Inadequate pain medication management is pervasive in nursing homes (NHs). Licensed practical nurses (LPNs) deliver the majority of licensed nursing care, but LPNs are neither trained nor licensed to provide comprehensive pain assessment and medication management. In this study, we describe how pain medication management occurs in NHs by exploring LPNs' management approaches, while considering scope-of-practice differences between RNs and LPNs. Using comparative case studies of 10 NHs in North Carolina and Minnesota, we found practice variations in pain detection, assessment, and medication administration. Differences clustered in three areas: (a) the extent to which RNs and LPNs connected formally and informally to provide pain care, (b) the degree to which RNs and LPNs were considered interchangeable with one another, and (c) the RN-to-LPN ratio. Results highlight quality issues and suggest ways to improve pain medication management in NHs.