Riverside Nursing: Withheld Blood Pressure Meds - OH
Resident 02 at Riverside Nursing and Rehabilitation Center was supposed to get Midodrine whenever her systolic blood pressure fell below 110. The hypotension medication was ordered in November 2024, but staff failed to administer it on at least four documented occasions when her blood pressure qualified.
The resident, who has been at the facility since February 2023, suffers from right-side paralysis, chronic lung disease, end-stage kidney failure, and bipolar disorder. She depends on staff for basic care including toilet hygiene, bathing, and moving in bed.
Her physician ordered Midodrine 2.5 milligrams every eight hours as needed for low blood pressure. The instructions were clear: give the medication when systolic pressure drops below 110, but hold it if pressure rises above that threshold.
On June 3, nurses recorded her blood pressure at 97/50. She didn't get the medication.
Before dialysis on July 24, her pressure measured 105/78. No Midodrine.
On July 31, it was 106/64. Again, no medication.
August 5 brought another qualifying reading of 104/67. Staff still didn't administer the prescribed drug.
Nurse Practitioner 800 confirmed during an August 7 interview that the facility had failed to give the medication on all four occasions. The NP explained that staff should check the resident's blood pressure three times daily to monitor for possible Midodrine administration.
"The facility staff should have administered Midodrine as ordered prior to dialysis," the nurse practitioner told inspectors.
The medication administration records for June, July, and August showed no documentation that Midodrine was ever given on the dates when the resident's blood pressure readings indicated she needed it.
For someone with end-stage renal disease requiring dialysis, maintaining stable blood pressure becomes critical. Low blood pressure can cause dizziness, fainting, and inadequate blood flow to vital organs. The condition becomes particularly dangerous during dialysis, when fluid removal can further drop already-low pressure.
The facility's own medication administration policy requires staff to provide resident-centered care that meets physical needs and to administer medication only as prescribed by providers. The policy emphasizes following physician orders exactly.
Federal inspectors reviewed four residents' medication administration as part of a complaint investigation. Only Resident 02 experienced the significant medication error, though the facility houses 164 residents total.
The inspection classified the violation as causing minimal harm or potential for actual harm. However, the failure to treat documented hypotension in a dialysis patient represents a basic breakdown in following physician orders.
Midodrine works by constricting blood vessels to raise blood pressure in people with chronic low blood pressure. For dialysis patients, the medication can be particularly important before treatments, when fluid removal often causes blood pressure to drop further.
The resident remains cognitively intact according to her July assessment, meaning she likely understood when staff failed to provide her prescribed medication despite her qualifying symptoms.
The violation occurred during a complaint investigation numbered 1259566, suggesting someone reported concerns about medication administration at the facility. Federal inspectors found the complaint substantiated through their review of medical records and staff interviews.
Riverside Nursing and Rehabilitation Center must now submit a plan of correction explaining how it will prevent similar medication errors. The facility has not indicated whether it has since administered the prescribed Midodrine to Resident 02 or improved its blood pressure monitoring protocols.
The resident continues to require dialysis three times per week for her end-stage kidney disease, making proper blood pressure management an ongoing necessity for her care and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Nursing and Rehabilitation Center from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH was cited for violations during a health inspection on September 2, 2025.
Resident 02 at Riverside Nursing and Rehabilitation Center was supposed to get Midodrine whenever her systolic blood pressure fell below 110.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.