Cycle 1
Health 2025-01-17 · Fire 2025-01-17
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Plattsburgh, NY
Champlain Valley Physicians Hosp Med Ctr S N F
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
75 Beekman Street, Plattsburgh, NY
(518) 562-7760
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
36
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
University Of Vermont Health Network
Operator or chain grouping
Approved since
1975-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 2 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
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
1.00
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
4.77
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,148
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.45
Composite VBP score used to determine payment impact.
Payment multiplier
1.0146
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.28
Baseline 16.92% · Performance 18.98% · Measure score 5.28 · Achievement 5.28 · Improvement 0
Healthcare-associated infections
6.98
Baseline 6.43% · Performance 5.75% · Measure score 6.98 · Achievement 6.98 · Improvement 4.25
Total nurse turnover
8.01
Performance 30.95% · Measure score 8.01 · Achievement 8.01 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.51
Baseline 3.82 hours · Performance 4.08 hours · Measure score 3.51 · Achievement 3.51 · Improvement 0.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.69% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 7.97% · Lower 95% interval 6.66% |
| Discharge to community | 60.58% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 135 · Observed rate 53.33% · Lower 95% interval 50.97% |
| Medicare spending per beneficiary | 0.58 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 83.33% |
95.27%
11.9 pts worse
|
Numerator 20 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.75% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 0% · Lower 95% interval 2.66% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 86 |
| Staff flu vaccination coverage | 81.63% |
42%
39.6 pts better
|
Numerator 40 · Denominator 49 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.4 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 7.4% |
91.2%
83.8 pts worse
|
93.4%
86 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q3 4.5% · Q4 9.4% · 4Q avg 7.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.0%
1.2 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 4.5% · Q4 9.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
18.5%
16.3 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q3 0.0% · Q4 3.4% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.1%
0.4 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q3 4.8% · Q4 6.7% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
13.5%
2.6 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q3 9.1% · Q4 6.5% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.8% |
14.8%
22 pts worse
|
16.7%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q3 37.5% · Q4 37.0% · 4Q avg 36.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.1% |
0.2%
0.9 pts worse
|
0.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.0% |
15.1%
0.1 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.3% |
15.5%
3.8 pts worse
|
14.9%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q4 4.5% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 9.3% |
0.6%
8.7 pts worse
|
1.0%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q3 0.0% · Q4 6.5% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 13.3% |
1.4%
11.9 pts worse
|
1.7%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q3 4.8% · Q4 19.4% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
20.8%
4.9 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q4 22.4% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.9%
2.7 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q3 13.5% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.1% |
76.7%
31.6 pts worse
|
81.7%
36.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 40.5% · Q4 57.7% · 4Q avg 45.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
9.7%
5.3 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 14.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.0% |
20.6%
17.4 pts worse
|
23.9%
14.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.0% · Observed 42.9% · Expected 26.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-14 · Fire 2022-10-14
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2019-12-19 · Fire 2019-12-19
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-17
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-17
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-17
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-17
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-17
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-02-28
F · Potential for more than minimal harm
2022-10-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-20
F · Potential for more than minimal harm
2022-10-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-10-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-14
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2022-12-20
E · Potential for more than minimal harm
2022-10-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-11-30
E · Potential for more than minimal harm
2019-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-30
E · Potential for more than minimal harm
2019-12-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-01-30
E · Potential for more than minimal harm
2019-12-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-01-30
E · Potential for more than minimal harm
2019-12-19
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2020-02-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-17
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-17
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 2025-02-26
D · Potential for more than minimal harm
2024-07-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-29
E · Potential for more than minimal harm
2022-10-14
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 2022-11-30
E · Potential for more than minimal harm
2022-10-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-14
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-14
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 2022-11-29
D · Potential for more than minimal harm
2022-10-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-10-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-11-29
C · Minimal harm
2022-10-14
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-11-30
E · Potential for more than minimal harm
2019-12-19
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 2020-01-30
D · Potential for more than minimal harm
2019-12-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-01-30
D · Potential for more than minimal harm
2019-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-30
Penalties and ownership
What sits behind the stars
Ownership
The University Of Vermont Health Network Inc.
5% Or Greater Direct Ownership Interest · Organization
Bourgeois, Linda
Corporate Director · Individual
Donoghue, Kelly
Corporate Director · Individual
Fesette, Neil
Corporate Officer · Individual
Goerlitz-Coryer, Elizabeth
Corporate Director · Individual
Gregory, Richelle
Corporate Director · Individual
Kollar, Matej
Corporate Officer · Individual
Kollar, Matej
W-2 Managing Employee · Individual
Lebeau, Michelle
Corporate Officer · Individual
Lebeau, Michelle
W-2 Managing Employee · Individual
Mark, Lisa
W-2 Managing Employee · Individual
Mcauliffe, John
Corporate Director · Individual
Niles, Graham
Corporate Director · Individual
Prather, Monticia
Corporate Director · Individual
Recny, Thomas
Corporate Director · Individual
Ryan, Molly
Corporate Director · Individual
Vicencio, Elizabeth
Corporate Director · Individual
Webber, Richard
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Meadowbrook Healthcare
Plattsburgh, NY
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Plattsburgh Rehabilitation And Nursing Center
Plattsburgh, NY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Clinton County Nursing Home
Plattsburgh, NY
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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