Failure to Employ Licensed Social Worker and Involuntary Seclusion of Resident
Summary
The facility failed to employ a full-time licensed or certified social worker, impacting the care of all residents, including Resident #226. Resident #226, who was cognitively intact and his own responsible party, was moved against his will to a locked memory care unit without the involvement of a social worker to plan his care and discharge. The facility staff did not honor his request to stay in his current room or plan for his discharge back to the community or an assisted living facility. The move was justified by the staff as a precaution against elopement risk, despite the resident having no history of elopement and being able to make his own decisions. Resident #226, who had diagnoses including end-stage renal disease, stroke history, and diabetes, expressed dissatisfaction with the memory care unit, citing a lack of personal items, inadequate clothing, and poor living conditions. He reported that his requests for discharge planning were ignored, and he was involuntarily secluded in the memory care unit. The facility's lack of a social worker from June 28 to November 19, 2024, further compounded the issue, as the newly hired social worker was not familiar with the resident's case and did not document his desire for discharge. Interviews with facility staff revealed a lack of clear policy or procedural guidance for moving residents to the memory care unit. The Director of Nursing and Administrator could not provide a pathway for such decisions, and there was no evidence in the clinical record that the resident's physician was notified of the move or his discharge wishes. The facility's failure to provide adequate social work services and respect the resident's rights resulted in involuntary seclusion and a deficiency in care.
Penalty
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The facility failed to ensure that an LN maintained a valid, active nursing license while providing care. One LN’s license had lapsed, as confirmed through Nursys and the state board verification system, yet the LN continued working for an extended period. Interviews with administrative and nursing leadership revealed that HR was responsible for license verification and tracking expirations, but due to multiple HR staff turnovers, required checks of nursing licenses and the nurse aide registry had not been kept current, contrary to the facility’s own background screening policy.
The facility failed to ensure that a nurse employed in a supervisory RN role held an active, recognized RN license consistent with state requirements. A nurse with a Virginia compact RN license, later suspended, was working while the Maryland Board of Nursing did not recognize the license due to graduation from a non-approved program. The nurse also held a Maryland LPN license and was reportedly changed from an RN to an LPN supervisor, but facility HR could not provide documentation of when this change occurred or when the RN license was forfeited. Review of the nurse’s education and licensure history showed the school attended was removed from the state’s approved list for LPN programs before the LPN license was issued.
A facility allowed an LVN to work 14 shifts with an expired nursing license, contrary to its own job description requiring a current, active license. The LVN reported believing the license was still active and was unaware it had expired until it was renewed 22 days after the expiration. A review of state licensing records confirmed the license had gone delinquent and inactive due to failure to renew, and the DON acknowledged that the facility’s requirement for an active license was not followed, potentially affecting 59 highly vulnerable residents.
A CNA who had completed an LPN program but had not yet passed boards or obtained an LPN license was assigned a group of residents and independently performed licensed nurse duties, including accessing the med cart and med room, handling Schedule II controlled substances, and administering medications to several cognitively intact residents without an overseeing nurse. Video footage, resident interviews, and staff statements confirmed that this staff member was functioning as an LPN under a "license pending" designation that did not meet Illinois Nurse Practice Act requirements, and the facility’s own job description required current LPN or RN licensure for charge nurse duties.
An LPN worked on multiple shifts while their nursing license was under suspension, and the facility did not prevent this, affecting all residents present on those days. Facility records showed that the LPN’s license was suspended according to the state licensing agency, yet timesheets confirmed the LPN worked during the suspension period while the census reflected dozens of residents in the building. Human Resources later stated the LPN had not disclosed the suspension and acknowledged that nurses should not work when their licenses are suspended, consistent with state licensing guidance prohibiting practice during a suspension.
A medication aide continued to pass medications with an expired certification after her credential lapsed, despite the facility’s requirement for a current Texas medication aide certification and a policy allowing only state-licensed or permitted staff to administer medications. Personnel and timecard records showed she worked and was observed passing medications after expiration, while registry checks reflected an expired status. The medication aide reported she was unaware her certification had expired and cited renewal payment issues, and the DON acknowledged tracking expiration dates, knowing the aide’s certification was expired, and continuing to check TULIP, which showed the certification as expired but active.
