Memorial Manor
MEMORIAL MANOR in PEMBROKE PINES, FL — inspection on November 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
09/12/25, 09/13/25 and 09/14/25. On 10/27/25 at 11:52 AM, an interview was conducted with Staff A, Registered Nurse (RN), who was asked what do you consider a resident change in condition and stated a mental status change, appetite not as usual and vital signs off from normal.
Staff A was asked what would you do then and replied she will call the doctor.On 10/27/25 at 2:10 PM, an interview and a side-by-side review of Resident #2's clinical record was conducted with the Director of Nursing (DON).
The review revealed the resident had a low BP on 09/13/25, and on 09/14/25.
The DON was apprised the resident's BP readings were off from her baseline, prior documented readings were anywhere from 130's 150's and 160's with HR readings between 70's and 80's and had an elevated HR 144 on 09/14/25.
The DON was asked to submit written evidence regarding Resident #2's physician notification of low BP, an elevated HR and not given BP medications for three (3) consecutives days.
The DON stated she did not see any written notification to the physician. On 10/27/25 at 3:12 PM, an interview was conducted with Staff B, RN who was asked what would you do if your resident has a change in vital signs and replied, call the supervisor, call the doctors, get new orders, send them out and call the family.
Consequently, a side-by-side review of Staff B's nurses note dated 09/14/25 for Resident #2 was conducted.
Staff B was asked if she notified Resident #2's low blood pressure reading of 84/50 and the heart rate of 114 to the physician and stated she rechecked the blood pressure one hour later and it was okay.
The RN was asked why she did not notify the physician of the changes to the BP and HR and stated she looked at the history and noticed the blood pressure reading was kind of baseline, was asymptomatic, added the resident was not eating, having a low BP and elevated HR she was dehydrated, got report she was not eating very well, but make up by drinking ensure.
Staff B was asked if she thought Resident #2 was dehydrated, why did not call the doctor? Staff B stated she would like more proof, rechecked the BP in one hour and it was okay for not calling the doctor.
There was no written evidence that Staff B rechecked the resident's elevated HR.
Staff B stated the resident was hypertensive and believed she held the medications and stated, critical thinking is thinking on your feet and will call the doctor after she exhausted all of her nursing knowledge, will call the supervisor after all of steps were done, added this where we are, what do I do now.
Staff B was asked if she discussed Resident #2's low blood pressure and elevated heart rate with the supervisor and stated she did not. On 10/27/25 at 5:59 PM, during an interview, the DON was asked if the nurse was to call the physician with changes on vital signs and medication held due to low blood pressure and stated a standard of practice is to hold the medication if the BP is low.
The DON stated the physician should have been notified and added a low blood pressure could be due to multiple reason, a sustained low BP is a cause to call the physician.
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