Unlicensed Personnel Performed LPN Duties Without Verification
Summary
The facility failed to ensure that personnel had the appropriate state licensure to provide care and services to residents. This deficiency was identified when S5, an unlicensed personnel, worked in the capacity of an LPN and performed nursing tasks without a Louisiana nursing license. The issue was discovered after S5 had been providing care and services to residents from November 20, 2024, until January 24, 2025, affecting 87 residents. The facility's Professional Licensure Verification Policy required that all employees with a professional license be verified upon hire and as required through the appropriate licensure board. However, S5's status was changed from a Certified Nurse Aide (CNA) to an LPN without verifying the necessary licensure. S5 signed the Licensed Staff Job Description, and the facility documentation confirmed that S5 provided care in the capacity of an LPN without having passed the National Council Licensure Examination for Practical Nurses (NCLEX-PN) in Louisiana. Interviews revealed that the Team Member Specialist (TMS) was responsible for verifying licensure but failed to do so before changing S5's status. The Director of Nursing (DON) allowed S5 to start training as an LPN without verifying licensure, and the Administrator directed the status change and allowed S5 to perform LPN duties without ensuring a valid license. This oversight led to an immediate jeopardy situation, as there was a likelihood of serious injury, harm, or death due to having unlicensed personnel providing nursing services.
Removal Plan
- Unlicensed Personnel was suspended and terminated.
- Administrator, DON, and TMS were in-serviced on licensure verification and reporting wrongdoing.
- Cognitive resident interviews were completed by Regional RN regarding any medication administration concerns or other nursing concerns.
- Full facility wide audit started on all nurses to ensure active license in place.
- In-service on reporting wrongdoing was completed by Administrator, DON, TMS, and staff.
- Audits were completed of resident's electronic medical records documentation who received care from Unlicensed Personnel while Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.
- TMS to verify licensure prior to nurse hired or role change if currently working. DON would be provided with a copy for double verification at the facility level.
- Corporate Compliance Officer to audit weekly for compliance for three months and annually.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An unlicensed OM was found acting as the facility administrator for more than two years, despite state records showing a different reported administrator and a posted NHA license holder who was not present. OM signed grievance logs and QAPI documents as administrator, introduced himself that way, and staff and a resident confirmed he was directing facility operations. State license review showed OM did not hold an active NHA license, while the NHAH stated OM should not have been calling himself the administrator.
An LPN-level nursing supervisor worked a shift after the nurse's license had expired, and the DON confirmed the nurse provided care without a valid license.
An LPN worked 33 days while his nursing license was suspended, and the facility did not know the license had been suspended because he did not notify anyone. State licensure review and confirmation from the OBN verified the LPN did not have an active license.
Failure to verify RN license upon hire for an as-needed RN. HR stated the license check was missed when the nurse was hired, and corporate later notified the facility that the individual did not have RN licensure. The personnel file contained no RN license, and the Administrator stated HR should have verified the license at hire.
Expired ADON Nursing License: The facility failed to ensure an ADON had a valid active LVN/LPN license. Record review showed the license had expired, and the renewal application was submitted late. The ADON stated she was unaware the license had lapsed and reported that she had still performed some nursing tasks, including medication administration and assessments, during the inactive licensure period. The DON and ADM were not aware of the expired license, and no licensure or credentialing policy was provided.
An LVN worked with an expired license after the facility failed to properly verify her credential status. The DON was unaware of the expired license, and the Administrator said the issue was found during an audit of licensed nurses. HR stated license checks were done on hire and annually, but the report used did not fully show the expiration date. The LVN said she did not know her license had expired.
