Memorial Manor
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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MEMORIAL MANOR in PEMBROKE PINES, FL 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 PEMBROKE PINES, FL, (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 MEMORIAL MANOR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.