LPN D started employment in June 2025 as a graduate practical nurse after completing nursing school but continued working as a licensed nurse through early November using only an Illinois license obtained in late October. The worker resigned November 5 after state inspectors began asking questions.
"I passed the licensure examination a couple weeks ago and started working as an LPN at the facility right after that," LPN D told inspectors November 5. The worker had been providing care to residents with surgically created airways, administering tube feedings, giving insulin medications, and treating wounds.
LPN D was "rarely monitored or paired with an experienced nurse," according to the inspection report.
Missouri regulations allow graduate practical nurses to work for a maximum of 90 days after graduation while awaiting licensure. LPN D graduated from nursing school June 16 and started work June 25, meaning the 90-day window expired in mid-September.
Records show LPN D worked scheduled shifts October 5-7, October 10, October 14, October 22, October 24-26, October 29-31, and November 3-4. The worker was listed on schedules as both a graduate practical nurse and licensed practical nurse during this period.
The facility houses 170 residents.
National nursing license verification records showed LPN D held no Missouri license but was licensed in Illinois with an original issue date of October 29. The worker had been functioning as a fully licensed nurse for at least a week before obtaining any state license.
Interim Director of Nursing told inspectors November 6 that graduate practical nurses "were expected to work with another nurse at all times" with "oversight from a licensed nurse every day they work." The nursing director said human resources was responsible for checking employee credentials and following up on graduate nurses' licensing status.
The nursing director and administrator both started employment November 3 and "were not made aware of the situation," according to the inspection report.
Administrator and Regional Director of Operations said during a November 6 interview they "were not aware that LPN D was not licensed in Missouri." They expected human resources staff to verify all employee credentials.
The regional director said graduate practical nurses "should be precepted or working with another nurse until officially licensed" and that human resources should track the 90-day deadline.
Regional human resources staff told inspectors November 7 that he was "not aware of LPN D's status." The facility had two human resources workers before he temporarily took over the position.
The regional HR representative said facility human resources should verify applicants' backgrounds and authorization to work in the state. He expected the facility to collect school transcripts, copies of nursing examination registration, and testing authorization with dates.
"A GPN can work until licensed or for 90 days after graduation, whichever comes first," the regional HR staff member told inspectors.
LPN D's employee file contained a certificate showing completion of practical nursing education on June 16, 2025, and documentation of full-time employment as a graduate practical nurse starting June 25.
The worker had been caring for some of the facility's most medically complex residents. Tracheostomy patients require specialized airway management, and insulin administration demands precise dosing knowledge to prevent dangerous blood sugar fluctuations.
Multiple facility officials pointed to human resources as responsible for tracking licensing requirements, but the temporary regional HR representative acknowledged being unaware of the unlicensed worker's status until inspectors raised questions.
The facility's scheduling records showed LPN D working regularly through early November, more than a month past the September deadline when graduate nurse privileges should have expired.
LPN D resigned the same day state inspectors interviewed the worker about licensing status, ending a four-and-a-half-month period of unlicensed practice that spanned both graduate nurse and purported licensed nurse roles.
State inspectors found the violation had "potential to affect all residents" at the 170-bed facility, though they classified the harm level as minimal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Sophia Health & Rehabilitation Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
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