The Monarch At Brooklyn Rehab And Nursing Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the facility at 1:11 after elopement procedure was initiated.Review of the staff written statements dated 09/01/2025 revealed that on 09/01/2024, Resident #203 was in the dining room at 8:00 AM for breakfast.
The resident was administered medications at 9:30 AM and received their 10:00 AM Ensure supplement. At about 10:30 AM, the resident went to the bathroom and refused to go back to the dining room and was walking up and down the hallway. Certified Nursing Assistant #6 documented in their written statement that
the last time they saw Resident #203 was at 11:00. The Resident Incident/Investigation Report dated 09/01/2024 documented that based on review of camera footage, Resident #203 left the unit at approximately 11:20 AM on 09/01/2024. The resident was observed in the lobby area and exited the building at 11:25 AM. The front desk security guard was interacting with two (2) visitors who needed assistance with entering information on the kiosk when the resident walked by him and exited through the front entrance. The facility investigation documented all wander alert mechanisms were checked and working, however, Resident #203's wander alert device was not working at the time. On 08/11/2025 at 2:23 PM an interview was conducted with Certified Nursing Assistant #6 who was on the unit at the time Resident #203 eloped. They stated the resident was on 30-minute checks and that the resident was a wanderer. They stated on the day of the incident; they found out that Resident #203 was missing when they cannot find the resident during lunch time. They stated they immediately started searching for the resident.
On 08/12/2025 at 12:37 PM, an interview was conducted with the Receptionist, who stated that the front desk has one receptionist during the day and a security guard at nighttime. They stated they are responsible for screening visitors and making sure residents do not leave the facility unescorted. The receptionist stated they have pictures of residents who are wanderer at the front desk. The receptionist stated that elevators will not move when a resident with a wander alert device board and the front will lock when a wander alert device is near the door, the door will not open. The Receptionist stated they were not working on the day of the incident.On 08/14/2025 at 10:42 AM, an interview was conducted with the Assistant Director of Nursing who stated that they reviewed Resident #203's elopement incident and they discovered that the resident's wander alert device was not working at the time the resident exited. They also stated that at the time of the elopement, the elevator does not stop even when a resident with wander alert device gets in. On 08/14/2025 at 9:43 AM, an interview was conducted with the Director of Nursing who stated they were recently hired at the facility and was not working at the facility at the time of the elopement incident. They stated they reviewed the records related to the incident and found that the resident's wander alert device was not working at the time of elopement. They also stated that the security was distracted as
they were attending to visitors10 NYCRR 415.12(h)(2)
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THE MONARCH AT BROOKLYN REHAB AND NURSING CENTER in BROOKLYN, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BROOKLYN, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE MONARCH AT BROOKLYN REHAB AND NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.