New Riverdale Rehab: Abuse Care Plan Failure - NY
Nobody had.
The finding emerged during a recertification survey conducted between March 12 and March 19, 2025, at the facility located at 641 West 230th Street in the Bronx. Inspectors reviewed care planning records for three residents and flagged one, identified in the report as Resident 36, for the absence of any abuse-related care plan. The violation was cited at a level of minimal harm or potential for actual harm.
Resident 36 had been admitted to the facility with diagnoses that included arthritis and hypertension. Their cognition was documented as intact on the admission assessment. They were discharged at some point in 2024, then readmitted in January 2025.
It was shortly after that readmission, on January 25, that the incident occurred. According to the facility's own incident report, Resident 36 came forward around noon that day to say that a certified nursing assistant had called them handicapped and crippled. Resident 36 reported it to the Assistant Director of Nursing.
The facility wrote it up. The incident report exists. What does not exist, inspectors found, is anything in Resident 36's care plan that acknowledged the allegation, addressed the risk, or outlined any steps to protect them going forward.
On March 12, the first day of the survey, an inspector sat down with Resident 36 at 2:14 in the afternoon. The resident said that about two weeks ago, a certified nursing assistant had called them handicapped. They said they had reported it to the Assistant Director of Nursing.
That account matched the January incident report almost exactly, except for one detail: Resident 36 placed the incident about two weeks before the March interview, while the documented incident report was dated January 25. Whether this reflects a separate incident, a misremembering of the timeline, or something else, the inspection report does not resolve. What it does establish is that by the time inspectors spoke to Resident 36, the resident was still describing the episode as recent and unresolved.
The care plan file confirmed there was nothing there to find. No goals. No interventions. No timeframes. No documentation that the interdisciplinary team had ever convened to address the fact that this resident had alleged verbal abuse by a staff member.
The facility's own care planning policy, revised as recently as January 2025, the same month as the incident, states that the interdisciplinary team is responsible for developing resident care plans. That team apparently never applied that responsibility to Resident 36's situation.
When the Director of Nursing was interviewed on the final day of the survey, March 19, at 1:39 in the afternoon, she confirmed the gap directly. Resident 36 had been discharged in 2024 and readmitted in January, she said. No abuse care plan had been initiated for the resident when they came back.
The Administrator, interviewed the same morning at 9:18, said the facility should have opened a new medical chart when Resident 36 was readmitted in January 2025. The alleged verbal abuse, the Administrator said, should have been included in an abuse care plan.
Should have been. Was not.
The facility's own leadership, its Director of Nursing and its Administrator, each confirmed on the record that what happened was a failure. Neither offered an explanation for why, after the incident report was filed on January 25 and the Assistant Director of Nursing had been notified, no one on the care team took the next step.
The gap here is not subtle. A resident with intact cognition reported being called handicapped and crippled by someone employed to care for them. They told a supervisor. The facility documented it. And then, for the weeks that followed, including all seven days of the federal survey, Resident 36 continued living at New Riverdale Rehab and Nursing without any written plan in their file to address that experience or protect them from it happening again.
Care planning for abuse risk is not a formality. For a resident who has already alleged victimization by a staff member, a care plan is the mechanism through which a facility commits, in writing, to specific protective steps: who monitors the situation, how often, what warning signs to watch for, what the resident's own preferences are for how to handle future concerns. Without one, the allegation sits in an incident report and goes nowhere.
Resident 36's situation is documented as one case out of three reviewed for care planning. Inspectors sampled 31 residents in total during the survey. The report does not indicate that additional care planning failures were found among the other residents reviewed, and it would be inaccurate to suggest the problem extended beyond what was cited. But the finding that was cited involves a resident who reported being demeaned by a staff member and then received, by the facility's own admission, no structured response in their care record.
The Director of Nursing knew. The Administrator knew. The Assistant Director of Nursing had been told by the resident directly. The incident report was in the file.
Resident 36, cognitively intact, arthritis and hypertension, readmitted in January to a facility that had cared for them before, had already done everything a resident is supposed to do. They identified what happened. They named who did it. They went to a supervisor. They told an inspector.
The care plan page stayed blank.
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 4, 2026 · Our methodology
New Riverdale Rehab and Nursing in Bronx, NY was cited for abuse-related violations during a health inspection on March 19, 2025.
The violation was cited at a level of minimal harm or potential for actual harm.
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.