New Riverdale Rehab: Drug Monitoring Failure - NY
The chain of events started in early February. A pharmacy consultant reviewed Resident 39's medication regimen on February 11, 2025, and flagged a problem: the resident was on Depakote, but no recent serum level appeared anywhere in the chart. The consultant recommended one be drawn, noting the standard schedule calls for a level two weeks after starting the drug, then every six months after that.
The next day, a nurse practitioner reviewed the recommendation and agreed. "Will do," the response note read. A physician's order went in the same day, February 12, directing that a serum valproate level be drawn the following morning.
Nobody drew it. Or if they did, nobody could find any evidence of it.
By the time inspectors arrived on March 19, more than five weeks had passed since the order was written. The chart contained no documentation that the blood had been collected. There was no follow-up note from the nurse practitioner. No record of the physician checking back. The test had been ordered, and then, as far as the paper trail showed, forgotten.
Depakote, also sold under the generic name valproic acid, is used to treat seizures, bipolar disorder, and certain types of migraines. Blood levels matter because the drug has a narrow therapeutic window. Too little and it may not control the condition it was prescribed for. Too much and it can damage the liver, suppress bone marrow, or cause other serious harm. Monitoring is how clinicians know which side of that line a patient is on.
When inspectors sat down with the nurse practitioner at 9:23 that morning, the explanation was straightforward: the Depakote level had been ordered as recommended, and after that, the nurse practitioner waited for a registered nurse to report back with results. No one ever did. The nurse practitioner said they were never notified that the results hadn't come in, and never learned why the blood hadn't been drawn.
The medical director, interviewed three hours later, did not accept that account as sufficient. The nurse practitioner, the director said, should have followed up when results failed to arrive.
That gap, between the person who ordered the test and the person who was supposed to tell them what happened, is where the monitoring fell apart. The pharmacy consultant caught the original problem. The nurse practitioner agreed to fix it. The order was written. And then no one owned what came next.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. The facility's plan of correction was not included in the inspection report; inspectors directed anyone seeking that information to contact the nursing home or the state survey agency directly.
What the record does not contain is any documentation that anyone at New Riverdale, in the five weeks between the order and the inspection, noticed the gap and tried to close it. The nurse practitioner was waiting to hear something. The registered nurses apparently said nothing. The physician who co-signed the order left no follow-up note. The February 12 entry, "Agree Will do," was the last entry anyone made on the subject until a federal inspector asked about it in March.
Resident 39 remained on Depakote throughout that period, their actual blood level unknown.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Riverdale Rehab and Nursing from 2025-03-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 5, 2026 · Our methodology
New Riverdale Rehab and Nursing in Bronx, NY was cited for violations during a health inspection on March 19, 2025.
The chain of events started in early February.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.