Mount Olive Center: Wrong Blood Pressure Meds Given - NC
The deficiency, cited during a complaint inspection completed October 1, 2025, centered on Resident #113, who had been diagnosed with orthostatic hypotension, a condition in which blood pressure drops sharply when a person stands or changes position. The resident's physician had prescribed two medications with opposite effects. Midodrine HCl, taken daily, was meant to raise blood pressure. Coreg, a beta-blocker, was meant to lower it. The physician had written an order specifying that Coreg should be held — not given — if the resident's systolic blood pressure read below 150 millimeters of mercury.
The order was not followed. Nursing staff gave Coreg anyway, on days when the resident's systolic reading came in under that threshold.
When inspectors confronted the physician, she said she had not reviewed Resident #113's medication administration records for July, August, or September of 2025. Three months of documentation showing the error had occurred. She had seen none of it.
What makes this harder to dismiss as a clerical oversight is the pharmacology involved. Coreg suppresses the heart's response to adrenaline, reducing both heart rate and the force of contractions. In a patient whose blood pressure is already running low, that effect can push readings further down. The physician explained this dynamic directly to inspectors: because Resident #113 was simultaneously taking Midodrine to raise blood pressure, the two drugs had been partially canceling each other out. The resident's pressure stayed in a normal range not because care was being delivered correctly, but because one medication was compensating for the misapplication of another.
That is not a treatment plan. That is a medication error sustained across a calendar quarter, masked by the coincidental effect of a second drug.
The facility recorded the deficiency under F0760, the federal tag covering medication errors, at a harm level described as minimal harm or potential for actual harm. That language reflects CMS's assessment of what was documented, not necessarily the outer boundary of what could have occurred. A patient with orthostatic hypotension whose blood pressure drops unexpectedly is at elevated risk for falls, fainting, and the injuries that follow.
Mount Olive Center sits on Smith Chapel Road in Wayne County, a small facility in a part of eastern North Carolina where long-term care options are limited and residents often have few alternatives. The inspection was triggered by a complaint, not a routine survey, meaning someone raised a concern before inspectors arrived.
The physician's account to inspectors is worth sitting with. She had not seen the July records. She had not seen the August records. She had not seen the September records. Three months of medication administration documentation, each sheet showing that a conditional order was being ignored, and none of it had reached her attention or prompted a review. The facility's nurses administered the drug. Someone recorded the blood pressure readings. Someone signed the administration records. And the ordering physician, the person responsible for knowing whether her orders were being followed, remained unaware.
Resident #113's blood pressure held. This time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mount Olive Center from 2025-10-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
Mount Olive Center in Mount Olive, NC was cited for violations during a health inspection on October 1, 2025.
The resident's physician had prescribed two medications with opposite effects.
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.