The Monarch at Brooklyn Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at The Monarch at Brooklyn Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 22, 2021

  Based on observation, interviews and record review conducted during an abbreviated survey (NY 395) the facility failed to ensure that a resident remained free from resident to resident abuse. This was evident for 2 out of 3 residents sampled (Resident #1 and Resident #2,). Specifically, Resident #1 was observed lying in bed with blood all over their face, blood at the back of the head; with swollen eyes and swollen and bleeding lips. Resident #1 was admitted to the hospital and was diagnosed with Acute Bilateral Nasal Fracture and Soft Tissue Swelling of the Face. Facility failed to protect Resident #1 from Resident #2, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] This resulted in actual harm to Resident #1 that was not an immediate jeopardy. […]

• No harm, potential for more than minimal, widespreadF812Jan 3, 2022

  Based 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). The findings are: The facility policy and procedure titled Food Preparation and Handling reviewed 04/30/2016 documented to provide meals prepared using methods and techniques designed to preserve maximum nutritive value, enhanced flavor and be free of injurious organisms and substances. […]

• No harm, potential for more than minimal, widespreadF880Jan 3, 2022

  Based 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. […]

• No harm, potential for more than minimal, patternF812Sep 15, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF656Jan 3, 2022

  Based on record review and staff interviews conducted during the Recertification/Complaint Survey (NY 651 & NY 00 8) 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. […]