Unlicensed OM Functioned as Administrator
Penalty
Summary
The facility failed to ensure that the administrator who supervised and directed facility operations was licensed according to state regulation. Surveyors found that the unlicensed Operations Manager (OM) had been functioning in the administrator role for more than two years and five months, while the facility’s posted nursing home administrator license holder was not present at the facility. The post board near the nurses station identified a nursing home administrator license holder, but the OM was the person signing and presenting himself as the administrator. Record review showed that two facility financial reports submitted to the state agency for 12/31/23 and 12/31/24 listed OM as the administrator and did not list the Reported Administrator (RA). State agency database review showed RA was reported as the facility’s administrator from 3/2023 to 5/2025, while the state nursing home administrator license database showed OM did not have a nursing home administrator license. The facility screening log also listed OM as administrator, and OM’s business card identified him as Administrator. During interview, OM stated he was responsible for grievances, signed grievance logs as administrator, and said he started as administrator in 3/2023. Interviews with staff and residents confirmed OM was acting in the administrator role. The DON and ADON stated OM had been the administrator for almost three years since the operating organization purchased the facility. Resident 9, who had heart failure, kidney disease, and respiratory failure, had a BIMS score of 15 and was alert and oriented; Resident 9 stated OM was the administrator and that he spoke with OM frequently. The DON stated OM was the administrator at QAPI meetings, and monthly QAPI documents from 1/2025 through 6/2025 showed OM signed in as administrator. OM later stated the NHAH was the administrator of the building, while the NHAH stated they were the reported administrator from 4/2025 to 8/2025 and were unaware of OM acting as the facility administrator.
Unlicensed Nursing Supervisor Worked a Shift
Penalty
Summary
The facility did not ensure that one member of the nursing staff was appropriately licensed while providing care to residents. Review of facility documentation showed that Employee E3 worked as a nursing supervisor from 7:00 a.m. until 12:00 a.m. on one reviewed day, and further review showed that E3's nursing license had expired before that shift. An interview with the Director of Nursing confirmed that Employee E3 worked without a valid nursing license on that day.
LPN Worked With Suspended License
Penalty
Summary
The facility failed to ensure LPN #853 had a valid and active nursing license. Review of the State licensure database showed the LPN did not have an active license, and email correspondence from the Chief of Compliance at the Ohio Board of Nursing verified that the license had been suspended and remained suspended. The report states the suspension began on 11/20/25. Review of LPN #853’s time punches showed he worked 33 days while his nursing license was suspended, including multiple shifts from late November 2025 through March 2026. Interview with the Administrator and the Regional Director of Clinical Services confirmed the facility did not know the license was suspended because LPN #853 did not notify anyone of the suspension.
Failure to Verify RN License at Hire
Penalty
Summary
The facility failed to verify the license qualification of a registered professional nurse upon hire for 1 of 3 licensed professionals reviewed, identified as V4. V3, the Director of Human Resources, stated that V4 was hired in August 2025 as an as-needed staff nurse and that it was an oversight on her part not to properly verify V4's RN license at the time of hire. In March 2026, V3 and facility administration were notified by the corporate office that V4 did not have the license qualification as a registered nurse. V1, the Administrator, stated that V3 should have ensured the nursing license was checked and verified upon hire. Review of V4's personnel record showed no RN license on file, and the health care worker registry dated 8/13/25 listed work eligibility as eligible.
Expired ADON Nursing License
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 4 staff reviewed, specifically the ADON. Record review showed the ADON had been employed at the facility since [DATE], and TBON license verification showed the ADON’s LVN/LPN license had an expiration date of [DATE]. The license renewal application receipt showed the ADON submitted a renewal application with the required late fee on [DATE]. During interview, the ADON stated she was notified by the facility that her license had expired and said she had not realized she was practicing with an expired license. She stated she rarely performed bedside nursing tasks and mostly did administrative work, but acknowledged that during the inactive licensure period she had administered medications and completed assessments on two to three occasions when nurses were not available. The DON stated she was not aware the ADON’s license had expired, and the ADM stated the ADON had not notified him about the delinquent license. The facility did not provide any policies related to licensure and credentialing staff.
Expired LVN License Not Identified
Penalty
Summary
The facility failed to ensure that one of six licensed staff reviewed, LVN B, maintained an active nurse license in accordance with state law. Record review showed LVN B was hired at the facility and that a Texas Board of Nursing verification checked by the facility showed her license had expired. A daily staffing assignment/sign-in log also showed LVN B worked on a day after the license expiration was identified in the record review. During interviews, the DON said she was not aware LVN B had an expired nurse license. The Administrator said she learned of the expired license during an audit of licensed nurses and stated LVN B was immediately removed from the schedule. HR said license checks were done on hire and annually, but the last check of licensed staff was completed in [DATE] and LVN B's expiration was missed because the report was not fully reviewed to see the expiration date. LVN B said she did not know her license had expired and stated she had last renewed it in [DATE]. The facility policy on credentialing nursing service personnel required staff who provide resident care or treatment within the scope of their license or certification to present verification of such license.
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