Failure to Ensure Licensed Nurse Maintained Active Nursing License
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed nurse maintained a valid, active nursing license while working. The facility had a census of 54 residents with a sample of 14 residents. Facility documentation dated 02/17/26 showed that an administrative staff member identified that one licensed nurse’s (LN H’s) nursing license had lapsed on 11/30/25. The facility verified the lapse through searches on the Nursys national nurse licensure database and the Kansas State Board of Nursing (KSBN) verification website. On 03/23/26, surveyors independently confirmed via Nursys and KSBN that LN H’s license had lapsed on 11/30/25, yet LN H continued to work at the facility with the lapsed license until 02/17/26. Administrative staff interviews revealed that human resources (HR) staff were responsible for verifying valid licenses and tracking expiration dates, but this process had not been maintained. An administrative nurse stated that recent turnover in HR staff contributed to nursing license and nurse aide registry checks not being kept up to date. Another administrative staff member reported that, after turnover of three different HR staff in the prior six months, she discovered that nursing license verifications had not been completed for some time. The facility’s Background Screening Investigations policy, dated November 2023, documented that for any licensed professional applying for a position involving direct resident contact, the respective licensing board is to be contacted to determine if any sanctions have been assessed against the applicant’s license.
Failure to Verify and Maintain Appropriate Nursing Licensure for Supervisory Role
Penalty
Summary
The deficiency involves the facility’s failure to ensure that employed nursing staff held active professional licenses consistent with state law and their job descriptions. A complaint alleged that a registered nurse was employed as an RN supervisor without an active license over a defined period. Review of this staff member’s personnel file showed that the individual held an RN license issued in Virginia with compact designation, but that license was suspended several months after issuance. The personnel file also listed Maryland as the staff member’s primary address. The Maryland Board of Nursing did not recognize this nurse’s license because the nurse graduated from a program that was not approved by the Board. Further review and interviews revealed that the nurse had an active Maryland LPN license and that her role at the facility was changed from RN to LPN supervisor, but the human resources representative could not recall or provide documentation of when this role change occurred. The HR representative stated that all RNs licensed from Florida had to either sit for the Maryland Board of Nursing exam or forfeit their license, and that this nurse forfeited the RN license, but HR could not provide documentation of when this occurred. In an interview, the nurse reported graduating from VMT Education Center and later sitting for the Maryland LPN boards, stating that she delayed testing because the school would not release her transcript due to unpaid tuition. Review of the Maryland Board of Nursing and VMT Education Center information showed that VMT was not recognized by the Board and had been removed from the approved list because it did not meet LPN qualifications, and that the nurse’s LPN license was issued months after the school’s removal from the approved list.
Unlicensed LVN Worked Multiple Shifts with Expired License
Penalty
Summary
The facility failed to ensure that a licensed vocational nurse (LVN) held a valid and current license while working, resulting in one LVN working with an expired license for multiple shifts. A letter from the Board of Vocational Nursing and Psychiatric Technicians showed that the LVN’s license became delinquent and inactive after it was not renewed, and it was not renewed again until 22 days after its expiration. Review of the facility’s Nursing Staff Assignment and Sign-in Sheets showed that this LVN worked 14 shifts during the period when the license was expired. In a telephone interview, the LVN stated she believed she was working with an active license and was unaware it had expired. During a concurrent interview and record review, the DON confirmed that the facility’s job description for LPN/LVN required a current, unencumbered, active license to practice in the state and acknowledged that this requirement was not followed. This failure had the potential to place 59 highly vulnerable residents at risk due to the LVN’s non-compliance with the legal requirement to practice nursing.
