A pressure ulcer slowly tore open a hole in the skin over Sam Frank Ray’s tailbone, leaving his raw bone exposed over weeks to the infection that eventually killed him, according to a lawsuit his family filed late last year.

Bedsores, the byproduct of cut-off blood circulation when the body lies still in one position for too long, are considered highly preventable injuries. They can be avoided by repositioning an immobilized person once every two hours. But they can turn lethal if they’re allowed to progress.

Ray’s lawyers say he was left in the same position through 33 separate eight-hour shifts in September 2024. Staff failed to reposition him and take him to the toilet, instead directing him to use adult diapers and await being changed, likely increasing his infection risk, the lawsuit alleges.

Ray’s family didn’t know anything was wrong until he was hospitalized as the infection spiraled out of control, according to Michael Hill, a lawyer representing Ray’s family. The family’s lawsuit against the Arbors at Sylvania, in Toledo, is pending.

“It’s a catastrophic situation at that point. And he passes away,” Hill said in an interview. “It’s one of those things where he should have never gotten a bedsore to begin with.”

The lawsuit Hill filed notes Ray’s death is similar to that of a woman named Lucy Garcia, a patient at the Arbors at Oregon, a nearby nursing home in the same chain. A lawsuit filed by her estate said the same thing happened there, with an infected bedsore leading to her death in July 2024.

“All the tissue on her backside down to her bone had died off, including muscle,” Garcia’s lawsuit states. “The open bedsore was exposed to Lucy’s own feces and urine from Arbors at Oregon leaving her in soiled adult diapers, and the wound was infected with bacteria causing sepsis.”

Garcia’s estate dropped the lawsuit against the Arbors at Oregon with prejudice, which means she can’t make the same claim again and suggests the parties reached a private settlement. Neither side would confirm.

About a year after Garcia’s death, regulators cited the facility for bedsore problems and other shortfalls.

State inspectors have repeatedly flagged patient deaths and treatment errors at Arbors homes. And lawyers suing some of the facilities say the operators pare down staffing to bare minimums, leaving patients exposed to preventable falls, bedsores, infections and escapes.

Taken together, lawsuits and regulatory inspections of the 16 skilled nursing home facilities that comprise the Arbors at Ohio — places to stay for those who need less care than a hospital but more than most families can provide at home — paint a picture of care that at times ranges from poor to dangerous.

Since Jan. 1, 2024, at least 11 plaintiffs have filed lawsuits accusing Arbors facilities of negligence or medical errors that caused patients’ deaths, according to thousands of pages of court records analyzed by Signal Statewide.

In that same time frame, state inspectors have faulted three Arbors facilities in Ohio for contributing to the death of three patients via different sorts of medical errors.

Documented incidents at some Arbors nursing homes, recorded by state health officials on behalf of the federal Centers for Medicare and Medicaid Services, include a summer zoo trip that led to multiple heat-related hospitalizations, a forgotten ventilator application that nearly killed a patient, instances of residents going missing for days, and others, according to a review of hundreds of pages of nursing home inspection reports.

Administrators at several Arbors facilities named in this report deferred comment to Prestige Healthcare, a Louisville management company that operates the chain. Bill Gray, a company spokesperson, declined to comment on a list of written questions. Attorneys representing the company in court didn’t respond to written questions.

“The company’s position is no comment,” Gray said.

Spotty Penalties from Regulators

Accountability from regulators is spotty, as control of the facilities is divided between unique operating companies for each facility, related entities that own the land the nursing homes sit on, and Prestige Healthcare.

The Ohio Department of Health considers violations on a one-by-one basis and does not consider that facilities are a member of a chain or larger system, a spokesperson said.

Over the most recent three-year period, CMS, the final arbiter for discipline of nursing homes, has fined Arbors facilities on 18 occasions for a total of more than $648,000, according to agency data as of mid-June. The Ohio Department of Health recommends that a facility be fined, but CMS sets the amounts. The final figure typically reflects a 35% reduction in exchange for facilities agreeing not to contest the penalty.

The fines comprise a small sum compared to facility revenue. Data provided by the Ohio Department of Medicaid shows Medicaid has paid Arbors facilities a total of $233 million in revenue over the past three calendar years. That sum doesn’t include payments from private insurers.

ODH spokesperson Ken Gordon added that the department can also withhold future Medicaid reimbursement payments if the facilities fail to remediate any shortcomings in 15- and 180-day windows.

“It is important to understand there is a wide range of enforcement actions, which are governed in part by the severity of the violations and also a facility’s past history,” Gordon said. “Fines are only one of those actions. The idea is to prompt swift action to correct the issue.”

CMS inspections state that poor care at three Arbors facilities — Milford, Stow and Minerva — contributed to patients’ deaths. Only one facility paid a fine: the Arbors at Milford, where CMS claims a nurse’s failure to notify staff physicians of a patient’s worsening diabetes attack contributed to the resident’s “untimely death.”

The facility paid a $35,000 fine in connection with the incident. That year, it received more than $6.2 million in revenue from Medicaid repayments.

At the Arbors at Stow, CMS blamed a patient’s “medication non-compliance” that caused her death on the facility’s staff. Regulators fined the facility $48,000 but suspended the payment — the facility received $6.8 million via Medicaid reimbursement revenue that year.

Staff’s failure at the Arbors at Minerva to notify a doctor before a patient’s downward spiral and death, as described by CMS, occurred in January 2025 according to an inspection report. Records as of mid-June do not reflect any fine in connection with that incident.

CMS declined to comment or answer written questions.

Lawsuits Allege Negligence

The wrongful death lawsuits identified by Signal Statewide filed against the Arbors all allege that thin staffing led to the falls and bedsores that caused patients’ deaths.

Along with Lucy Garcia, the estates of now-deceased patients of at least two other Arbors facilities have filed wrongful death lawsuits since January 2024 that have ended with plaintiffs dropping their cases with prejudice, suggesting a private settlement.

That includes Brenda McNeil, who died of a brain bleed caused by a fall that occurred two days after she checked in to the Arbors at Oregon.

It also includes the estate of Sharon Kay Abner, a 68-year-old West Virginia woman, which sued after a pressure ulcer devolved into sepsis and osteomyelitis, an infection of the bone. Her case was also dropped with prejudice, indicating a likely private settlement. The pattern of lawsuits ending in apparent settlements, combined with ongoing regulatory citations, suggests the facilities’ legal and compliance challenges are far from resolved.