Hawthorne Center: Wrong Blood Pressure Med Given - FL
Midodrine raises blood pressure. It is prescribed specifically for patients whose pressure drops too low. Giving it when pressure is already elevated works against the drug's purpose and against the body.
The physician order for Resident 108, in place since March 13, 2026, and reissued on May 20, read the same way both times: administer midodrine 5 milligrams three times a day for low blood pressure, hold if systolic blood pressure is greater than 120. The instruction could not have been simpler.
It was ignored at least 21 times.
On May 1, the resident's blood pressure was 132 over 84. A nurse gave the midodrine at 2:00 in the afternoon. On May 3, the reading was 130 over 81. The drug was given again. On May 6, 130 over 72, and midodrine went in at 6:00 in the morning. On May 10, the reading reached 140 over 72, the highest recorded that month, and a nurse administered the medication at 10:00 that night.
The pattern continued through May 11, 12, 13, 14, 15, 17, 18, and into the days after the order was supposedly discontinued on May 20. On May 21, with a reading of 145 over 78, a nurse gave the drug at 10:00 PM. On May 23, at 145 over 65, it was given again. On May 24, twice, with readings of 121 over 66 both times. On May 27, a reading of 124 over 62, and the medication was administered at 6:00 in the morning.
Every one of those blood pressure readings exceeded the physician's threshold. Every checkmark on the medication administration record, according to the facility's own Director of Nursing, meant the drug had been given.
When inspectors interviewed a registered nurse identified in the report as Staff K on May 28, the nurse said the checkmarks meant administration. "I don't know why there is a checkmark," the nurse said. "I always check the parameters for medications. If I hold a medication, I document a number in the MAR and a nursing note. I am not sure what happened with" the resident's midodrine.
The Director of Nursing confirmed the same system. A checkmark meant the drug was given. A number in the record, with an accompanying nursing note, meant it had been held. There were no numbers. There were no nursing notes indicating a hold. There were checkmarks, date after date, next to blood pressure readings that should have stopped every dose.
Nobody held it. Nobody documented a reason. Nobody, apparently, questioned it.
The inspection report does not say whether Resident 108 experienced symptoms from receiving a blood pressure-elevating drug while already hypertensive. It does not say whether any physician was notified during May that the parameters were being ignored. It does not name a nurse responsible for any specific administration.
What the record shows is that for most of a month, a resident received a medication their doctor had explicitly ordered withheld under exactly the conditions that existed each time a nurse walked in and gave it anyway.
Federal inspectors cited the deficiency at a level of minimal harm. That classification reflects the regulatory determination about documented injury. It does not address what a month of unnecessary midodrine does to an elderly resident's cardiovascular system, or what it means that the nurses who administered it, when asked, could not explain why.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hawthorne Center For Rehabilitation and Healing Of from 2026-05-29 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
HAWTHORNE CENTER FOR REHABILITATION AND HEALING OF in OCALA, FL was cited for violations during a health inspection on May 29, 2026.
Midodrine raises blood pressure.
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.