Two weeks before Joan Cody died, a Kansas employee urged state regulators to investigate alleged abuse and neglect at her northeast Kansas memory care facility.
“I don’t normally reach out unless I believe (state) intervention is necessary, but I must bring a serious situation to your attention,” wrote Hector Rodriguez, a long-term care ombudsman, in a Jan. 12 email.
Cody, a 94-year-old Kansas Citian, had dementia. For the past three months, Rodriguez had helped her family raise alarms about her care at Santa Marta in Olathe, first with facility administrators and then with state regulators.
But despite numerous calls to the Kansas Department for Aging and Disability Services and two formal complaints, officials had not sent anyone to investigate.
Rodriguez’s January email described alleged harassment from the facility’s wellness director, retaliatory withholding of pain medication and staff tampering with a camera that Cody’s family installed in her room as their concerns mounted.
More importantly, he wrote, Cody was repeatedly falling, most recently resulting in a broken pelvis that went unnoticed by staff until shift changeover.
“From both the (family’s) and my perspective as a long-term care ombudsman, the resident is at serious risk,” Rodriguez wrote in his email to Dawne Altis, the KDADS assistant commissioner who manages nursing home surveyors. “I know your team is very busy, but I believe this matter requires immediate attention.”
Altis never replied to the email, according to the ombudsman office. Fifteen days later, Cody died. A coroner attributed her death to complications from a fall.
“She didn’t have to suffer like this,” said Jennifer Hernandez, Cody’s great-niece. “It could have been avoided.”
Nearly five months after Cody’s death, Hernandez said she still has not received an update from KDADS on the complaints she filed.
Elder care advocates say Cody’s case reflects chronic failures by Kansas regulators to investigate complaints of nursing home abuse and neglect in a timely manner, putting vulnerable residents at risk.
In some cases, residents die waiting for help.
“Our office has seen times where a resident has passed before KDADS is able to go out and investigate,” said Haely Ordoyne, the lead Kansas long-term care ombudsman and Rodriguez’s supervisor. The ombudsman office is independent from KDADS, and advocates for residents.
The claims are supported by data indicating a critical shortage of nursing home investigators. According to numbers provided by KDADS in May and June, more than half of surveyor positions for nursing facilities and state-licensed adult care homes are currently vacant.
In recent years, the agency has received between 7,000 and 9,000 annual complaints of abuse, neglect and exploitation at federally and state-licensed adult care homes. A team of about 61 surveyors is supposed to investigate those claims — but only 29 of the positions are currently filled.
Spokespeople for KDADS did not make Altis or another agency representative available for an interview. They said over email that they could not provide information on Cody’s case because of confidentiality requirements.
In an email, KDADS communications director Cara Sloan-Ramos said the agency recognizes “the crucial role our surveyors play in ensuring the health and safety of residents in Kansas long-term care facilities by thoroughly and promptly investigating allegations of neglect and abuse.”
“We agree that an appropriate staffing level is essential to maintain the timeliness and thoroughness of these critical investigations,” she added. “Increased staffing would allow us to fulfill our oversight responsibilities more effectively and better protect vulnerable individuals in our state.”
Santa Marta administrators declined to discuss the allegations about Cody’s care for this story, citing patient privacy.
“We are sorry to hear of Ms. Hernandez’s concerns regarding the care of Ms. Joan Cody and extend our deepest sympathy during this difficult time,” Colleen Hollestelle, Santa Marta’s president and CEO, said in an email. “At Santa Marta, we are fully committed to providing high-quality care to each of our residents. Out of respect for patient privacy, and in compliance with federal regulations, we cannot discuss individual care. We take all concerns seriously and are reviewing this matter in accordance with our internal policies and applicable state regulations.”
Critical vacancies
Between 2003 and 2023, surveyor vacancy rates in Kansas swelled from 4% to 51%, according to a report from the U.S. Senate Special Committee on Aging — placing the state’s regulatory team among the most understaffed in the country.
“Too few survey staff create failures at all levels,” wrote Camille Russell, the state’s long-term care ombudsman in 2023, in a letter to congressional leaders, despite “significant effort on the part of individual survey staff in ever more difficult conditions.”
“Poor conditions in nursing homes are directly connected to insufficient enforcement capacity of survey, certification, and licensing entities,” she wrote.
