When Unlicensed Nursing Triggers a Two-Level Increase

On November 10, 2026, the Sixth Circuit posted United States v. Gallarzo, No. 26-1119. The court affirmed a 75-month prison sentence. It held that the district court did not clearly err by adding two offense levels under USSG §2B1.1(b)(16)(A), because Gallarzo worked as a nurse without a license and her duties included narcotics, intravenous lines, and catheter removals. The slip opinion is marked "not recommended for publication." The court's opinion list gives November 10, 2026, as the publication date. The PDF itself does not print a separate "filed" line. Read the decision (PDF).

What happened

Leticia Gallarzo pleaded guilty in the Western District of Michigan to two counts. One was aggravated identity theft, 18 U.S.C. § 1028A, tied to her work at a skilled nursing facility. The other was false statements relating to health care matters, 18 U.S.C. § 1035. A grand jury had returned six counts in September 2023. The government dismissed the other four: wire fraud, a second identity-theft count, a second false-statement count, and production of a false identification document.

The opinion describes an earlier federal case. In October 2017, Gallarzo was convicted in federal court of using falsified information to get work as a registered nurse at health-care facilities in Texas. In January 2023, the Department of Health and Human Services Office of Inspector General started an exclusion case because of that conviction. The office then prohibited her from taking part in all federal health-care programs for five years.

She was discharged from supervised release in the Western District of Michigan in August 2021. About a year later, she applied for nursing jobs in Michigan. She used the license number of a Michigan registered nurse, whom the opinion identifies only as L.T.C.P. One employer turned her down and notified the FBI. Another hired her. In August 2022 she started as a floor nurse at a skilled nursing home. She later became a unit manager and supervised other nurses. The facility later demoted her.

Staff told investigators that her duties included giving medication, including narcotics, starting intravenous lines, pulling peripherally inserted central catheter lines (a PICC line is a tube placed in a large vein), checking vital signs, and supervising nursing assistants. In June 2023, Michigan State Police could not find a valid Michigan nursing license for her. They did confirm L.T.C.P.'s license number.

While she was waiting to be sentenced, she absconded on bond until her arrest in California in September 2025. During that time, the opinion says, she obtained medical work in Illinois using a physician assistant's identity, then worked as a nurse in the Los Angeles area using a California nurse's license number. The increase the court reviewed was the one tied to the Michigan skilled-nursing work, not those later jobs.

The two-level increase

USSG §2B1.1 is the theft, property, and fraud guideline. The 2026 Guidelines Manual, effective November 1, 2026, still places this increase at §2B1.1(b)(16)(A). The text says that if the offense involved "the conscious or reckless risk of death or serious bodily injury," the court adds 2 levels. If the resulting offense level is less than level 14, the court raises it to level 14. The same numbered paragraph, subsection (b)(16)(B), is a different two-level increase, for possessing a dangerous weapon in connection with the offense. Gallarzo is about subsection (A).

The opinion does not say whether the level-14 floor changed Gallarzo's offense level. It does say the amended presentence report added two levels under §2B1.1(b)(16)(A) because "the offense involved the conscious or reckless risk of death or serious bodily injury." An offense level is the number that, with the criminal history category, produces the advisory range.

The court used the Guidelines' definition of serious bodily injury. Application Note 1(L) to USSG §1B1.1 defines it as "injury involving extreme physical pain or the protracted impairment of a function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation." That is the wording the opinion quotes.

Gallarzo objected in writing. She agreed she was not formally educated or licensed as a nurse. She argued that she had some medical training and years of on-the-job experience, and that this was enough to do the work safely. The opinion, describing the presentence report, says that from 1996 to 2000 she attended Belford University, which the report calls a fraudulent online school, and that she said she did not learn of that fraud until after she finished. It also says she reported medical-assistant training in 1998 and several semesters of medical-assistant study at Davenport University between 2004 and 2011, without a degree. Disputes like this belong in the response to the presentence report.

The district court overruled the objection. It said the risks in her conduct were "obvious" because she was "unqualified" and "untrained in many of the acts that she was performing as a nurse."

