Cycle 1
Health 2025-07-31 · Fire 2025-07-31
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Charleston, WV
Thomas Hospitals Skilled Nursing Unit
5-star overall rating with 5-star inspections with 4 recent health deficiencies
333 Laidley Street, Charleston, WV
(304) 347-6500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
29
Certified beds
Average residents
15
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wvu Medicine
Operator or chain grouping
Approved since
1991-04-15
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
3.54
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.54
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.07 · national 2.35
Total nurse hours
7.94
All reported nurse hours · state 3.69 · national 3.89
Licensed hours
5.08
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
7.18
Weekend nurse staffing · state 3.18 · national 3.43
Weekend RN hours
2.41
Weekend registered nurse coverage · state 0.39 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
3.65
CMS adjusted RN staffing hours
Adjusted total hours
8.20
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 43% · national 46%
SNF VBP
Value-based purchasing
Program rank
782
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0185
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.01
Baseline 24.71% · Performance 21.24% · Measure score 4.01 · Achievement 0 · Improvement 4.01
Healthcare-associated infections
8.76
Baseline 5.38% · Performance 5.22% · Measure score 8.76 · Achievement 8.76 · Improvement 3.73
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 196 · Observed rate 7.65% · Lower 95% interval 8.2% |
| Discharge to community | 66.19% |
50.57%
15.6 pts better
|
Better than the National Rate · Eligible stays 201 · Observed rate 72.64% · Lower 95% interval 60.7% |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98.68% |
95.27%
3.4 pts better
|
Numerator 149 · Denominator 151 |
| Falls with major injury | 0.66% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 151 |
| Discharge self-care score | 25.2% |
53.69%
28.5 pts worse
|
Numerator 31 · Denominator 123 |
| Discharge mobility score | 41.46% |
50.94%
9.5 pts worse
|
Numerator 51 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 4.64% |
2.29%
2.3 pts worse
|
Numerator 7 · Denominator 151 · Adjusted rate 7.2% |
| Healthcare-associated infections requiring hospitalization | 5.22% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 0.88% · Lower 95% interval 2.56% |
| Staff COVID-19 vaccination coverage | 1.89% |
8.2%
6.3 pts worse
|
Numerator 1 · Denominator 53 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 23 · Denominator 23 |
| Discharge function score | 42.28% |
56.45%
14.2 pts worse
|
Numerator 52 · Denominator 123 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 90 · Denominator 100 |
| Transfer of health information to patient | 80.39% |
96.28%
15.9 pts worse
|
Numerator 41 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 21.33% |
25.2%
3.9 pts worse
|
Numerator 16 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 31.1% |
78.8%
47.7 pts worse
|
81.7%
50.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 34.1% · Q3 34.0% · Q4 25.7% · 4Q avg 31.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
12.4%
1.9 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 8.8% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.1%
0.7 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.4% |
79.4%
14 pts better
|
79.7%
13.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
23.0%
2.2 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 15.4% · Expected 17.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-12 · Fire 2022-10-12
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-07-14 · Fire 2021-07-14
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-07-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-09-13
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-07-31
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-07-31
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-07-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-01
E · Potential for more than minimal harm
2022-10-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-10-18
E · Potential for more than minimal harm
2022-10-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-18
E · Potential for more than minimal harm
2022-10-12
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-10-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-10-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-10-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-10-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-10-18
F · Potential for more than minimal harm
2021-07-14
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2021-07-15
E · Potential for more than minimal harm
2021-07-14
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-07-15
D · Potential for more than minimal harm
2021-07-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-07-15
Penalties and ownership
What sits behind the stars
Ownership
West Virginia United Health System, Inc
5% Or Greater Direct Ownership Interest · Organization
Barker, George
Operational/Managerial Control · Individual
Barker, George
Corporate Director · Individual
Breedlove, Paul
Corporate Director · Individual
Challa, Kishore
Operational/Managerial Control · Individual
Challa, Kishore
Corporate Director · Individual
Ellis, Terrell
Operational/Managerial Control · Individual
Ellis, Terrell
Corporate Director · Individual
Epperly, John
Operational/Managerial Control · Individual
Epperly, John
Corporate Director · Individual
Fairless, Lyle
Operational/Managerial Control · Individual
Fairless, Lyle
Corporate Director · Individual
Francisco, Paige
Operational/Managerial Control · Individual
Francisco, Paige
Corporate Officer · Individual
Gizzi, Jason
Operational/Managerial Control · Individual
Gizzi, Jason
Corporate Officer · Individual
Higgs, Donald
Operational/Managerial Control · Individual
Higgs, Donald
Corporate Director · Individual
Kawash, Stephen
Operational/Managerial Control · Individual
Kawash, Stephen
Corporate Director · Individual
Kawash, Stephen
Corporate Officer · Individual
Lavenski, Susan
Corporate Director · Individual
Mayfield, Angela
Operational/Managerial Control · Individual
Mayfield, Angela
Corporate Director · Individual
Mayfield, Angela
Corporate Officer · Individual
Pack, Ashley
Operational/Managerial Control · Individual
Pack, Ashley
Corporate Director · Individual
Robinson, Mark
Operational/Managerial Control · Individual
Robinson, Mark
Corporate Director · Individual
Rosencrance, James
Operational/Managerial Control · Individual
Rosencrance, James
Corporate Director · Individual
Rosencrance, James
Corporate Officer · Individual
Sayre, David
Operational/Managerial Control · Individual
Sayre, David
Corporate Director · Individual
Sayre, David
Corporate Officer · Individual
Slaughter, Craig
Operational/Managerial Control · Individual
Slaughter, Craig
Corporate Director · Individual
Slaughter, Craig
Corporate Officer · Individual
Stover, Matthew
Operational/Managerial Control · Individual
Stover, Matthew
Corporate Director · Individual
West Virginia United Health System, Inc
Operational/Managerial Control · Organization
Wright, Albert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Complete Care At Oak Ridge LLC
Charleston, WV
3-star overall rating with 3-star inspections with $16,039 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Arthur B Hodges Center, The
Charleston, WV
4-star overall rating with 5-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Charleston Healthcare Center
Charleston, WV
3-star overall rating with 2-star inspections with $12,831 in total fines with 23 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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