Sherman Oaks Health & Rehab didn't document any monitoring for bleeding and bruising in a resident taking two powerful blood thinners — Eliquis and clopidogrel — during March 2025, according to federal inspection records. The resident's care plan, initiated in April 2024, specifically warned staff to watch for "abnormal bleeding" and "easy skin bruising" daily.
The facility's Director of Nursing admitted during the March inspection that monitoring for bleeding with blood thinner use "was considered standard of practice." She acknowledged that without proper monitoring, residents could experience "bleeding that was unnoticed, which may harm the resident leading to hospitalization and death."
Resident 42 had been readmitted to the facility in April 2024 with diagnoses including epilepsy and paroxysmal atrial fibrillation, an irregular heartbeat condition. Doctors prescribed Eliquis 5 mg once daily starting April 25, and added clopidogrel 75 mg once daily in August.
The resident's medication administration record for March showed nurses were supposed to give both blood thinners — Eliquis at 9 a.m. and clopidogrel twice daily at 9 a.m. and 5 p.m. But the same record contained no documentation that staff ever checked for bleeding or bruising symptoms.
The care plan had been clear about the risks. It stated the resident was "at risk for bleeding and bruising due to anticoagulant therapy" and set a goal of "no unrecognized sign and symptoms of bleeding daily." Staff were supposed to "assess for signs and symptoms of bleeding" and "assess for other possible causes of bruising."
None of that monitoring happened.
The same resident was also prescribed gabapentin 600 mg three times daily for epilepsy. The care plan warned staff to watch for drug toxicity symptoms including "nausea, vomiting, dizziness, severe drowsiness, blurred visions, double vision, altered level of consciousness, chest pain and shortness of breath." Again, medication records showed no monitoring occurred.
The Director of Nursing told inspectors that monitoring for drug toxicity with gabapentin "was important to minimize the side effects of gabapentin and prevent harm such as chest pain and shortness of breath." She said the facility had "failed to implement the Care Plan to accurately reflect the needs of Resident 42."
A second resident faced different but equally serious monitoring failures. Resident 79, readmitted in September 2024 with high cholesterol, was prescribed atorvastatin 20 mg at bedtime to manage hyperlipidemia. The resident's care plan called for monitoring the medication's effectiveness and obtaining "laboratory work as ordered."
Six months later, inspectors found no lipid panel had ever been ordered. The resident's clinical chart contained no laboratory results measuring cholesterol levels either before or after admission.
The Director of Nursing explained that checking lipid levels was "important to know if the medications was effective, and not causing more harm than benefit." She admitted the facility had failed to properly monitor the resident and said "lipid panel monitoring was considered standard of practice."
The facility's consulting pharmacist, interviewed by phone on March 18, acknowledged the monitoring failures during monthly medication reviews. The pharmacist had reviewed both residents' drug regimens in December 2024, January 2025, and February 2025 but failed to identify the lack of bleeding monitoring for the blood thinners or the absence of lipid testing.
"Without adequate monitoring these medications have the potential to be used unnecessarily causing more harm than benefit," the pharmacist told inspectors. The pharmacist confirmed that monitoring for bleeding and bruising with clopidogrel and Eliquis use, and lipid monitoring for residents on atorvastatin, were both "considered standard of practice."
A third resident, identified only as Resident 40, was also found to lack proper monitoring for side effects of apixaban, another blood thinner used to prevent clots related to heart and blood vessel conditions.
The facility had comprehensive policies requiring exactly the kind of monitoring that didn't happen. The anticoagulation protocol, last reviewed in September 2024, instructed staff to "assess for any signs or symptoms related to adverse drug reactions" and "monitor for possible complications in individuals who are being anticoagulated."
Another policy on adverse consequences and medication errors stated that "residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported." The policy defined adverse consequences as "unpleasant symptoms or events" that could include "impairment or decline in an individual's mental or physical condition."
The medication regimen review policy required the consulting pharmacist to perform comprehensive monthly reviews, evaluating residents' responses to medications "to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy."
Despite these detailed policies, the systematic monitoring failures continued for months. The Director of Nursing promised inspectors that monitoring would be "immediately implemented" for the affected residents. She said lipid panels would be "immediately ordered" for Resident 79.
Federal inspectors classified the violations as having "minimal harm or potential for actual harm" but noted they affected "some" residents. The inspection findings revealed what the Director of Nursing called "suboptimal care leading to the use of unnecessary medications causing potential side effects and negatively impacting their physical, mental, and psychosocial well-being."
The blood thinners at the center of the violations — Eliquis, clopidogrel, and apixaban — are powerful medications that require careful monitoring precisely because undetected bleeding can be fatal. The facility's own policies acknowledged this reality, but staff failed to follow through on the daily assessments that could have caught problems before they became life-threatening.
For Resident 42, the combination of two blood thinners without proper monitoring created compounded risks that went unrecognized for months. For Resident 79, six months passed without anyone checking whether the cholesterol medication was working or causing harmful side effects.
The consulting pharmacist's admission that these monitoring practices were "standard" underscored how routine the oversights had become. Three separate residents, three different medications, the same pattern of neglect.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Oaks Health & Rehab from 2025-03-14 including all violations, facility responses, and corrective action plans.