Inspection Reports for
New Riverdale Rehab and Nursing
641 West 230th Street, Bronx, NY, 10463
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
273% worse than New York average
New York average: 5.1 deficiencies/year
Deficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 20
Date: Mar 19, 2025
Visit Reason
Inspection revealed multiple standard health and life safety code citations related to quality of care, abuse reporting, physical environment, and safety systems. Most deficiencies were corrected by May 2025.
Findings
Inspection revealed multiple standard health and life safety code citations related to quality of care, abuse reporting, physical environment, and safety systems. Most deficiencies were corrected by May 2025.
Deficiencies (20)
Care plan timing and revision
Develop/implement comprehensive care plan
Drug regimen review, report irregular, act on
Free from abuse and neglect
General requirements
Nutrition/hydration status maintenance
Physician visits - review care/notes/order
Reporting of alleged violations
Right to survey results/advocate agency info
Safe/clean/comfortable/homelike environment
Self-determination
Services provided meet professional standards
Electrical equipment - testing and maintenanc
Electrical systems - other
Emergency lighting
Fire drills
Gas equipment - cylinder and container storag
Physical environment
Sprinkler system - installation
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 19, 2025
Visit Reason
The inspection was conducted as a Recertification Survey from 03/12/2025 to 03/19/2025, including complaint investigations related to abuse, neglect, and environmental conditions.
Complaint Details
The complaint investigation (NY00371559 and NY00372528) revealed failure to protect residents from abuse and neglect, including a physical altercation between Residents #242 and #117 resulting in injury, and failure to timely report alleged abuse and injuries to the State Department of Health.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment with multiple environmental issues in resident rooms. Additionally, the facility failed to ensure residents were free from abuse and neglect, including a resident-to-resident physical altercation causing actual harm. The facility also failed to timely report alleged abuse and injuries of unknown origin to the State Department of Health and did not ensure physician follow-up on medication monitoring.
Deficiencies (4)
Residents' rooms were not cleaned, had broken appliances and furniture, and chipped paint in Unit 3.
Resident #242 punched Resident #117 causing a laceration requiring emergency medical intervention and sutures.
Failure to timely report alleged abuse, neglect, or injuries of unknown origin to the New York State Department of Health.
Physician failed to follow up on serum Depakote level ordered for Resident #39.
Report Facts
Residents reviewed for abuse: 31
Residents involved in abuse incident: 2
Sutures required: 7
Emergency room visits: 2
Medication dosage: 625
Date serum level ordered: Feb 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding abuse investigations and reporting failures | |
| Administrator | Interviewed regarding environmental issues and abuse incident | |
| Facilities Director | Interviewed regarding environmental rounds and maintenance | |
| Nurse Practitioner | Ordered Depakote serum level and failed to follow up on results | |
| Medical Director | Interviewed regarding physician follow-up on lab results | |
| Assistant Director of Nursing | Interviewed regarding investigation of verbal abuse allegation |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Mar 19, 2025
Visit Reason
The Recertification Survey was conducted from 03/12/2025 to 03/19/2025 to assess compliance with regulatory requirements for New Riverdale Rehab and Nursing.
Complaint Details
The survey included complaint investigations (NY00371559 and NY00372528) related to abuse, neglect, and mistreatment allegations involving Residents #25, #36, #93, #117, and #242. Some allegations were not reported timely or appropriately to the State Department of Health.
Findings
The facility was found deficient in multiple areas including failure to honor resident self-determination regarding bathing preferences, failure to post survey results accessibly, unsafe and unclean resident environment, failure to prevent resident-to-resident abuse, failure to timely report suspected abuse and neglect, incomplete and untimely care planning, failure to maintain resident nutritional status, and failure to follow up on medication monitoring laboratory tests.
Deficiencies (10)
Resident #5's bathing preference was not honored; resident received bed baths despite scheduled showers and no documented refusal.
Facility did not post survey results in a place readily accessible to residents and visitors; survey results were kept in a binder inside the security office without notice of availability.
Resident rooms in Unit 3 were not cleaned, had broken appliances and furniture, chipped paint, urine stains, and missing locks.
Resident #242 physically abused Resident #117 resulting in actual harm; inadequate supervision and monitoring despite known aggressive behavior.