For years, Russell and others charged with defending the rights of residents in long-term care facilities have repeatedly said, in interviews and legislative testimony, that Kansas does not have adequate resources to oversee nursing homes and respond to allegations of harm.
Little appears to have improved.
At an April 2025 Kansas legislative oversight meeting, Ordoyne, the current lead ombudsman, warned state lawmakers that a scarcity of surveyors had led to dangerous lapses in oversight capacity.
“If you’re paralyzed and your bed is malfunctioning, it’s going to take them at least two weeks to get out to investigate that,” she said.
She told lawmakers that her office frequently fields complaints about errors in medication distribution — such as nursing home staff giving someone medication intended for a different resident, or not distributing medication altogether.
Physical and verbal abuse from nursing home staff; injuries and death resulting from inadequate staffing; resident “dumping” — all are common complaints described in the ombudsman office’s 2024 annual report. But out of the thousands of complaints that ombudsmen assist with each year, only 58% are fully or partially resolved.
That’s because, while ombudsmen like Ordoyne and Rodriguez can help residents file formal complaints with KDADS and attempt to resolve issues between residents and nursing home staff, their power ends when facilities stop cooperating. Only KDADS surveyors have the jurisdiction to issue fines and penalties.
Ordoyne doesn’t think KDADS’ oversight failures are due to negligence, but instead a lack of resources. At the April meeting, she urged lawmakers to raise the agency’s budget so it could incentivize more people to work in those roles.
Still, in an interview, she said delayed investigations can cause profound harm to residents.
“We have seen people become more depressed about situations and feel almost a sense of a loss of the will to live,” she said. “They feel like they don’t matter.”
KDADS Secretary Laura Howard did not address staffing shortages or issues with investigation timelines in her testimony at the April meeting, and the agency declined a request to speak to her. In an email, Sloan-Ramos said KDADS supports Ordoyne’s recommendation to increase surveyor staff.
“We appreciate the ombudsman’s advocacy on this important issue and look forward to working in future legislative sessions to address these staffing needs,” Sloan-Ramos said.
Low wages may be partly to blame for the staffing issues. A current KDADS surveyor job posting lists an annual salary of $60,000 to $62,000 and a requirement that applicants be licensed registered nurses. The pay is well below what nurses can make in other jobs. Data from the Bureau of Labor Statistics shows that, last year, the average annual wage for registered nurses in Kansas was $79,430.
It’s particularly difficult for Kansas to hire nurses for below-market wages in an economy where they’re already in high demand. More than half of long-term care providers in Kansas say a limited pool of registered nurses is a primary obstacle for them in filling essential roles, according to a recent survey by LeadingAge Kansas, which represents nonprofit nursing facilities.
In an email, a KDADS spokesperson said the agency is considering options for raising pay so the jobs are competitive with other nursing positions.
“I felt powerless”
Cody’s home in South Kansas City, Missouri, is filled with Chiefs memorabilia and mementos from her life. During her career, she managed properties at the Country Club Plaza and worked for the Kansas City Board of Trade. In retirement, she volunteered with an animal therapy program at St. Joseph’s Hospital.
Now, Cody’s ashes rest in an urn on the mantlepiece.
Hernandez, who wears a necklace with Cody’s thumb print on it, said Cody was like a mother to her.
“She had this vibrant personality. She had so many friends,” Hernandez said. “She was always so generous and so kind and loving.”
During the two and a half years that Cody lived at Santa Marta, Hernandez repeatedly raised concerns with administrators about the care her aunt received, according to emails reviewed by the Kansas News Service.
She questioned why she would find Cody sitting in dirty clothes and bedsheets, and worried when Cody developed skin rashes and dental infections. A security camera that Hernandez installed showed a male resident entering Cody’s room unattended on multiple occasions.
Her largest concerns revolved around staff’s failure to prevent Cody from falling. Hernandez said staff would frequently neglect to attach foot pedals to Cody’s wheelchair, which made it easier for her to get out of the chair and fall. The problem was discussed frequently in text messages between Hernandez and Cody’s hospice team reviewed by the Kansas News Service, as well as a July 31, 2024, inspection report by state surveyors.
Video footage showed that staff didn’t consistently keep a fall mat at Cody’s bedside, increasing the likelihood that falls would result in injury.
