Nursing Home Neglect and Kansas's Surveyor Shortage
Libby Hastings • November 25, 2025
A recent KAKE News report
highlights how Kansas’s severe shortage of state nursing home inspectors is putting residents at serious risk. Families say long delays in inspections allow neglect to continue unchecked, sometimes with devastating consequences.
One of the most troubling stories comes from Jennifer Hernandez, whose aunt lived at Santa Marta in Olathe. Santa Marta advertises itself as "Luxury Senior Living in Johnson County, KS". A camera Hernandez installed in her aunt’s room recorded her aunt lying on the floor after falling out of bed. Nearly an hour passed before anyone checked on her. In the video, you can see her aunt struggling to get up on her own. Hernandez placed the camera because she was already worried about her aunt’s care.
Sadly, the fall wasn’t the only issue. Her aunt was also found in dirty clothes, had unexplained bruising, and developed an eye infection. Hernandez repeatedly begged the facility to follow her aunt’s care plan, but she was ignored or dismissed.
The family turned to the Long-Term Care Ombudsman’s Office, which can request an investigation by the Kansas Department for Aging and Disability Services (KDADS) state surveyors at the resident's request. These investigations can lead to fines, penalties, or corrective action. In Kansas, complaint investigations can take more than a year to start.
This is especially alarming because surveyors are one of the only independent sources of information the public has about nursing home quality. Their reports are often the only transparent, verifiable records families can rely on when choosing a facility. Surveyors are also one of the few entities with the authority to hold nursing homes accountable when care breaks down.
And Kansas is falling far behind. The state has 303 federally certified nursing facilities, which must be inspected at least every 15.9 months, with a national average of 12 months. Kansas is currently averaging 19.9 months between these mandatory inspections.
In Hernandez’s case, an ombudsman even emailed KDADS, warning that staff had tampered with the camera and that the resident was at severe risk. A state inspector never came. Her aunt later fell again, broke her pelvis, and died days later in severe pain.
While the state’s inspection delays are a major part of the problem, the facilities themselves also bear responsibility. Too often, homes put profits over people, cutting corners on staffing, training, and basic care. But it becomes even harder to push for stronger regulations when facilities aren’t being held accountable for meeting the baseline requirements already in place. When the “ceiling” of what a facility does is the bare minimum required by federal and state governments, residents are the ones who suffer.
Kansas’s inspection workforce is stretched far too thin to enforce even the most basic standards. In July, KDADS had 51 surveyor positions — 28 of them empty. The agency later reduced the total positions to 36 and raised salaries, but still has 13 vacancies. That leaves just 23 surveyors responsible for inspecting and investigating more than 300 nursing homes statewide.
Families, advocates, and ombudsmen agree: until Kansas fully staffs and supports its survey team, neglect will go unnoticed, problems will go uncorrected, and residents will remain in danger.
On March 19, 2026, a Washington Post article highlighted a recent Office of Inspector General for the Department of Health and Human Services investigation that brought renewed national attention to a troubling reality inside America’s nursing homes: powerful antipsychotic drugs are being used not as treatment, but as control. The report found that some facilities are misdiagnosing residents with schizophrenia to justify prescribing antipsychotic medications. These drugs are often not approved for people with dementia and carry serious risks, including falls, strokes, and even death. In many cases, these medications are used to manage behaviors that are not dangerous, such as calling out, resisting care, or expressing distress. The result is what advocates have long warned about: the use of chemical restraints to sedate residents for staff convenience. A National Problem Decades in the Making The misuse of antipsychotic drugs in long-term care has been documented for years. In April 2024, KABC highlighted this issue in our advocacy work, noting that hundreds of thousands of nursing home residents nationwide are given antipsychotic medications, often without appropriate clinical justification. These drugs carry an FDA “black box” warning for use in older adults with dementia due to an increased risk of death. Federal efforts over the past decade have aimed to reduce unnecessary use, yet as of early 2026, approximately 17% of long-stay nursing home residents in the United States are still receiving antipsychotic medications. At the same time, recent federal policy discussions in March 2026 have raised concerns among advocates that loosening reporting requirements could reverse progress made in reducing inappropriate use. Kansas Is Not Immune This issue hits close to home. In 2022, the Kansas Legislature’s Senior Care Task Force released a report to the 2023 Legislature identifying the administration of antipsychotic medications and protections against abuse and neglect as critical areas for reform. The Task Force emphasized that these medications could have serious and even fatal consequences for older adults, particularly when used inappropriately. Advocates in Kansas have reported that up to 26% of nursing home residents, and nearly 40% of those with dementia, have been prescribed antipsychotic medications in recent years, despite well-documented risks. While some facilities have made progress, reductions in use have stalled in recent years, raising concerns that systemic issues remain unresolved. Why It Happens At its core, the misuse of antipsychotic drugs is often a symptom of deeper systemic problems, many of which have been exacerbated since the COVID-19 pandemic. Experts and investigators point to: Chronic understaffing, intensified since 2020 Lack of training in dementia care Pressure to manage behaviors quickly Lack of person-centered practices in care Gaps in oversight and accountability Non-drug approaches, like personalized care, meaningful activities, and addressing unmet needs, are widely recognized as best practice. But they require time, staffing, and resources that many facilities continue to lack in 2026. When those supports are missing, medication restraint becomes the default. What Proper Care Should Look Like Clinical guidance has long been clear, and yet remains unchanged in 2026. Antipsychotic medications should be a last resort, used only when: Non-drug interventions have failed The resident poses a risk to themselves or others The benefits outweigh the serious risks Even then, they should be used cautiously, closely monitored, and regularly reevaluated. The Path Forward for Kansas Kansas has an opportunity, and an obligation, to act. Building on the 2022 Senior Care Task Force recommendations, advocates continue in 2025–2026 to call for: Expanded access to geriatric mental health specialists Stronger oversight and enforcement Improved training in dementia and person-centered care Greater transparency for residents and families Meaningful solutions to the ongoing staffing crisis At its heart, this is about dignity. Older adults in Kansas adult care homes deserve care that respects their humanity, not treatment that silences it.
Kansas Advocates for Better Care testified on FE waiver funding and supported bills on decision-making, dementia training, and memory care standards.