had not been prepared stored above an open box containing watermelon. --Observation of a second refrigerator found sliced ham and a unsliced section of ham stored above an open box containing bags of lettuce. --The floor of the walk-in freezer was littered with tape, pieces of boxes, crushed food items, crumbs and debris. --The kitchen cook, employee #31, was observed to be preparing/handling food was not wearing a hair restraint. DOM #6 confirmed the following: meat should not be stored above fruit and vegetables; the floor of the walk-in freezer needed cleaned; and the cook was not wearing a hair restraint. b) Unit Resident pantry At 2:08 PM on 10/12/22, observation of the unit's food pantry with Unit Manager, Registered Nurse (RN) #15 found food items belonging to Resident #66 in the refrigerator. RN #15 identified a container of tomato sauce and meatballs with no date to indicated when prepared and placed in the refrigerator and no date to indicate when to discard. In addition, a plastic glass containing a partially consumed frozen drink from a fast - food restaurant for Resident #66 was stored in the freezer of the refrigerator. RN #15 removed the items from the refrigerator. At approximately 2:45 PM on 10/12/22, RN #15 provided a copy of a policy entitled, Home Food, effective 04/2019: .The facility will refrigerate label and dated prepared or perishable food items in the patient specific nourishment refrigerator . .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected multiple residents

. Based on staff interviews and review of time card, the facility failed to have an Infection Control Preventionist (IP) at least part time. This failed practice had the potential to affect more than ...

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. Based on staff interviews and review of time card, the facility failed to have an Infection Control Preventionist (IP) at least part time. This failed practice had the potential to affect more than a limited number of residents. This was a random opportunity for discovery. Facility census: 17. Findings included: a) Infection Control Preventionist On 10/12/22 at 10:00 AM in an interview with the IP regarding the hours the IP worked in the facility, the IP stated that she worked at the facility approximately 4-6 hours per month. She further stated that she was shared with a sister hospital as well as with the Skilled Care Unit and the rest of the hospital. In addition, she stated she depends on the unit management to complete infection control audits and monitor infection control practices. An attempt was made to obtain the IP's time card to review the hours worked on the Skilled Care Unit. During the interview on 10/12/22 at 10:00 AM, the IP stated she was salaried and therefore did not clock in and/or out so there were no records of the hours she worked in any facility. .
Jul 2021 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

. Based on observation, record review and interview, the facility failed to accurately ensure a resident's advance directive was correct on the information board at the nurses' desk. The facility fail...

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. Based on observation, record review and interview, the facility failed to accurately ensure a resident's advance directive was correct on the information board at the nurses' desk. The facility failed to ensure the advance directive was completed and documented in the resident's electronic medical record (EMR). This was true for one (1) of 11 residents reviewed for advance directives. Resident identifier: #7. Facility census: 11. Findings included: a) Resident #7 A record review, on 07/13/21 at 8:15 AM, revealed a Skilled Nursing Unit admission Communication form in the medical record that stated, Do Not Resuscitate DNR. An interview with Registered Nurse (RN) #1, on 07/13/21 at 8:25 AM, revealed the Information board located at the Nurses' desk was color coded as to a resident's current resuscitation status. RN #1 stated, if the Resident is a full code their name would be written in black on the information board and if the resident is a DNR their name would be written in red on the board. An observation of the information board, on 07/13/21 at 8:30 AM, revealed Resident #7's name was written in black on the information board. An interview with the Director of Nursing (DON), on 07/13/21 at 9:20 AM, revealed the information board was wrong for Resident #7's advance directives and stated the issue would be fixed. The DON revealed the information board was used for a quick glance to help staff when working on the floor. DON stated the advance directives section in Resident #7's Electronic Medical Record (EMR) was not completed but the advanced directive information of DNR was added immediately. .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected multiple residents

. Based on facility documentation review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that consisted of the minimum required members. The fac...

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. Based on facility documentation review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that consisted of the minimum required members. The facility failed to ensure the Administrator, Owner or a Board member participated and was included as a member of the Skilled Nursing Unit (SNU) quarterly QAA committee. The failed practice had the potential to affect more than unlimited number of residents on the SNU. Facility census: 11. Findings included: a) Skilled Nursing Unit QAA Committee A facility document titled Health Facility Key Personnel was reviewed, on 07/13/21 at 10:46 AM. The document was provided by the Director of Nursing DON and listed the SNU QAA Committee members. The Health Facility Key Personnel form excluded the Administrator as a member of the SNU QAA Committee. The SNU QAA Committee members were as followed: Director of Nursing DON Minimum Data Set MDS Coordinator Social Worker Activities Director Lead Physical Therapist Occupational Therapist Medical Director Dietician An additional facility document titled, SNU Quality Care Conference Council Meeting was reviewed on 07/13/21 at 11:00 AM. The documentation contained three (3) sign in sheets for the SNU QAA Committee meetings. The dates included 01/06/21, 04/07/21 and 05/26/21. The SNU QAA sign in sheets revealed no attendance or participation by the Administrator, Owner or a Board member. An interview with DON, on 07/14/21 at 9:00 AM, revealed everyone who attended the SNU quarterly QAA meetings are required to sign in. DON confirmed the sign in sheets for the SNU QAA committee meetings were correct. DON confirmed the list of quarterly QAA meeting members were correct on the Health Facility Key Personnel form. .
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

. b) Quality Assessment and Assurance Committee Role A facility document titled Health Facility Key Personnel was reviewed, on 07/13/21 at 10:46 AM. The document was provided by the Director of Nursin...