By late last year, Hernandez was waking up throughout the night to check on her aunt through the camera.
But nothing prepared her for what she saw on Dec. 14, 2024. Cody fell out of bed — and laid there for more than two hours before staff checked on her, according to video footage and notes reviewed by the Kansas News Service.
With Rodriguez’s help, Hernandez began reporting the incidents to state regulators. It’s unclear how many times she contacted KDADS in the final months of Cody’s life. The agency said it cannot provide records of the complaints to her or the Kansas News Service. But within a two-month period, Hernandez recalls contacting the agency’s complaint hotline over a dozen times.
“I felt powerless,” she said. “I was watching her slip away from me.”
KDADS compiled her concerns into two formal complaints. But the agency still doesn’t appear to have looked into them.
Emails reviewed by the Kansas News Service show that when Hernandez attempted to get records of her complaints and any subsequent investigations in February, KDADS staff told her to submit an open records request with the agency’s freedom of information officer. When she did so, the officer told Hernandez that complaint information and any written findings are confidential and not subject to the Kansas Open Records Act.
“An outcome letter will be provided to the complainant(s) by the Survey, Certification, and Credentialing Commission (SCC) when it is available,” the officer said in an email.
Hernandez said she still has not received an outcome letter.
Missing urgency
Advocates for elderly and disabled people argue that Kansas officials are not always forthcoming about the extent of the state’s struggles to regulate nursing homes.
Dan Goodman, executive director of Kansas Advocates for Better Care, said a lack of transparency has created doubt about the urgency of the problem.
“There seems to be a sense of hopelessness or helplessness in dealing with the issue,” Goodman said. “I just don’t hear any urgency out of (KDADS) or out of elected officials to say that we really need to deal with this.”
In written legislative testimony over the past few years, KDADS has repeatedly reported its surveyor shortages to lawmakers and requested budget increases to aid with hiring. But the issue is rarely highlighted in verbal remarks, and the requests are rarely granted.
Both Goodman and Ordoyne say the problem appears to have taken a back seat to other priorities.
“Everybody knows it’s an issue, but there’s not anything being done about it,” Ordoyne said.
Complaint triage
Nearly 15,000 Kansans live in federally licensed nursing homes, and thousands more live in state-licensed adult care facilities. Residents, family members and staff can report suspected abuse, neglect or exploitation to KDADS through a phone hotline or by email.
Sloan-Ramos, the KDADS spokesperson, said the average time it takes the agency to investigate a complaint depends on its severity and urgency. She said KDADS’ process for triaging complaints is based on federal guidelines, which include maximum timelines for state regulators:
- Complaints alleging immediate jeopardy — where a facility’s noncompliance with state or federal requirements has caused or is likely to cause serious harm, injury, impairment, or death — must be investigated within three business days of receipt.
- When immediate jeopardy is not present, states are supposed to categorize complaints as high, medium and low priority. High-priority complaints concern harm that negatively impacts a person’s physical or psychosocial status, and must be investigated within 18 business days.
- Medium-priority complaints concern issues that haven’t resulted in physical or psychosocial harm yet, but that could cause “more than minimal harm” in the future. They must be investigated within 45 calendar days.
- Low-priority complaints concern situations of “no actual harm with a potential for minimal harm” in the future, and have no federally mandated complaint timeline. State regulators have the option of initiating a complaint survey or tracking these complaints for potential focus at the facility’s next annual survey.
In practice, relying on annual inspections for addressing low-priority complaints means some residents can wait as long as two years for assistance. Regulators are supposed to conduct routine inspections of adult care homes every 9 to 15 months, but further delays sometimes occur.
Delayed investigations can extend the amount of time residents must endure abuse or dangerous conditions. They also make it harder for regulators to substantiate complaints, reducing the likelihood that facilities will be held accountable. Misplaced records, staff turnover and resident deaths can make it difficult for investigators to find evidence of an incident months or years afterward.
KDADS did not respond to questions about whether severity and urgency determinations are communicated to people who file complaints, or whether those determinations have an appeals process. The agency declined to provide information on how Hernandez’s complaints about Cody’s care were classified and said complaint severity and triage information is confidential.
Because Hernandez filed her complaints between November 2024 and January 2025 and hasn’t received an outcome letter yet, it appears likely that her complaints were classified as low-priority. If true, they would likely be addressed during the facility’s next annual inspection.
