Riverside Nursing and Rehab: Missed Hypotension Meds - OH
That was not the only time.
The resident, identified in federal inspection records only as Resident #02, has lived at Riverside since February 2023. She has right-sided paralysis, end-stage renal disease, chronic obstructive pulmonary disease, and bipolar disorder. She depends on dialysis to survive and on staff for nearly every physical task, including getting out of bed and going to the bathroom. Inspectors noted she is cognitively intact.
In November 2024, her physician ordered Midodrine, a medication used to raise blood pressure. The instructions were specific: give one 2.5-milligram tablet by mouth every eight hours as needed. Hold the dose if her systolic blood pressure is above 110. Give it if her systolic pressure falls below 110.
Her blood pressure fell below 110 on four separate dates spanning June through August 2025. On June 3, it was 97 over 50. On July 24, it was 105 over 78. On July 31, it was 106 over 64. On August 5, it was 104 over 67. Three of those readings were documented during pre-dialysis assessments, the window when managing blood pressure matters most for a patient whose kidneys no longer function on their own.
The medication administration records for June, July, and August 2025 contained no documentation that Midodrine was given on any of those four dates.
The nurse practitioner who reviewed the case, identified in the inspection report as NP #800, confirmed what the records showed. In an interview on August 7, 2025, she said the order was always meant to work the way it was written: check the blood pressure, compare it to the threshold, give the medication if the number falls below 110. She said staff should have been checking Resident #02's blood pressure three times a day to monitor whether Midodrine was needed. She said staff should have given the medication before dialysis on the dates it was missed. Then she confirmed, directly, that the facility had not done so on June 3, July 24, July 31, or August 5.
The inspection was triggered by a complaint, filed under complaint number 1259566, and completed September 2, 2025. Federal investigators cited the failure as a significant medication error, though they classified the level of harm as minimal or potential rather than actual. One resident out of four reviewed for medication administration was affected. The facility's census at the time was 164.
Midodrine is not a complicated drug to administer. It does not require clinical judgment about whether to use it. The order told staff exactly when to give it and exactly when to hold it. The blood pressure threshold that should have triggered the dose was crossed four times over ten weeks. The medication sat unused each time.
For a patient on dialysis, low blood pressure is not a minor inconvenience. Dialysis itself can cause blood pressure to drop further, and patients arriving at treatment already hypotensive face compounded risk. The nurse practitioner's statement that Midodrine should have been given prior to dialysis reflects that reality. The pre-dialysis timing of three of the four missed doses was not incidental.
Resident #02 is cognitively intact. She knows what medications she takes. Whether she or anyone on her behalf raised the alarm that led to the complaint inspection, the records do not say.
What the records do say is that for at least four days across three months, her blood pressure signaled that she needed help, and the help that had been prescribed and ordered and was available went ungiven.
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.
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 22, 2026 · Our methodology
RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH was cited for violations during a health inspection on September 2, 2025.
The resident, identified in federal inspection records only as Resident #02, has lived at Riverside since February 2023.
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.