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. b) Quality Assessment and Assurance Committee Role A facility document titled Health Facility Key Personnel was reviewed, on 07/13/21 at 10:46 AM. The document was provided by the Director of Nursing (DON) and listed the Skilled Nursing Unit (SNU) Quality Assessment and Assurance (QAA) Committee members. The Health Facility Key Personnel form excluded the Infection Preventionist (IP). The SNU QAA Committee members were as followed: Director of Nursing DON Minimum Data Set MDS Coordinator Social Worker Activities Director Lead Physical Therapist Occupational Therapist Medical Director Dietician A facility document titled, SNU Quality Care Conference Council Meeting was reviewed on 07/13/21 at 11:00 AM. The documentation contained three (3) sign in sheets for the SNU QAA Committee meetings. The dates included 01/06/21, 04/07/21 and 05/26/21. The SNU QAA sign in sheets revealed no attendance or participation by the Infection Preventionist. A facility document titled, Thomas Health Infection Preventionist Job Description reviewed on 07/14/21 at 8:30 AM, revealed job duties as assigned for the Infection Preventionist position. The documentation revealed, the Infection Preventionist's role was to compile and interpret surveillance reports to Quality Council or appropriate committees or speciality areas on a regular basis. An interview with DON, on 07/14/21 at 9:00 AM, revealed everyone who attended the SNU quarterly QAA meetings are required to sign in. DON confirmed the sign in sheets for the SNU QAA committee meetings were correct. DON confirmed the list of quarterly QAA meeting members were correct on the Health Facility Key Personnel form. Based on review of record review and interview, the facility failed to ensure the employee, who was designated as the Infection Preventionist for the unit, had completed specialized training in infection prevention and control. Additionally, the facility failed to ensure the Infection Preventionist was a member of the Skilled Nursing Unit Quality Assessment and Assurance Committee and reported on the infection control program, to the committee, on a regular basis . This practice had the potential to affect all residents in the facility. Facility census: 11. Findings included: a) Infection Preventionist training An interview, with the Infection Preventionist, on 07/13/21 at 3:05 PM, revealed the employee had not completed a specialized training in infection prevention and control. A review of the information provided for review, dated 2019, provided no evidence of a specialized training. Training included reporting and data collection with no specified length of event, and educational activity for continuing education. An interview with the DON, on 07/13/21 at 07:50 AM, revealed the facility had not ensured the Infection Preventionist had completed a specialized training for infection prevention and control because they were unaware of the requirement to do so. .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Grade B+ (85/100). Above average facility, better than most options in West Virginia.
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most West Virginia facilities.
  • • 32% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
  • • 14 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Thomas Hospitals Skilled Nursing Unit's CMS Rating?

CMS assigns THOMAS HOSPITALS SKILLED NURSING UNIT an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Thomas Hospitals Skilled Nursing Unit Staffed?

CMS rates THOMAS HOSPITALS SKILLED NURSING UNIT's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 32%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Thomas Hospitals Skilled Nursing Unit?

State health inspectors documented 14 deficiencies at THOMAS HOSPITALS SKILLED NURSING UNIT during 2021 to 2025. These included: 14 with potential for harm.

Who Owns and Operates Thomas Hospitals Skilled Nursing Unit?

THOMAS HOSPITALS SKILLED NURSING UNIT is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by WVU MEDICINE, a chain that manages multiple nursing homes. With 29 certified beds and approximately 15 residents (about 52% occupancy), it is a smaller facility located in CHARLESTON, West Virginia.

How Does Thomas Hospitals Skilled Nursing Unit Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, THOMAS HOSPITALS SKILLED NURSING UNIT's overall rating (5 stars) is above the state average of 2.7, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.

What Should Families Ask When Visiting Thomas Hospitals Skilled Nursing Unit?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Thomas Hospitals Skilled Nursing Unit Safe?

Based on CMS inspection data, THOMAS HOSPITALS SKILLED NURSING UNIT has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Thomas Hospitals Skilled Nursing Unit Stick Around?

THOMAS HOSPITALS SKILLED NURSING UNIT has a staff turnover rate of 32%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Thomas Hospitals Skilled Nursing Unit Ever Fined?

THOMAS HOSPITALS SKILLED NURSING UNIT has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Thomas Hospitals Skilled Nursing Unit on Any Federal Watch List?

THOMAS HOSPITALS SKILLED NURSING UNIT is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.