Records show KDADS last conducted an annual survey of Santa Marta in July 2024. That means, if the facility’s next annual inspection is not delayed, it could be October before regulators respond to the incidents that Hernandez says led to her aunt’s death in January.
Nationwide problems
Kansas has one of the highest rates of nursing home surveyor vacancies in the U.S., but experts say problems with inadequate oversight are not unique to the state. Health care workforce shortages have contributed to similar issues around the country. In the last year alone, reporting has documented high surveyor vacancies in New York, North Carolina, Virginia and Oregon.
“It’s pretty consistent across all the states, struggles with being able to locate qualified survey staff and retain them,” said Marilyn Rantz, professor emerita at the University of Missouri Sinclair School of Nursing.
High death rates among nursing home residents and poor infection control during the COVID-19 pandemic exposed the deadly ramifications of a chronically understaffed industry. But Nina Kohn, a law professor at Syracuse University, said that in the years since, most states have failed to enforce regulations that would prevent similar crises from happening in the future.
“The fact that we’re continuing to see inadequate oversight — even after we learned, amid the pandemic, how dangerous that could be — suggests that nursing home residents really aren’t a priority for our public officials,” she said.
And because around three-fourths of nursing home residents pay for their care primarily through Medicaid and Medicare, a lax regulatory environment can also enable fraud and misuse of tax dollars.
“The state is paying for incredibly vulnerable people to be in institutions, and we don’t have the most basic oversight of whether those institutions are caring for people in a way that is safe,” Kohn said. “We also don’t have the oversight needed to ensure that taxpayer money is being used to provide the care the taxpayers are paying for.”
After a yearlong Congressional investigation, the 2023 U.S. Senate report on the matter concluded that state agencies responsible for oversight “are in crisis,” and noted that officials from the Obama, Trump and Biden administrations had flagged the issue in budget requests.
States have a federal mandate to regulate nursing homes that receive Medicare and Medicaid funding. But Kohn and other advocates said they’re rarely held accountable for failing to fulfill their oversight responsibilities.
“We often treat nursing home residents as expendable,” Kohn said. “These are people who are typically quite old and quite disabled, and they’re in institutions where they’re not visible to the general public. And it creates a situation that’s potentially really dangerous.”
A first-of-its-kind lawsuit is currently testing the limits of states’ accountability. The class action suit, filed on behalf of thousands of disabled Maryland nursing home residents, alleges oversight failures by state regulators — including a backlog of uninvestigated complaints and delayed annual inspections — violate residents’ rights under the Americans with Disabilities Act. In April, a federal judge rejected Maryland’s attempt to have the lawsuit dismissed, an early win for residents.
If the Maryland residents prevail, it would be one of the first instances of a state facing consequences for failing to adequately regulate its nursing homes. Experts said it could motivate other states, like Kansas, to invest in improving oversight.
“The system let them down”
By most standards, the facility where Cody died appears to perform relatively well.
Kansas hasn’t fined Santa Marta or suspended its Medicare payments over the last three years. The facility has a four out of five star rating based on a federal rubric that combines inspection reports, staffing numbers and other quality measures. In particular, its reported staffing ratio of 7.5 nurse hours per resident per day far exceeds state and national averages.
But advocates say those metrics — and Kansans’ ability to make informed decisions when choosing a facility to care for themselves or their family members — are meaningless without adequate oversight.
“The industry has demonstrated that it’s not capable or willing to police itself,” said Goodman, the Kansas Advocates for Better Care director.
“Families are left jaded,” he added. “The facility let them down. The system let them down. The public officials let them down.”
Hernandez said she hopes speaking out about her aunt’s experience helps motivate Kansas officials to prioritize residents’ dignity by improving the state’s oversight capacity.
“I want to change how I remember the end of her life,” she said, “and I want to make it so that this doesn’t happen to any other family.”
Rose Conlon reports on health for KMUW and the Kansas News Service. The Kansas News Service is a collaboration of KCUR, KMUW, Kansas Public Radio and High Plains Public Radio focused on health, the social determinants of health and their connection to public policy. Kansas News Service stories and photos may be republished by news media at no cost with proper attribution and a link to ksnewsservice.org.
