The Monarch At Brooklyn Rehabilitation And Nursing
The Monarch at Brooklyn Rehabilitation and Nursing in Brooklyn, NY — inspection on August 14, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
resident went to the bathroom and refused to go back to the dining room and was walking up and
09/01/2024 documented that based on review of camera footage, Resident #203 left the unit at
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.