Cycle 1
Health 2024-05-06 · Fire 2024-05-06
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Sleepy Hollow, NY
Kendal On Hudson
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
One Kendal Way, Sleepy Hollow, NY
(914) 922-1000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
26
Certified beds
Average residents
23
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Kendal
Operator or chain grouping
Approved since
2005-06-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 5 staffing / 4 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
Staffing
Hours and turnover
RN hours / resident day
1.80
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.93
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.34
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
1.00
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.36
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.99
CMS adjusted RN staffing hours
Adjusted total hours
5.43
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,996
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9999
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.49
Baseline 18.84% · Performance 19.35% · Measure score 4.49 · Achievement 4.49 · Improvement 0
Healthcare-associated infections
0
Baseline 7.06% · Performance 7.71% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.46
Baseline 36.36% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 9
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 | 8.76% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 1.15% · Lower 95% interval 5.76% |
| Discharge to community | 50.65% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 47.37% · Lower 95% interval 41.56% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | 58.06% |
53.69%
4.4 pts better
|
Numerator 18 · Denominator 31 |
| Discharge mobility score | 41.94% |
50.94%
9 pts worse
|
Numerator 13 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 43 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.71% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 8.93% · Lower 95% interval 4.44% |
| Staff COVID-19 vaccination coverage | 2.02% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 99 |
| Staff flu vaccination coverage | 81.67% |
42%
39.7 pts better
|
Numerator 98 · Denominator 120 |
| Discharge function score | 74.19% |
56.45%
17.7 pts better
|
Numerator 23 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 60.87% |
25.2%
35.7 pts better
|
Numerator 14 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.7
1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
91.2%
3.2 pts better
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · 4Q avg 94.4% |
| 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 | 1.4% |
3.0%
1.6 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
6.1%
1.6 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.5% |
13.5%
12 pts better
|
19.6%
18.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.3% |
14.8%
12.5 pts worse
|
16.7%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.8% |
15.5%
7.3 pts worse
|
14.9%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
0.6%
3.2 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.6% |
20.8%
6.2 pts better
|
19.8%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
6.9%
5.3 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
76.7%
11.3 pts better
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 73.9% · Q2 90.9% · Q3 92.9% · Q4 92.6% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
9.7%
9.7 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.2% · 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 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
78.8%
12.1 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.9% |
20.6%
8.3 pts worse
|
23.9%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 25.0% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-12 · Fire 2022-05-12
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-12-18 · Fire 2019-12-18
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-14
E · Potential for more than minimal harm
2022-05-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-08
E · Potential for more than minimal harm
2022-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-05-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-05-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-08
C · Minimal harm
2022-05-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-07-08
C · Minimal harm
2022-05-12
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-07-08
E · Potential for more than minimal harm
2019-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-21
E · Potential for more than minimal harm
2019-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-21
D · Potential for more than minimal harm
2019-12-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-03-21
D · Potential for more than minimal harm
2019-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-21
D · Potential for more than minimal harm
2019-12-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-03-21
C · Minimal harm
2019-12-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2020-03-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-06
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 2024-06-21
D · Potential for more than minimal harm
2024-05-06
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-06
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 2024-06-21
E · Potential for more than minimal harm
2022-05-12
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 2022-05-31
E · Potential for more than minimal harm
2019-12-18
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 2020-01-15
E · Potential for more than minimal harm
2019-12-18
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 2020-01-15
Penalties and ownership
What sits behind the stars
Ownership
Eccleston, Jean
Corporate Officer · Individual
Eccleston, Jean
W-2 Managing Employee · Individual
Gearity, Victoria
Corporate Director · Individual
Klapproth, Pamela
W-2 Managing Employee · Individual
Lillis, Bernard
Corporate Director · Individual
Linetski, Olga
W-2 Managing Employee · Individual
Mcgovern, Kyle
Corporate Director · Individual
Morris, Barry
Corporate Director · Individual
Murphy, Adriana
Corporate Director · Individual
Napoleon, Edward
Corporate Director · Individual
Permut, Howard
Corporate Director · Individual
Persell, Caroline
Corporate Director · Individual
Regan, Shirley
Operational/Managerial Control · Individual
Smith, Howard
Corporate Director · Individual
Sorice, John
Corporate Director · Individual
Tepper, Lynn
Corporate Director · Individual
Wacht, Lisa
W-2 Managing Employee · Individual
Wexler, Sharon
Corporate Director · Individual
Wood, Deborah
Corporate Director · Individual
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