Allegation of verbal abuse by a Certified Nursing Assistant towards Resident #36 was not reported to the New York State Department of Health.
Failure to timely report suspected abuse, neglect, or injuries of unknown origin to the administrator and State survey agency within required timeframes for multiple residents.
Resident #36 had no comprehensive care plan developed to address risk for abuse or victimization.
Resident #40's comprehensive care plan was not reviewed and revised after incidents of non-compliance with the smoking policy.
Resident #39's serum Depakote level was ordered but there was no documented evidence that the serum level was obtained or followed up by the nurse practitioner or physician.
Resident #122 experienced significant weight loss of 12% over 3 months with no proactive interventions documented.
Report Facts
Weight loss percentage: 12
Sutures: 7
Medication dosage: 625
Medication review recommendation date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Nursing Supervisor | Interviewed regarding Resident #5 bathing schedule and Resident #40 smoking care plan. |
| Director of Nursing | Interviewed multiple times regarding bathing preferences, abuse investigations, reporting, and care plan reviews. | |
| Administrator | Interviewed regarding posting of survey results and abuse reporting responsibilities. | |
| Certified Nursing Assistant #1 | Interviewed regarding Resident #5 bathing preferences. | |
| Licensed Practical Nurse #1 | Interviewed regarding Resident #5 bathing preferences. | |
| Facilities Director | Interviewed regarding environmental rounds and maintenance. | |
| Social Service Director | Interviewed regarding Resident #242's aggressive behavior. | |
| Nurse Practitioner | Interviewed regarding follow-up on Depakote serum level for Resident #39. | |
| Medical Director | Interviewed regarding follow-up responsibilities for laboratory results. | |
| Assistant Director of Nursing | Interviewed regarding abuse investigations and communication with dietary. | |
| Registered Nurse #3 | Documented bleeding incident for Resident #117. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jul 31, 2023
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Jun 21, 2023
Visit Reason
Complaint Survey with multiple standard health and life safety code citations including encoding/transmitting resident assessments, free of accident hazards, reporting of alleged violations, resident rights, safe environment, cooking facilities, electrical systems, fire drills, and illumination of means of egress. Most deficiencies corrected by July-August 2023.
Findings
Complaint Survey with multiple standard health and life safety code citations including encoding/transmitting resident assessments, free of accident hazards, reporting of alleged violations, resident rights, safe environment, cooking facilities, electrical systems, fire drills, and illumination of means of egress. Most deficiencies corrected by July-August 2023.
Deficiencies (13)
Encoding/transmitting resident assessments
Free of accident hazards/supervision/devices
Reporting of alleged violations
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Cooking facilities
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Fire drills
Illumination of means of egress
Portable fire extinguishers
Stairways and smokeproof enclosures
Standards of construction for new existing nh
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 21, 2023
Visit Reason
The inspection was conducted due to complaint investigations and recertification surveys focusing on allegations of abuse and safety concerns related to resident wandering and elopement.
Complaint Details
The complaint investigation revealed that the facility did not report two separate incidents of resident-to-resident physical abuse within the required 2-hour timeframe. The investigation concluded no reasonable cause to believe abuse occurred in one incident, but reporting was still late. Additionally, a resident with a history of removing a Wander Alert Device eloped undetected through a broken emergency exit door, which was later repaired and staff disciplined.
Findings
The facility failed to report alleged resident-to-resident abuse incidents to the New York State Department of Health within the required 2-hour timeframe for 4 residents. Additionally, the facility did not ensure a safe environment free from accident hazards, as evidenced by a resident eloping through a broken emergency exit door undetected. Corrective actions and plans of correction were implemented to address these deficiencies.
Deficiencies (2)
Failure to timely report suspected abuse involving residents #43, #92, #99, and #117 to the NYSDOH within 2 hours.
Failure to ensure resident environment was free from accident hazards, allowing Resident #340 to elope through a broken emergency exit door.