Unlicensed Staff Functioning as LPN and Independently Administering Medications
Penalty
Summary
The facility failed to ensure that staff functioning in licensed nursing roles held active licensure in accordance with state law. Video surveillance from the evening of 1/15/26 showed a CNA, identified as V5, removing keys to the medication cart and medication room from her pocket, opening the medication cart, popping medications into cups, taking the cups to resident rooms, opening the Schedule II controlled medication box, popping Schedule II medications into cups, signing out Schedule II medications in the count binder, and accessing the medication room without a nurse present. The licensed nurse schedule for that date documented that V5 was assigned a portion of the resident population, with no specific licensed nurse assigned to oversee her. Multiple cognitively intact residents confirmed that V5 independently administered their medications that evening. One resident (R1), with a BIMS score of 15 on the 1/9/26 MDS, stated that V5, whom he recognized as a former CNA who had “finished her courses” and was now “a nurse,” brought his medications on the evening of 1/15/26 and that he did not see another nurse with her. Another resident (R3), also with a BIMS score of 15 on the 12/13/25 MDS, reported that V5 brought her medications that night and that V5 had previously worked with another nurse but had not been doing so recently; she saw only CNAs when V5 brought her medications. A third resident (R4), with a BIMS score of 15 on the 11/25/25 MDS, similarly reported that the “new girl” (V5) gave him his medications and that he did not see her working with another nurse. Staff interviews and record review confirmed that V5 did not hold an active LPN license and did not meet Illinois requirements for “license-pending” practice. V5 stated she had completed an LPN program on 12/15/25 and was scheduled to sit for boards on 1/23/26, and that she was working as “LPN License Pending” and was supposed to be shadowing another nurse, not working independently. The DON (V2) stated that V5 was working as an LPN License Pending and that this status meant she did not yet have a license and should work under another nurse; V2 acknowledged V5 had not presented any documentation indicating she had passed the NCLEX. Another LPN (V7) reported that she had not been present when V5 administered medications on 1/15/26 and that V5 had been working independently as a licensed nurse for about a week, based on information that V5 was on a provisional license. The Illinois Nurse Practice Act excerpt in the report specifies that a license-pending LPN must have passed the licensure exam and presented official written notification of successful passage, among other criteria, and the facility’s job description for charge nurses requires maintaining current state nursing licensure, conditions that were not met in V5’s case.
LPN Worked While Nursing License Was Suspended
Penalty
Summary
The facility failed to ensure that nursing staff were working with an active nursing license, affecting all 91 residents in the facility. The facility data sheet dated 1/26/26 showed a current census of 91 residents. An undated copy of an LPN’s licensure summary from the state licensing agency showed that this nurse’s license was suspended from 12/15/25 through 12/24/25. Timesheet summaries printed on 1/26/26 showed that this LPN worked on 12/16/25, 12/19/25, and 12/23/25, all during the period of license suspension. Daily census sheets printed on 1/26/26 showed that the facility census was 67 on 12/16/25, 64 on 12/19/25, and 66 on 12/23/25, indicating residents were present while the LPN worked with a suspended license. During an interview on 1/26/26 at 10:20 AM, the Human Resources staff member stated that the LPN did not inform the facility of the temporary suspension and acknowledged that nurses should not work while their licenses are suspended. The state licensing agency’s frequently asked questions indicated that suspended licensees are prohibited from practice during the suspension term and may be subject to certain terms and conditions. No additional resident-specific medical histories or conditions were documented in relation to this deficiency.
Expired Medication Aide Certification Not Identified Before Medication Administration
Penalty
Summary
The facility failed to ensure that a medication aide had a current and valid medication aide certification before allowing her to administer medications. Personnel records showed that the medication aide was hired and that her medication aide certification expired on a specific date, yet timecard records indicated she continued working from the date of expiration through a later date. An observation documented that she was actively passing medications from the 100–400 medication cart during this period. Review of the Texas Nurse Aide Registry/Electronic Monitoring Registry showed the facility had checked the registry and that her certificate was listed as expired. The facility’s job description for a certified medication aide required a current medication administration certification from Texas, and the facility’s medication administration policy stated that only persons licensed or permitted by the state may prepare, administer, and document medications. In an interview, the medication aide stated she had been working at the facility off and on since 2015 and that her certification had been expired since December due to issues with her renewal payment. She reported that when she checked the TULIP database it showed she was still active with no new date, and she stated she did not know her certification had expired. She also stated that it was the DON’s responsibility to ensure her certification was current, although usually it was the staff member’s responsibility. In a separate interview, the DON stated she maintained a list of all medication aide certificate expiration dates and acknowledged that the medication aide’s certification had expired and that the aide continued to work while expired. The DON reported that during this time she kept checking TULIP, which showed the certification as expired but active, and acknowledged understanding the risk to residents of having a medication aide pass medications with an expired certification.
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