Canterbury Rehab: Medication Order Failures - VA
The January 29 inspection, triggered by a complaint, found that staff failed to clarify physician orders for a resident identified in records as Resident 5. That resident had orders, both dated January 14, 2026, for Midodrine and Clonidine. Midodrine raises blood pressure. Clonidine lowers it. The orders called for nurses to check the resident's blood pressure every eight hours to determine which medication, if either, was needed. The clinical record showed no evidence that those checks were happening.
The Midodrine order directed staff to give 10 milligrams through a feeding tube every eight hours as needed, but only when the resident's systolic blood pressure dropped below 100. The Clonidine order directed staff to give one tablet by mouth every eight hours as needed, but only when systolic pressure climbed above 170. Without a blood pressure reading, neither order could be followed correctly. A nurse administering one drug without knowing the current reading could be treating a condition that wasn't present, or making the opposite condition worse.
A licensed practical nurse interviewed the morning of the inspection said the expectation was clear: when a medication requires a blood pressure reading, take the blood pressure, then administer or hold the drug based on what the order says. The record didn't show that was happening for Resident 5.
What made the finding harder to explain was what the regional director of clinical services, identified in the report as administrative staff member 4, said when inspectors interviewed her later that morning. She acknowledged that Canterbury had already been cited on a previous inspection for problems with Midodrine orders specifically. At that point, she said, the facility had worked with physicians to move Midodrine from an as-needed order to a scheduled dose with parameters for when to hold it. Somehow, a new as-needed Midodrine order had appeared for this resident anyway, structured the same way the previous citation had flagged.
She called a PRN, or as-needed, order for Clonidine unusual. She said both orders needed to be clarified. That was the state of things on the afternoon of January 29, when the administrator, the director of nursing, and the regional director of operations were informed of what inspectors had found. No additional information was provided before the inspection team left the building.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. Canterbury is a 240-bed facility on Cambridge Drive in Richmond's West End.
The practical stakes in a case like this are not abstract. Orthostatic hypotension, the condition Midodrine treats, causes blood pressure to drop sharply when a person stands up. The drop can cause dizziness, fainting, and falls. Giving Midodrine to a resident whose blood pressure is already normal or elevated could push it dangerously high. Giving Clonidine to a resident whose pressure is already low could do the opposite. For a resident on a feeding tube, unable to communicate symptoms in the way an ambulatory patient might, the margin for error is narrower.
The facility knew about the Midodrine problem. It had been through a citation, worked with physicians, made changes. Then a new order arrived written the same way the old one had been, and no one flagged it. The regional director of clinical services said it herself: these orders need to be clarified.
On the morning the inspectors arrived, the blood pressure log for Resident 5 didn't show the checks that would have made either order safe to follow.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Canterbury Rehabilitation and Healthcare Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
CANTERBURY REHABILITATION AND HEALTHCARE CENTER in RICHMOND, VA was cited for violations during a health inspection on January 29, 2026.
The January 29 inspection, triggered by a complaint, found that staff failed to clarify physician orders for a resident identified in records as Resident 5.
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.