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 homes 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.

And that’s to say nothing of disturbing incidents at some Arbors nursing homes, documented by state health officials on behalf of the federal Centers for Medicare and Medicaid Services, including a summer zoo trip that led to multiple heat-related hospitalizations, a forgotten ventilator application that nearly killed a patient, instances of residents going missingfor 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 doesn’t 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, in January 2025, according to an inspection report. Records as of mid-June don’t reflect any fine.

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.

And it 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.

Lawyers for both sides declined comment on the final outcome of the lawsuits.

The claims from alleged victims of Arbors’ care are similar from case to case. The family of Philip Rice alleged he died from an infection caused by a pressure sore while residing at the Arbors at Marietta. The family of Nancy Altizer said she died following a fall and pressure sore while staying at the Arbors at Gallipolis. And Gary Wade Conner died after allegedly falling while staying at the Arbors at Oregon.

These cases are all pending and haven’t been ruled on by a court. Will Eadie, a Northeast Ohio attorney representing Conner’s family, declined to discuss a pending case but said he has filed “a fair number” of lawsuits against Arbors facilities.

He said the key indicator to gauge quality of care is staffing – a facility’s biggest source of overhead, and often the culprit behind preventable issues like bedsores or falls.

Arbors facilities average 2.9 out of 5 stars on staffing, according to CMS’ analysis of payroll data.

“Staffing is kind of the root of most nursing home problems,” Eadie said. “You’re really talking about nurses and aides who might want to do well, but they are burned out, overworked, or there’s a bad culture of it being OK to not have adequate care.”

Plenty of research backs up the idea. More nursing home staffing tends to produce better health outcomes for patients, studies show.

And a recent white paper from the National Bureau of Economic Research, relying on more detailed data required by regulators in Illinois, has accused nursing home industry operators of “tunneling profits” to related entities to understate their earnings. Those “hidden profits” would equate to a 36% increase in a ratio that measures staffing hours per resident.

A hellish trip to the zoo

Some of the problems flagged in the CMS inspections – which are carried out regularly or in response to complaints by the Ohio Department of Health – were nonfatal in nature but still injurious and troubling.

Case in point – a field trip for 13 residents that the Arbors at Pomeroy, in Southeast Ohio, organized to the Columbus Zoo in June 2025.

While the heat index crept up to 90 degrees, the residents spent a long six hours at the zoo. Some complained about the heat and duration. According to the report, the day started to sour on the drive home, where residents were boarded onto a bus that hadn’t been cooled down, where they ate fast food on board with the doors open.

“The Administrator stated the van was really hot inside (all the doors and windows were open at that time) and she did not know why it was so hot,” a state inspector wrote.

One resident started to get “restless, jerking on other people’s seats” before opening the emergency window on the bus. He then became unresponsive, according to CMS’ writeup of the incident. He was unconscious for about 15 minutes until an ambulance arrived.

“(He) had a temperature of 105.7 degrees Fahrenheit and was transferred to the hospital where he was placed on a ventilator and treated for heat stroke,” an inspector wrote.

Another resident found unresponsive had a temperature of 104 degrees and was treated for heat stroke.

“(She) stated she went to the hospital but stated she did not remember much about the day,” the CMS inspection states. “The resident did not recall eating a sack lunch at the zoo or eating at a fast-food restaurant on the way home. The resident was unable to recall when she got too hot.”

They didn’t make it home until midnight. A custodian who inspectors summoned for an interview said she was told by her superiors to “only say nice things and not be negative,” according to CMS. She wrote out a statement for inspectors, but it was re-written by the director of nursing “due to the things she had written.”

CMS fined the facility $37,551 in connection with its inspection, according to data tracked by investigative journalism outlet ProPublica.

An abrupt discharge

Sherry Kemp Woodyard knew her husband, a 71-year-old veteran wrestling with dementia and post-traumatic stress disorder, had been through a tumultuous few months at the Arbors at Delaware. This at times included aggressive behavior, police intervention and a trip to a behavioral health facility to stabilize him.

But she didn’t know that the facility administrator refused to take Walter Woodyard back to the facility after his last hospitalization, instead attempting to drop him off at Kemp’s home. The administrator didn’t provide any advance notice, she said.

Kemp wasn’t home, and could only communicate with her confused husband and the facility administrator by phone and Ring doorbell camera as they stood outside in an unusually bitter February chill.

“The administrator is saying ‘I’m not taking him back, I’m leaving him on the porch,’” Kemp said in an interview. “It’s 12 degrees there.”

Instead, Woodyard was taken to Grady Hospital, which doesn’t offer behavioral care. A social worker called Kemp.

“She says, ‘I have your husband.’ And the words she used to me was that he was ‘dumped’ here,” Kemp said. “And saying that word, I was like, ‘What do you mean he was dumped here?’”

Kemp eventually arranged for her husband’s transfer to a Veterans Affairs facility near Dayton, where he now resides.

An outraged Kemp soon filed a complaint with the Ohio Department of Health, of which she provided a copy. The complaint sparked an unannounced inspection of the facility.

The state officials substantiated Kemp’s allegations, citing the facility for failing to ensure the safe discharge of Woodyard.

Moreover, they found a spread of other problems in the facility. Several of the residents’ rooms there measured between 54 and 60 degrees Fahrenheit.

“Your complaint was completed in conjunction with additional surveys,” Angela Fox, a survey administrator, wrote to Kemp earlier this year in response to her complaint.

“Our investigation revealed Arbors at Delaware does not meet the requirements of the (Medicaid) program and was cited for violations of federal and/or state regulations where appropriate.”

What is the Arbors at Ohio?

The corporate structure of the chain of facilities makes it difficult to unspool the question of who’s responsible when something goes wrong.

Several Arbors facilities declined to comment about CMS findings but referred inquiries to “corporate” – a reference to Prestige Healthcare, a Louisville company, which declined comment.

Company paperwork points to a mazelike structure. For instance, Arbors at Delaware LLC lists as its agent the Delaware Opco LLC, whose business filings include the address of Prestige Healthcare.

In 2023, the nursing home’s land was purchased by a property holding company. This structure is true of several Arbors facilities reviewed by Signal Statewide.

CMS data, analyzed by the investigative news outlet ProPublica, list as major investors in the Arbors chain the B&Y Healthcare S Corp, B&Y Trust, Cody Healthcare S Corp and Craig Flashner 2007 Trust. And according to the same database, Craig Flashner and B&Y Trust are affiliated with Medilodge, another chain of 50 nursing homes around Michigan.

The legal architecture has a purpose, according to Hill, a lawyer who has sued the company. Every entity is either there to limit tax liability or insulate the owners from the financial risks of a lawsuit, he said.

Arbors, he said, probably isn’t much better or worse than other major nursing home chains. He noted his several pending cases against an industry rival in central Ohio, claiming the facility’s understaffing and neglect led to a man’s death.

“I think what you’re seeing is a representation of chains across Ohio, and really, across the country,” he said. “I don’t think there’s anything particularly abnormal, unfortunately, about the Arbors.”

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This story was originally published by Signal Ohio and distributed through a partnership with The Associated Press.

Jake Zuckerman/signal Ohio, The Associated Press