The Human Cost of Lax Oversight in Nursing Homes

A Call for Reform and Accountability

In the United States, over 1 million elderly and disabled individuals reside in nursing homes, placing their trust—and their lives—in the hands of long-term care facilities. Yet, as a recent report from NPR and WESA (“A lack of nursing home oversight is a problem for many states,” July 15, 2025) makes painfully clear, that trust is often betrayed due to chronic oversight failures, underfunding, and investigator shortages.

At KBD Attorneys, we’ve long advocated for stronger protections for nursing home residents. This recent report confirms what we’ve seen in case after case: when regulatory agencies are understaffed and slow to respond, vulnerable residents suffer—and too often, they die without dignity or justice.

A Tragic Case in Kansas: When Oversight Comes Too Late

The story of Joan Cody, a 94-year-old woman with dementia living in a Kansas memory care facility, illustrates the devastating human cost of inaction. Joan’s great-niece, Jennifer Hernandez, had installed a Ring camera in her room out of concern for her care. What she saw was horrifying: Joan fell out of bed and lay on the ground for more than an hour and a half before anyone responded. Just weeks later, she fell again and broke her pelvis. Despite multiple complaints to the Kansas Department for Aging and Disability Services (KDADS), no investigation was conducted before Joan passed away due to complications from the fall.

This wasn’t an isolated incident. Hernandez reported more than a dozen events to KDADS over months. Still, regulators failed to respond for six months—by which time it was too late to intervene or prevent further harm. This pattern of neglect reflects a broader systemic issue, not only in Kansas but across the country.

The National Crisis of Nursing Home Oversight

According to a 2023 report from the U.S. Senate Special Committee on Aging, state agencies responsible for inspecting and regulating nursing homes are in “crisis.” Staffing shortages, high turnover, stagnant federal funding, and low pay for investigators have left agencies struggling to fulfill their oversight responsibilities. Kansas is one of nine states where at least 50% of nursing home investigator positions are vacant.

To make matters worse, investigators in many states must be registered nurses (RNs), yet the starting salary for these roles often falls far below the average RN wage. In Kansas, for instance, nursing home investigators start at $60,000—nearly $20,000 less than the average RN salary in the state. With these pay disparities, it’s no surprise that qualified professionals are choosing more lucrative opportunities elsewhere.

The result? Complaints go uninvestigated, abuse and neglect go unpunished, and residents lose faith in a system meant to protect them. As Kansas long-term care ombudsman Haely Ordoyne noted, “We have seen people become more depressed… and kind of feel almost a sense of, you know, loss of the will to live because they feel like they don’t matter.”

The Legal Repercussions and Hope for Change

There may be legal consequences on the horizon for states that fail to fulfill their federal mandates. In Maryland, a class-action lawsuit brought by Justice in Aging and other legal advocacy groups alleges that the state’s failure to properly oversee nursing homes violates the rights of disabled residents under the Americans with Disabilities Act (ADA).

If the court sides with the plaintiffs, this case could set a precedent forcing other states to prioritize oversight—finally making nursing home regulation a true legal and moral imperative. At KBD Attorneys, we’re closely watching the outcome of this lawsuit and supporting efforts that give victims and their families a legal pathway to justice.

What KBD Attorneys Is Doing About It

KBD Attorneys is committed to exposing and litigating cases involving nursing home abuse, neglect, and wrongful death. We’ve seen firsthand how chronic understaffing and weak enforcement mechanisms allow facilities to cut corners, ignore safety protocols, and devalue the lives of their residents.

We’ve written extensively on these issues, including:

• The $4.5 million settlement involving six Michigan nursing homes over allegations of gross neglect.

• The $2.1 million Medicaid payback in New Jersey linked to staffing violations in multiple facilities.

• Tragic outcomes such as fatal infections, preventable falls, and untreated pressure ulcers—all common when oversight fails.

When oversight agencies don’t act, we do. Our attorneys help families pursue justice, holding nursing homes and their parent companies accountable in court. But litigation is not enough. The regulatory system must be reformed so that investigations happen promptly, enforcement has real teeth, and residents’ rights are actually protected.

A Nationwide Wake-Up Call

The death of Joan Cody should not be just another statistic. It should serve as a national wake-up call. Regulatory agencies must be properly funded and staffed. Inspector salaries must be competitive. And there must be accountability when oversight failures result in harm.

Nursing home residents are not invisible. They are beloved parents, grandparents, veterans, and neighbors. They deserve more than excuses and budget shortfalls—they deserve respect, safety, and dignity.

If You Suspect Neglect, Speak Out

If you suspect that your loved one is being mistreated in a nursing home or assisted living facility, don’t wait for regulators to act. Document the situation, report it to your state’s ombudsman office, and reach out to an experienced nursing home abuse attorney. At KBD Attorneys, we’re here to listen, investigate, and fight for justice when others won’t.

The time to act is now. For Joan Cody and the countless others like her.

Sources:

• Rose Conlon, “A lack of nursing home oversight is a problem for many states,” WESA/NPR, July 15, 2025. https://www.wesa.fm/2025-07-15/a-lack-of-nursing-home-oversight-is-a-problem-for-many-states