New Riverdale Rehab: Medication Monitoring Failure - NY
The resident, identified in inspection records only as Resident 39, was first prescribed Depakote Sprinkles in January 2023. The order was renewed in February 2025. Every day, she received five 125-milligram capsules three times a day with food, 625 milligrams per dose, 1,875 milligrams total. The prescription ran without interruption into March 2025, when federal surveyors from the Centers for Medicare and Medicaid Services showed up at the facility at 641 West 230th Street.
Depakote, the brand name for valproic acid, is a drug that requires careful management. At therapeutic doses it controls seizures and mood episodes. At toxic levels, it can cause liver damage, dangerous drops in platelet counts, and encephalopathy, a form of brain dysfunction that can look, in a patient with pre-existing dementia, like nothing more than a bad day. Physicians routinely order blood tests to track valproic acid levels and liver function in patients on the drug. The inspection record contains no indication that those results were reviewed, tracked, or acted on.
The facility's own policies said the right things. A physician services policy, reviewed as recently as January 2025, stated that attending physicians would "address laboratory and other diagnostic test results in a timely manner based on the resident's condition and the clinical significance of the results." The same policy required physicians to monitor medications for continuing indications and for possible adverse drug reactions, and to take into account concerns raised by pharmacy consultants. A separate laboratory policy, also revised in January 2025, spelled out that test results would be reported to the facility and that concerns about how results were handled should be communicated up the chain to the Director of Nursing or Medical Director.
Both policies were current. Neither appears to have mattered for Resident 39.
She had moderately impaired cognition, according to a quarterly assessment completed under the federal Minimum Data Set process. The assessment also noted she had been receiving both anticonvulsant and antipsychotic medications since her admission. A resident with that profile, on that drug, at that dose, for that length of time, is precisely the kind of patient those monitoring policies exist to protect.
The inspection record does not say whether Resident 39 suffered any physical harm. It does not say whether blood draws were ordered and simply not documented, or never ordered at all. What it says is that inspectors could find no evidence of physician review of lab and diagnostic results for a vulnerable woman on a high-dose medication that requires exactly that kind of oversight.
New Riverdale Rehab and Nursing is a 160-bed facility in the Riverdale neighborhood of the Bronx. The inspection that produced this finding was a standard health survey completed March 19, 2025.
The facility's plan of correction was not included in the inspection materials reviewed for this report.
What the record leaves behind is a woman with dementia, a standing prescription that ran for more than two years, and a gap where the physician oversight should have been.
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.
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Last verified: November 4, 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, identified in inspection records only as Resident 39, was first prescribed Depakote Sprinkles in 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.