Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Memorial Manor during CMS and state inspections, most recent first.
A resident with a history of hypertension had blood pressure medications withheld for three consecutive days due to low BP and elevated HR, but the physician was not notified as required by facility policy. Nursing staff recognized the abnormal vital signs and deviation from baseline, yet failed to document physician notification or consult with supervisors. The DON confirmed there was no evidence of physician notification regarding the resident's condition or the held medications.
The facility failed to monitor the behaviors of residents on psychotropic medications, as evidenced by the lack of documentation for four residents. Despite care plans requiring behavior monitoring, staff interviews revealed inconsistencies in documentation practices, with some staff unaware of behavior monitoring flow sheets and others using them only when behaviors were present. This resulted in significant gaps in monitoring, particularly for residents with severe cognitive impairments and those on multiple psychotropic medications.
A resident with Alzheimer's and other conditions was served meals that did not meet the IDDSI guidelines for a pureed diet, as they contained lumps and lacked uniform consistency. The Speech-Language Pathologist and Food Service Director confirmed the deficiency, noting that pureed bread, made in-house, did not meet the required standards, affecting ten residents.
Failure to Notify Physician of Held Blood Pressure Medications and Abnormal Vital Signs
Penalty
Summary
The facility failed to notify a resident's physician after blood pressure medications were held for three consecutive days due to low blood pressure. According to the facility's policies, the physician should be notified of significant changes in a resident's condition, including abnormal vital signs and when medications are held. Review of the clinical record for a resident with a history of hypertension, hypokalemia, and anemia showed that blood pressure readings were significantly lower than the resident's baseline, and heart rates were elevated over several days. Despite these findings, there was no documentation that the physician was notified about the low blood pressure, elevated heart rate, or the decision to withhold blood pressure medications. Nursing notes indicated that the resident experienced low blood pressure readings and elevated heart rates on multiple occasions, with the resident also exhibiting poor appetite and weakness. The medications Irbesartan, Metoprolol, and Nifedipine were not administered for three consecutive days due to these low readings. Staff interviews revealed that nurses recognized the abnormal vital signs and the deviation from the resident's baseline, but did not notify the physician or supervisor as required by facility policy. One nurse stated she rechecked the blood pressure and found it acceptable, but there was no evidence that the elevated heart rate was rechecked or that the physician was informed. Further interviews with the Director of Nursing confirmed that there was no written evidence of physician notification regarding the resident's low blood pressure, elevated heart rate, or the held medications. The DON acknowledged that the standard of practice is to notify the physician in such cases, and that sustained low blood pressure is a reason to contact the physician. The lack of documentation and failure to notify the physician constituted a deficiency in following the facility's policies and procedures for changes in resident condition and medication administration.
Failure to Monitor Behaviors of Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor the behaviors of residents receiving psychotropic medications, as evidenced by the lack of documentation and behavior monitoring for four out of five sampled residents. Resident #94, who was admitted with diagnoses including Mild Dementia and Major Depressive Disorder, was prescribed Zoloft but had no behavior monitoring documented since admission. Interviews with staff revealed inconsistencies in the use of behavior monitoring flow sheets, with some staff unaware of their existence and others indicating they were only used when behaviors were present. Resident #79, admitted with diagnoses such as Paraplegia and Major Depressive Disorder, was prescribed Mirtazapine but also had no behavior monitoring documented. The Director of Nursing acknowledged the absence of behavior monitoring flow sheets and progress notes specific to behaviors, despite the facility's policy requiring such documentation. The consultant pharmacist assumed that the absence of documentation indicated no behaviors, highlighting a lack of clarity in the facility's monitoring practices. Resident #73, with diagnoses including Depression and Adjustment Disorder with Anxiety, was on antidepressants but had no documented behavior monitoring or side effects monitoring. The Director of Nursing stated that behavior monitoring was only documented if behaviors were observed, leading to gaps in monitoring. Similarly, Resident #1, with severe cognitive impairment and multiple psychotropic medications, had numerous days without documented behavior monitoring, despite care plans indicating the need for such monitoring. These deficiencies indicate a systemic issue in the facility's approach to monitoring residents on psychotropic medications.
Failure to Provide Correct Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct diet consistency for a resident on a pureed diet, as observed during two separate meal times. The resident, who has Alzheimer's Disease, Bipolar Disorder, and Depression, was served meals that did not meet the International Dysphagia Standardization Initiative (IDDSI) guidelines for a pureed diet. The meals included pureed chicken, mashed potatoes, broccoli, bread, and cobbler, which were noted to have lumpy pieces and lacked a uniform consistency. This inconsistency was documented with photographic evidence. Interviews with the Speech-Language Pathologist and the Food Service Director revealed that the pureed diet should be smooth and creamy without any lumps or solid particles. It was noted that most pureed foods are purchased from an outside company, except for pureed bread, which is made in-house. The Food Service Director acknowledged that the pureed bread did not meet the required consistency guidelines, affecting ten residents on a pureed diet.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pembroke Pines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alexander "sandy" Nininger State Veterans Nursing | 0.7 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing And Rehabilitation Center | 4.8 mi | ★★★★★ | 0 | 0 |
| Sierra Lakes Nursing & Rehabilitation Center | 5.4 mi | ★★★★★ | 11 | 1 |
| Nspire Healthcare Miami Lakes | 5.4 mi | ★★★★★ | 7 | 0 |
| Gardens Nursing And Rehab Center | 5.5 mi | ★★★★★ | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.