Riverdale Nursing Home

F-F658 Services Meet Professional Standards

The findings are:

The facility policy titled Laboratory and Diagnostic Test Results with a revised date of 01/2025 documented that the Physician will identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider or other testing source will report test results to the facility. 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. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation.

The facility policy titled Physician Services with a reviewed date of 01/2025 documented that the physician will 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 physician will periodically review all medications prescribed for their patients and will monitor both for continuing indications and for possible adverse drug reactions. The medication review should take into account observations and concerns offered by pharmacy consultants and others regarding beneficial and possible adverse impacts of medications on the resident. The attending physician will perform accurate, timely and relevant assessments as needed. The physician will respond to notification of and will assess and manage acute and significant changes in resident condition.

Resident #39 had diagnoses of Non-Alzheimer's Dementia and Schizoaffective Disorder.

The quarterly Minimum Data Set assessment dated [DATE REDACTED] documented Resident #39 had moderately impaired cognition and had received anticonvulsive and antipsychotic medications since admission/entry or reentry into the facility.

A physician order which was initiated on 01/25/2023 and renewed on 02/25/2025 documented a medication order for Depakote Sprinkles 125 milligram capsules, delayed release, 5 capsules (625 milligrams) to be administered by oral route 3 times a day with food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 335096 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335096 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New Riverdale Rehab and Nursing 641 West 230th St Bronx, NY 10463

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 A Medication Administration Record dated March 2025 documented that Resident #39 was administered 625 milligrams of Depakote Sprinkles by oral route 3 times a day. Level of Harm - Minimal harm or potential for actual harm A care plan for psychotropic use was initiated for Resident #39 which was last reviewed on 03/07/2025. The facility interventions include to monitor laboratory results for drug levels. Residents Affected - Few

A Pharmacy Consultant Medication Regimen Review progress note dated 02/11/2025 documented Resident #39 was currently receiving Depakote, unable to locate a recent serum level in the chart, recommended 2 weeks after start then every 6 months thereafter. The note documented to please consider ordering.

A Medication Regimen Review Response progress note dated 02/12/2025 documented the Nurse Practitioner's response to the Consultant Pharmacist's recommendation for Resident #39 as follows -Agree Will do.

A Physician Laboratory Order dated 02/12/2025, documented Depakene - Serum Valproate one time 02/13/2025.

There was no documented evidence that the serum level for Depakote was drawn.

There was no documented evidence that the physician or the nurse practitioner followed up if the serum level has been completed.

On 03/19/2025 at 9:23 AM, the Nurse Practitioner was interviewed and stated that Depakote level was ordered for Resident #39 on 02/12/2025 as recommended by the pharmacy consultant. The Nurse Practitioner stated they wait for the Registered Nurse to inform them of the laboratory test results. They stated they were not notified of the results or the reason why was the serum level not obtained.

On 03/19/2025 at 12:23 PM, the Medical Director was interviewed and stated the Nurse Practitioner should have followed up timely when they had not received the laboratory results.

10 NYCRR 415.15 (b)(2)(iii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 335096