New Riverdale Rehab: Failed Lab Tests, Weight Loss - NY
The failure left Resident #39 at New Riverdale Rehab and Nursing without proper monitoring of Depakote, a medication that requires regular blood level checks to prevent serious side effects. The resident had been taking 625 milligrams of the drug three times daily since January 2023.
A pharmacy consultant flagged the problem in February, noting in the medical record that they "were unable to locate a recent serum level in the chart" and recommended testing "2 weeks after start then every 6 months thereafter." The consultant wrote: "Please consider ordering."
The nurse practitioner responded the next day, writing "Agree Will do" and ordering the blood test for February 13.
Nobody drew the blood.
When federal inspectors interviewed the nurse practitioner on March 19, they said they "wait for the Registered Nurse to inform them of the laboratory test results" and "were not notified of the results or the reason why was the serum level not obtained."
The Medical Director told inspectors that "the Nurse Practitioner should have followed up timely when they had not received the laboratory results."
The Director of Nursing said "the expectation was that the attending physician or the nurse practitioner will follow up on the laboratory results."
Resident #39 has diagnoses of non-Alzheimer's dementia and schizoaffective disorder. Their care plan specifically called for monitoring laboratory results for drug levels.
Meanwhile, another resident was losing dangerous amounts of weight while staff failed to intervene for months.
Resident #122 dropped from 133 pounds in late November to 117 pounds by the end of February — a loss of 16 pounds, or 12 percent of their body weight, in three months. The steepest decline came in early January, when their weight plummeted from 133.9 pounds to 116.6 pounds in less than a week.
The facility's own care plan set a goal for the resident to "increase 1-2 pounds weight gradually." Instead, they lost 17 pounds.
The resident has diagnoses including protein calorie malnutrition and a below-knee amputation. Their care plan called for monitoring weekly weights and food consumption during mealtimes.
No interventions were documented to address the weight loss through January and February.
A dietitian finally noted the problem on March 11, writing that the resident had "significant and undesirable weight loss of 16 pounds, 12% in 3 months; 20.4 pound weight loss, 14.8% in 5 months." The note said weight loss was discussed with the resident, who "acknowledged he has good appetite and that they were losing weight prior to admission due to their illness."
The plan remained the same: monitor intake and weekly weights.
The registered dietitian told inspectors on March 14 that they "have not seen Resident #122's January and February weight record and was informed of the weight loss in March." They said they "only come to the facility twice a week and cannot do everything."
Nurse Practitioner #1 said they "were not aware of Resident #122's weight loss until March" and "do not remember anybody discussing the resident's weight loss with them." They said "recommendations to manage weight loss should come from the dietitian."
The Assistant Director of Nursing said weight changes "are discussed during the morning meeting and is communicated to the dietary department" and that "weight records are on the resident's notes and can be reviewed by the dietitian."
The weight records show the resident's decline:
November 29: 133 pounds December 13: 125.2 pounds December 20: 134 pounds December 27: 133.9 pounds January 3: 116.6 pounds January 10: 116 pounds January 24: 116.1 pounds February 28: 117 pounds
The facility's weight policy states its purpose is "to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident."
For Resident #122, those records documented a steady decline that nobody addressed until March, when the weight loss had already occurred and the resident had stabilized at their much lower weight.
The facility's laboratory policy requires physicians to "identify, and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs." It states that "physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the Director of Nursing and/or the Medical Director."
For Resident #39, the system broke down completely. The pharmacy consultant identified the need. The nurse practitioner agreed and ordered the test. The blood was never drawn. Nobody followed up.
The policy warns that "such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation."
In this case, there was no result to manage because there was no test, despite the clear clinical need for monitoring a psychiatric medication that can cause serious side effects if blood levels become too high or too low.
Both cases revealed the same pattern: clear clinical needs identified in writing, plans made to address them, and then no follow-through when the plans weren't executed.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
NEW RIVERDALE REHAB AND NURSING in BRONX, NY was cited for violations during a health inspection on March 19, 2025.
The resident had been taking 625 milligrams of the drug three times daily since January 2023.
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.