Cycle 1
Health 2024-09-28 · Fire 2024-09-28
7 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Tarrytown, NY
Tarrytown Hall Care Center
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
20 Wood Court, Tarrytown, NY
(914) 631-2600
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Personal Healthcare Management
Operator or chain grouping
Approved since
1974-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 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
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,998
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.51
Baseline 21.37% · Performance 19.80% · Measure score 3.51 · Achievement 3.51 · Improvement 3.10
Healthcare-associated infections
0
Baseline 6.05% · Performance 7.80% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.64
Baseline 41.38% · Performance 36.56% · Measure score 6.64 · Achievement 6.64 · Improvement 2.42
Adjusted total nurse staffing
1.10
Baseline 3.30 hours · Performance 3.39 hours · Measure score 1.10 · Achievement 1.10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 132 · Observed rate 10.61% · Lower 95% interval 7.59% |
| Discharge to community | 48.91% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 40.17% · Lower 95% interval 38.74% |
| Medicare spending per beneficiary | 1.43 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 120 · Denominator 120 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 120 |
| Discharge self-care score | 67.53% |
53.69%
13.8 pts better
|
Numerator 52 · Denominator 77 |
| Discharge mobility score | 64.94% |
50.94%
14 pts better
|
Numerator 50 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 0.83% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 120 · Adjusted rate 0.58% |
| Healthcare-associated infections requiring hospitalization | 7.8% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 10% · Lower 95% interval 4.53% |
| Staff COVID-19 vaccination coverage | 6.63% |
8.2%
1.6 pts worse
|
Numerator 11 · Denominator 166 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 64.94% |
56.45%
8.5 pts better
|
Numerator 50 · Denominator 77 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 40 · Denominator 44 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 12 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
1.7
1.4 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.3
1.3 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
91.2%
3.7 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 95.9% · Q3 94.7% · Q4 95.1% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
95.3%
1 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.0%
0.8 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.1% · Q3 5.3% · Q4 4.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.3% |
18.5%
9.2 pts better
|
11.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 7.5% · Q3 9.5% · Q4 2.3% · 4Q avg 9.3% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
6.1%
1.4 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 4.2% · Q3 9.1% · Q4 6.2% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
13.5%
4.9 pts worse
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 16.3% · Q3 22.1% · Q4 20.6% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.0% |
14.8%
0.8 pts better
|
16.7%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 16.0% · Q3 14.1% · Q4 10.8% · 4Q avg 14.0% · 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.7% |
15.1%
0.6 pts worse
|
16.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 12.5% · Q3 25.5% · Q4 15.0% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
15.5%
1.4 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.5% · Q3 23.3% · Q4 13.8% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.4%
0.1 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 2.3% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.7% |
20.8%
15.1 pts better
|
19.8%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 4.2% · Q3 6.3% · Q4 4.9% · 4Q avg 5.7% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
6.9%
4.2 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 4.6% · Q3 5.2% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
76.7%
6.2 pts better
|
81.7%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 72.4% · Q2 82.4% · Q3 87.8% · Q4 88.6% · 4Q avg 82.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
9.7%
2.4 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 12.4% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.2%
1 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 3.7% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.2% |
78.8%
7.4 pts better
|
79.7%
6.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
20.6%
1 pts worse
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 21.6% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-17 · Fire 2022-06-17
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-03-20 · Fire 2019-03-20
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-28
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 2025-01-22
E · Potential for more than minimal harm
2024-09-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-23
E · Potential for more than minimal harm
2024-09-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-09-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-09-28
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-09-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-09-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-09-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-22
E · Potential for more than minimal harm
2022-06-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-12
E · Potential for more than minimal harm
2022-06-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-08-12
D · Potential for more than minimal harm
2019-03-20
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2019-05-18
C · Minimal harm
2019-03-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-05-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-09-28
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-09-28
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-09-28
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-09-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-09-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-09-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-22
D · Potential for more than minimal harm
2019-03-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-05-19
D · Potential for more than minimal harm
2019-03-20
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-05-19
Penalties and ownership
What sits behind the stars
Ownership
Zagelbaum, Ephraim
5% Or Greater Direct Ownership Interest · Individual
Orzel, Avrohom
5% Or Greater Direct Ownership Interest · Individual
Zagelbaum, Yechiel
5% Or Greater Direct Ownership Interest · Individual
Zagelbaum, Yoel
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
5% Or Greater Direct Ownership Interest · Individual
Barth, Alexander
Corporate Officer · Individual
Biondo, Kirsty
Operational/Managerial Control · Individual
Hillman, Roy
Operational/Managerial Control · Individual
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