F0839

F

Unlicensed Staff Functioning as LPN and Independently Administering Medications

Metropolis, Illinois Survey Completed on 01-27-2026

Penalty

No penalty information released

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.