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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

1.80

Registered nurse staffing

LPN hours / resident day

0.54

Licensed practical nurse staffing

Aide hours / resident day

2.59

Nurse aide staffing

Weekend hours

4.26

Weekend nurse staffing

RN turnover

11%

Annual RN turnover

Total nurse turnover

21%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

0% 1 facilities 2018-01-10

Eccleston, Jean

W-2 Managing Employee · Individual

0% 1 facilities 2018-01-10

Gearity, Victoria