F0725

F

Persistent Weekend Understaffing Below Facility-Defined Minimums

Topeka, Kansas Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on weekends to meet residents’ basic and individual needs, as required by its own facility assessment and CMS PBJ staffing expectations. The facility had a census of 54 residents and a capacity of 60, with a facility assessment (last reviewed 03/19/26) that established minimum/optimal staffing levels for weekdays and weekends: for day and evening shifts, two licensed nurses, two CMAs, and four direct care staff (CNAs); and for night shift, two licensed nurses and two direct care staff. A review of the CMS PBJ CASPER 1705D report for FY 2026 Q1 showed the facility triggered for excessively low weekend staffing. Review of actual nursing schedules from 10/01/25 to 02/28/26 showed weekend staffing below the facility’s own minimum/optimal levels on all weekends in October, November, December, and February, and on two of four weekends in January.

Staff interviews confirmed that weekend staffing was expected to be the same as weekday staffing but was difficult to maintain. A licensed nurse stated that the typical goal for day and evening shifts was two nurses, four aides, and two medication aides, and for nights two nurses and two aides, and that weekends should be staffed the same way. Administrative nursing staff reported that an on-call schedule existed for weekends and that on-call staff and management were contacted to cover open slots, but also acknowledged that weekends had the most call-ins and were hard to cover. Administrative staff further confirmed that weekend staffing requirements were the same as during the week and were based on the facility assessment’s determination of the minimal number of staff needed to meet residents’ needs, yet the documented schedules showed repeated weekend shifts staffed below those minimums.