The Monarch at Brooklyn Rehabilitation and Nursing

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain a resident's right to a safe, clean, comfortable homelike environment. This was evident in one (1) (Unit 4) of 5 units observed. Specifically, the unit hallway, dayroom, and pantry room were observed with dark, brown-colored stains on the floor. The floor edges were observed with old, yellow-colored grease-like stains. A heavy strong old odor was also noted.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey from 08/07/2025 to 08/14/2025, the facility did not ensure that residents' Comprehensive Care Plans were reviewed and revised after each assessment. This was evident for one (1) (Resident #8) of five (5) residents reviewed for Unnecessary Medications. Specifically, there was no documented evidence that the Comprehensive Care Plans for Anticoagulation Therapy and Psychoactive Drug Use were reviewed and revised after the last quarterly Minimum Data Set assessment was completed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident for 2 (Resident #12 and #188) of 35 total sampled residents. Specifically, 1.) Resident #188's Minimum Data Set assessment did not accurately reflect their fall history; 2.) Resident #12's Minimum Data Set assessment documented they had diagnosis of Post Traumatic Stress Disorder. There was no documented evidence that the resident had this diagnosis.

Inspectors wroteBased on observation, record review, and interview during the Recertification and Abbreviated Survey (Incident 673700) the facility failed to ensure each resident received adequate supervision to prevent elopement. This was evident for one (1) (Resident #203) of two (2) residents reviewed for wandering and elopement out of 35 total sampled residents. Specifically, on 09/01/2024, Resident #203, who was severely impaired in cognition and had a wander alert device (a device that alerts staff when the resident is exiting the building), left the building undetected through the front door at 11:25 AM. Resident #203 was located by the facility staff approximately 300 feet from the facility and returned to the facility at 1:11 PM.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (incident 673540), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) out of five (5) residents (Resident #3) sampled for abuse. [...]

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 09/10/2023 to 09/15/2023, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during review of the kitchen facility task. Specifically, (1) staff were not wearing hair nets in the kitchen. (2) A staff member's personal bag was on the kitchen counter next to the meat slicer. (3) Food in the freezer was stored too close to the ceiling. (4) Food stored in the refrigerator was not covered and labeled.

Inspectors wroteBased on interviews and record reviews conducted during a Recertification Survey on 09/10/2023 to 09/15/2023, it was determined that for one (Resident #55) of seven residents, the facility did not ensure Resident # 55's property was safeguarded and free from loss or theft. Specifically, personal items which included 4-night gowns went missing. The facility did not investigate or complete a timely and thorough investigation of the missing property. Review of the facility policy and procedure titled, Resident Property documents the facility will maintain a safe environment for patient/resident property and will properly investigate all allegations of lost/missing or misappropriated property.

Inspectors wroteBased on observations, record reviews and staff interviews during the recertification survey, the facility did not ensure that nursing staff implemented the interventions of a resident's comprehensive care plan (CCP). This was evident for 1 of 7 residents reviewed for Pressure Ulcer (Resident #25) out of a total sample of 38 residents. Specifically, Resident #25 did not have heel booties applied at all times as per the CCP for Pressure Ulcer prevention.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey of 9/10/23 - 9/15/23, the facility did not ensure that the comprehensive care plans (CCPs)were reviewed and/or revised after each assessment and as needed to reflect changes in the resident needs. This was evident for 1 (Resident #60) of 8 residents reviewed for Activities of Daily Living (ADL) and 1 (Resident #46) of 5 residents reviewed for Unnecessary medications, out of an investigative sample of 38 residents. Specifically, (1) the Diabetes Mellitus CCP for Resident #46 was not reviewed and revised quarterly and after an episode of hypoglycemia. (2) the Dysfunctional coping or interaction CCP for Resident #60 was not reviewed and/or revised quarterly.

Inspectors wroteBased on observation, interviews, and record review conducted during a Recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure residents received proper treatment and assistive devices to maintain vision abilities. This was evident for Resident #52 and #103 reviewed for Communication. Specifically, 1) Resident #52 did not have a follow up consultation with the Ophthalmologist as recommended, and 2) Resident #103 did not have a recommended consultation with the Optometrist for glasses.

