Health inspection·February 3, 2026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of 20 sampled residents (Resident 13). * The facility failed to follow the physician's order for the administration parameters set for the carvedilol (a medication to treat high blood pressure) and midodrine (a medication to treat low blood pressure) medications. This failure had the potential for negative outcomes for the resident.Findings: Review of the facility's P&P titled Medication Administration - General Guidelines dated October 2017 showed medications are to be administered in accordance with written orders of the attending physician. Medical record review for Resident 13 was initiated on 1/29/26. Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's H&P examination dated 11/24/25, showed Resident 13 had capacity. Review of Resident 13's MAR for December 2025 showed the following physician's orders:- dated 11/24/25 (discontinued 12/5/25), to administer carvedilol 3.125 mg, give one tablet by mouth two times a day for hypertension (high blood pressure), hold for SBP less than 100 mmHg or heart rate less than 60; - dated 12/6/25, to administer carvedilol 3.125 mg, give one tablet by mouth two times a day for hypertension, hold for SBP less than 100 mmHg or heart rate less than 60;- dated 12/8/25 (discontinued 12/21/25), to administer midodrine HCl 2.5 mg, give one tablet by mouth two times a day for hypotension (low blood pressure), hold if SBP greater than 130 mmHg; and- dated 12/21/25, to administer midodrine HCl 5 mg, give one tablet by mouth two times a day for hypotension, hold if SBP greater than 140 mmHg. Review of Resident 13's MAR for December 2025 showed the following: - dated 12/3/25, the carvedilol was held at 0900 hours, however, there were no vital signs documented;- dated 12/10/25, the midodrine was held at 0900 hours, the BP was 127/71;- dated 12/10/25, the carvedilol was held at 1700 hours, the BP was 106/67 and heart rate was 61; - dated 12/11/25, the carvedilol was held at 0900 hours, the BP was 104/67 and heart rate was 69; - dated 12/11/25, the carvedilol was held at 1700 hours, the BP was 103/51 and heart rate was 93; - dated 12/12/25, the carvedilol was held at 1700 hours, however, there were no vital signs documented; - dated 12/17/25, the midodrine was administered at 0900 hours, the BP was 145/76; - dated 12/17/25, the carvedilol was held at 1700 hours, the BP was 105/62 and heart rate was 89; - dated 12/19/25, the midodrine was administered at 1700 hours, the BP was 137/64; - dated 12/21/25, the carvedilol was held at 0900 hours, the BP was 102/61 and heart rate was 82; - dated 12/22/25, the carvedilol was held at 0900 hours, however, there were no vital signs documented; - dated 12/22/25, the carvedilol was held at 1700 hours, however, there were no vital signs documented; - dated 12/24/25, the carvedilol was held at 0900 hours, the BP was 112/62 and heart rate was 75; - dated 12/25/25, the midodrine was held at 0900 hours, however, there were no vital signs documented; - dated 12/27/25, the carvedilol was held at 0900 hours, the BP was 108/51 and heart rate not documented; and- dated 12/27/25, the carvedilol was held at 1700 hours, the BP was 108/76 and heart rate was 76. Review of Resident 13's MAR Page 1 of 2 055121 055121 02/03/2026 Pelican Ridge Post Acute 466 Flagship Road Newport Beach, CA 92663

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for January 2026 showed the following: - dated 1/1/26, the carvedilol was held at 1700 hours, the BP was 108/64 and heart rate was 66; - dated 1/4/26, the carvedilol was held at 0900 hours, the BP was 104/64 and heart rate was not documented; - dated 1/4/26, the carvedilol was held at 1700 hours, the BP was 108/64 and heart rate was 78; - dated 1/5/26, the midodrine was held at 0900 hours, however, there were no vital signs documented; - dated 1/5/26, the midodrine was held at 0900 hours, however, there were no vital signs documented;- dated 1/5/26, the midodrine was administered at 1700 hours, the BP was 145/70; and - dated 1/8/26, the midodrine was administered at 0900 hours, the BP was 152/74. On 1/29/26 at 1532 hours, an interview and concurrent medical record review for Resident 13 was conducted with the DON. The DON was informed and verified the above findings. On 2/2/26 at 1310 hours, an interview was conducted with the Administrator. The Administrator was informed and stated the facility's policy was for the licensed nurses to follow the physician's orders. 055121 Page 2 of 2