Why the finding stood

The Sixth Circuit reviews that finding for clear error. It affirms when the finding is "plausible in light of the record viewed in its entirety." The appeals court does not replace the district court's choice with its own when the record supports the finding that was made.

The panel, in an opinion by Judge Clay, pointed to the tasks. Giving narcotic medication, starting intravenous lines, and pulling PICC lines could cause death or serious bodily injury if done wrong. Gallarzo said her experience kept patients safe even without a nursing license or a formal nursing education. The court answered that nursing education and licensing exist so that people who do those tasks do them safely. It also pointed to her performance problems and the demotion. The record does not pin down whether those problems were about nursing skill or about something else, such as being late. The court held that it is still plausible to read a performance-based demotion of an unlicensed nurse as evidence that she could not do the work safely.

The increase does not require proof that a patient was hurt. Quoting its published decision in United States v. Wala, 166 F.4th 583, 604–06 (6th Cir. 2026), the court said the sentencing judge must find that the risk was "actual, not conjectural." Wala was decided and filed on February 4, 2026. It is a published opinion about counterfeit pills, not about nursing. Gallarzo uses that standard for these facts.

The 75-month term and the identity-theft count

Section 1035 punishes false statements in a health-care matter by a fine, or by imprisonment of not more than 5 years, or both. Section 1028A is different. A person who, during and in relation to a listed felony, knowingly uses another person's means of identification without lawful authority "shall ... be sentenced to a term of imprisonment of 2 years," in addition to the punishment for that felony. The statute says that term does not run at the same time as any other prison term, including the term for the felony during which the identification was used. It also says the court shall not shorten the related felony to make up for the identity-theft term. See § 1028A(a)(1), (b)(2), and (b)(3).

USSG §2B1.6 matches that statute. The guideline sentence for a § 1028A count is the term the statute requires, and that term runs consecutively to any other prison term. Chapters Three and Four of the Guidelines do not apply to a count sentenced under §2B1.6. A count under § 1028A also stays outside the combined offense level in the multiple-count rule. Our note on how §3D1.1 treats a § 1028A count covers that step. The risk increase is a specific offense characteristic of §2B1.1. It is part of the calculation for the false-statement count. It is not a substitute for the two-year identity-theft term.

The opinion states the prison term as 75 months. It does not divide that total between the two counts, and it does not state the advisory range. The guidelines have been advisory since United States v. Booker, 543 U.S. 220 (2005). This appeal decided the risk finding. The judgment, including the 75-month term, was affirmed.

Publication and where it applies

The first page says the opinion is not recommended for publication. Sixth Circuit Rule 32.1(a) permits citation of an unpublished opinion. Rule 32.1(b) says published panel opinions are binding on later panels. A published opinion is overruled only by the court sitting en banc. Wala is the published opinion Gallarzo uses for the risk standard. Gallarzo is the court's application of that standard to unlicensed nursing work in this record.

Who it affects

• A person sentenced in Kentucky, Michigan, Ohio, or Tennessee on a §2B1.1 count. The government can seek two levels under §2B1.1(b)(16)(A) when the offense involved a conscious or reckless risk of death or serious bodily injury. If the level would otherwise stay below 14, the guideline raises it to 14. Wala is the published Sixth Circuit opinion on what kind of risk qualifies. Gallarzo shows one set of facts the court treated as enough: unlicensed nursing that included narcotics, intravenous lines, and PICC-line removals.
• A person whose job required a license the person did not have. The opinion does not say that every unlicensed job takes the increase. The court looked at tasks that can cause death or serious injury if they are done wrong, and at whether training and a license exist so that those tasks are done safely. A written objection belongs in the response to the presentence report.
• A person charged with both a fraud count and aggravated identity theft. The risk increase is scored on the §2B1.1 count. The § 1028A count carries its own two-year term, and that term runs consecutive to the other prison term.
• A person sentenced outside the Sixth Circuit. The guideline text is national. Wala and Gallarzo are Sixth Circuit decisions. Other circuits apply their own cases to §2B1.1(b)(16)(A).