The January 29 federal inspection revealed that nurses failed to check the resident's blood pressure every eight hours as required before administering two opposing medications. One drug, Midodrine, treats dangerously low blood pressure. The other, Clonidine, treats high blood pressure.
Resident #5 had physician orders for both medications dated January 14. The Midodrine order specified giving 10 milligrams through a feeding tube every eight hours "as needed" when systolic blood pressure dropped below 100. The Clonidine order called for one tablet by mouth every eight hours "as needed" when systolic blood pressure exceeded 170.
But clinical records showed no evidence that staff monitored the resident's blood pressure every eight hours to determine which medication was needed, if any.
Licensed practical nurse #4 confirmed the proper protocol during an inspector interview at 7:45 a.m. "When there is a medication that requires a blood pressure, the nurse should take the blood pressure and administer or hold the medication per the physician's order," the nurse said.
The facility's regional director of clinical services acknowledged the problematic orders during an 11:46 a.m. interview. She revealed that Canterbury had been cited for similar Midodrine issues on a previous survey and had worked with physicians to change such orders from "as needed" to scheduled doses with specific parameters for holding the medication.
"It was unusual to have a PRN order for Clonidine," she told inspectors, using the medical abbreviation for "as needed." She admitted these orders needed clarification.
The contradiction in medication orders created a potentially dangerous scenario. Midodrine raises blood pressure in patients who experience sudden drops when standing, a condition called orthostatic hypotension. Clonidine lowers blood pressure in patients with hypertension. Without proper monitoring, staff couldn't know whether the resident needed medication to raise or lower blood pressure, or neither.
The resident received medications through a feeding tube, indicating significant medical complexity that would make proper monitoring even more critical.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm," but the deficiency represented a failure to meet professional standards of quality care. The facility's own clinical director acknowledged the orders were problematic and unusual.
Canterbury's administrator, director of nursing, and regional director of operations were notified of the findings at approximately 4:45 p.m. on January 29. The facility provided no additional information before inspectors completed their review.
The inspection occurred in response to a complaint, though the report doesn't specify the nature of the original concern that prompted the federal review.
This wasn't Canterbury's first struggle with medication management. The regional clinical director's admission about previous citations for Midodrine orders suggests ongoing challenges with ensuring proper protocols for blood pressure medications.
The facility operates at 1776 Cambridge Drive in Richmond. Federal regulations require nursing homes to ensure all services meet professional standards of quality, including proper medication administration and monitoring.
Without consistent blood pressure monitoring, staff couldn't make informed decisions about whether the resident needed intervention for high or low blood pressure, potentially leaving dangerous fluctuations untreated or inappropriately medicating stable readings.
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.
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