Inspectors wroteBased on observations, record reviews, and staff interviews, during the recertification survey, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. This was evident for 1 of 7 residents reviewed for Pressure Ulcer (Resident #25). Specifically, during multiple observations, Resident #25 was observed without heel booties in place as ordered.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey conducted 9/10/2023 to 9/15/2023, the facility did not ensure a system was established to record the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. This was evident for 1 (6th Floor) of 5 medication carts. Specifically, the 6th Floor medication cart Narcotics Log (NL) was incomplete and did not match the narcotics medication count in 2 blister packs.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards. This was evident for 1 (6th Floor) of 5 floors. Specifically, an expired influenza vaccine vial was observed in the 6th Floor medication room.

Inspectors wroteBased on the observations and interviews conducted during the recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure garbage and refuse was properly disposed. This was evident during the Kitchen facility task. Specifically, waste, debris, and trash were not properly contained in closed dumpsters and the garbage dumpster area was not maintained to prevent potential feeding and harborage for pests.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 9/10/2023 to 9/15/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #120) of 38 total sampled residents. Specifically, Registered Nurse (RN) #1 did not practice hand hygiene and glove changes and Licensed Practical Nurse (LPN) #5 did not properly handle sterile gauze during wound care for Resident #120.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, potentially hazardous foods were not maintained at an acceptable temperature to prevent foodborne illness. This was evident during the Kitchen Observation task and 1 of units observed for Dining Observation task (2nd floor).

Inspectors wroteBased on observations, and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, 1) Oxygen tubing was observed touching the floor on three occasions. 2) A staff member was observed entering a room with signage of contact droplet precautions without wearing the appropriate Personal Protective Equipment (PPE). 3) There was no water management plan for Legionella with required components including but not limited to a) a facility-specific environmental risk assessment, b) a site-specific water management plan, or c) a sampling plan was in place. This was evident for 3 out of 37 residents (Residents # 95, #485 and #494 reviewed in the investigation sample.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification/Complaint Survey (NY 00258651 & NY 00 267928) from 12/27/2021 to 1/3/2022, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1) no CCP was developed and implemented for residents with skin break and 2) no CCP was developed for resident on oxygen therapy. This was evident for 3 out of 7 residents reviewed for Pressure Ulcer/Injury (Resident # 391, # 341, and # 540), and 1 out of 1 resident reviewed for Respiratory Care (Resident # 95) out of a sample of 39 residents.

Inspectors wroteBased on observations and interviews during the Recertification/Complaint Survey from 12/27/2021 to 1/3/2022, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag and tubing were left uncovered and exposed to public view. This was evident for 1 of 3 resident reviewed for Dignity (Resident #70) .

Inspectors wroteBased on observation, record review and interview conducted during a Recertification survey, the facility did not ensure a clean, comfortable, and homelike environment was maintained. Specifically, the patient tubs on the 2nd and 3rd floor were noted with stains on the bathtub that were discolored with pink and rust colored in the bathtub around the drain and leading down the wall from the tub handles. This was evident for 2 of 5 resident floors observed for the Environment (Floors 2 and 3).

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification survey from 12/27/2021 to 1/03/2022, the facility did not ensure an ongoing program of activities was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident based on the comprehensive assessment and care plan. Specifically, a resident was observed for extended periods of time not participating in meaningful activities. This was evident for 1 of 1 residents reviewed for Activities out of 37 sampled residents (Resident # 112). The finding is: The facility Policy and Procedure tilted Activities with reviewed on 10/13/2021 documented this facility to provide an ongoing program to support residents in their choice activities based on their comprehensive assessment, care plan, and preferences of each resident. [...]

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that needed services, care and equipment was provided to assure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition. Specifically, a resident was observed on multiple occasions not wearing a palm guard as per Physician's order to improve resident's contractures. This was evident for 1 of 4 residents reviewed for Position/Mobility out of a sample of 38 residents. (Resident #29)