Report Facts
Residents reviewed for abuse: 27
Residents with abuse reporting deficiencies: 4
Residents reviewed for accidents: 27
Residents with accident hazard deficiency: 1
Incident date: May 5, 2023
Incident date: Apr 27, 2023
Incident date: Oct 17, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse incidents and elopement event, acknowledged late reporting and described corrective actions |
| Director of Facility Maintenance | Director of Facility Maintenance (DFM) | Interviewed regarding elopement incident, described facility door and elevator security failures and corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 21, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 06/13/2023 to 06/21/2023 to assess compliance with federal regulations for nursing home certification.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity related to Foley Catheter privacy, environmental maintenance issues in resident units, delayed reporting of alleged abuse incidents to the state, late submission of Minimum Data Set (MDS) assessments, and inadequate supervision leading to a resident elopement incident.
Deficiencies (5)
Failure to ensure residents were cared for in a manner that maintained or enhanced their dignity, specifically Resident #46's Foley Catheter bag was uncovered and exposed to public view.
Failure to ensure a safe, clean, comfortable, and homelike environment, including missing window blind blades, dusty window sills, mismatching paint and floor tiles, and dirty radiator covers in Units 1 and 3.
Failure to timely report alleged abuse incidents involving residents to the New York State Department of Health within 2 hours.
Failure to electronically transmit Minimum Data Set (MDS) assessments to CMS within 14 days of completion for 24 of 25 residents reviewed.
Failure to ensure the resident environment was free from accident hazards and provide adequate supervision to prevent accidents, evidenced by Resident #340 eloping through a broken emergency exit door in the basement.
Report Facts
Residents sampled: 25
Residents affected: 1
Units affected: 2
Residents reviewed for abuse: 27
Residents affected by abuse reporting deficiency: 4
Residents reviewed for MDS submission: 25
Residents with late MDS submission: 24
Residents reviewed for accidents: 27
Residents affected by accident hazard: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Named in Foley Catheter privacy bag care finding |
| Licensed Practical Nurse #2 | LPN | Named in Foley Catheter care monitoring |
| Registered Nurse #1 | RN | Named in Foley Catheter care expectations |
| Director of Nursing | DON | Interviewed regarding abuse reporting and elopement incident |
| Director of Housekeeping and Maintenance | Interviewed regarding environmental maintenance | |
| Certified Nurse Aide #2 | CNA | Interviewed regarding maintenance reporting |
| MDS Coordinator | Interviewed regarding late MDS submissions | |
| Director of Facility Maintenance | DFM | Interviewed regarding elopement incident and facility door/elevator security |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 8, 2023
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 2, 2023
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 20, 2023
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 13, 2023
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 6, 2023
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Feb 28, 2023
Visit Reason
Complaint Survey with standard health citations related to care plan timing and revision and reporting of alleged violations, both isolated and corrected by March 2023.
Findings
Complaint Survey with standard health citations related to care plan timing and revision and reporting of alleged violations, both isolated and corrected by March 2023.
Deficiencies (2)
Care plan timing and revision
Reporting of alleged violations
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 10, 2023
Visit Reason
Complaint Survey with a standard health citation related to free from abuse and neglect, isolated and corrected in February 2023.
Findings
Complaint Survey with a standard health citation related to free from abuse and neglect, isolated and corrected in February 2023.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 10, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate an allegation of staff abuse involving Resident #1 and Housekeeping Staff #1 on 12/23/2022.
Complaint Details
The complaint investigation was substantiated based on the facility's Accident/Incident Investigation Report and surveillance video showing Housekeeping Staff #1 pushing Resident #1, causing a fall. Resident #1 reported being punched and pushed, and staff admitted to pushing the resident for fear of their life due to an alleged knife which was not found.
Findings
The facility failed to protect Resident #1 from staff abuse when Housekeeping Staff #1 pushed the resident backward in their wheelchair causing a fall. The resident did not sustain injuries. The investigation concluded that there was cause to believe resident abuse, mistreatment, or neglect occurred.
Deficiencies (1)
Failure to protect a resident from staff abuse resulting in a fall.
Report Facts
Residents sampled for abuse: 4
Date of incident: Dec 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HKS #1 | Housekeeping Staff | Named in abuse incident involving pushing Resident #1 |
| RNS #1 | Registered Nurse Supervisor | Documented resident's report and interviewed regarding incident |
| ADON | Assistant Director of Nursing | Investigated incident and provided statements about staff training and incident |
| CNA #1 | Certified Nursing Assistant | Witnessed events and provided interview about incident |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Feb 8, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate the facility's compliance with timely reporting of an elopement incident and review of care plan revisions following elopement attempts involving Resident #1.
Complaint Details
The visit was complaint-related, triggered by concerns about the facility's failure to timely report an elopement incident and failure to update the care plan after an elopement attempt. The facility concluded no evidence of abuse, neglect, exploitation, or mistreatment. The complaint was substantiated regarding delayed reporting and care plan deficiencies.
Findings
The facility failed to timely report an actual elopement of Resident #1 to the New York State Department of Health, reporting the incident six days late. Additionally, the facility did not ensure that Resident #1's care plan was reviewed and revised by the interdisciplinary team following an elopement attempt on 12/13/2022. Interviews revealed delays in reporting and lack of communication among staff regarding the incident.
Deficiencies (2)
Failure to timely report an actual elopement incident to the State Department of Health.
Failure to review and revise the resident's care plan by the interdisciplinary team following an elopement attempt.
Report Facts
Residents sampled: 7
BIMS score: 9
Days late reporting elopement: 6
Care plan review date: Dec 7, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Escorted Resident #1 to appointment and reported elopement |
| Director of Nursing | DON | Conducted investigation and delayed reporting to DOH |
| Assistant Director of Nursing | ADON | Responsible for investigating and reporting alleged violations |
| Registered Nurse #1 | RN | Documented incident on 12/13/2022 and did not update care plan |
| Social Worker | SW | Notified about incident and responsible for care plan updates |
| Administrator | Administrator | Aware of elopement incident and investigation |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 7, 2022
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 31, 2022
Visit Reason
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Findings
Covid-19 Survey with one standard health citation related to reporting to the national health safety network, widespread in scope and not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 30, 2021
Visit Reason
The inspection was a recertification survey conducted to assess compliance with Medicare/Medicaid regulations and facility standards.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate Medicare notices to residents discharged from skilled services, inadequate maintenance of a clean and homelike environment, incomplete and non-measurable care plans for residents with hearing impairment, failure to assist residents in gaining access to hearing services, lack of physician review and follow-up on residents' total care programs, and improper disposal of garbage with garbage compactor doors left open.
Deficiencies (6)
Failure to provide Advance Beneficiary Notice (ABN) to a resident planning to remain in the facility after skilled services ended.
Resident rooms and common areas not maintained in good repair or homelike manner, including broken blinds, soiled tables, leaking sinks, mis-hung privacy curtains, cracked plaster, and damaged furniture.
Lack of person-centered care plans with measurable goals and interventions to address hearing impairment for a resident.
Resident with hearing impairment did not receive audiology follow-up or assistive devices as recommended.
Physician did not review or follow up on resident's total program of care, including hearing impairment, at each required visit.
Garbage compactor door left open on multiple occasions, risking pest and animal intrusion.
Report Facts
Residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification: 3
Total sample of residents reviewed: 28
Medicare days left: 59
Residents reviewed for Communication/Sensory: 4
Residents affected by deficiencies: 1
Residents affected by deficiencies: 1
Garbage compactors: 2
Days garbage compactor door left open: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set Coordinator | Interviewed regarding failure to provide Advance Beneficiary Notice | |
| Corporate Director of Resident Assessment | Interviewed regarding Medicare waiver and notice requirements | |
| Housekeeper #1 | Interviewed about cleaning duties and reporting of maintenance issues | |
| Director of Facilities Management | Interviewed about monitoring staff and maintenance of facility environment | |
| Registered Nurse Supervisor | Interviewed about care plan responsibilities and hearing impairment care | |
| MDS Assistant | Interviewed about care plan creation and hearing impairment interventions | |
| Assistant Director of Nursing | Interviewed about care plan responsibilities and hearing impairment interventions | |
| Director of Nursing | Interviewed about care plan oversight and assessments | |
| Certified Nursing Assistant #3 | Interviewed about resident communication and hearing impairment | |
| Attending Physician | Interviewed about hearing impairment care and audiology follow-up | |
| Medical Director | Interviewed about physician responsibilities and resident care follow-up | |
| Assistant Food Service Director | Interviewed about garbage compactor use and door closure |
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