Deadly neglect claims trigger Ohio Arbors fines, lawsuits

A family lawsuit says a man died after weeks of a pressure ulcer that exposed his raw bone—an injury described as highly preventable but left untreated through multiple shifts at the Arbors at Sylvania. Across Ohio, lawsuits and federal and state inspections i

On an afternoon in September 2024. a man’s injuries should have been a routine check—something staff could have caught early and prevented. Instead. his family says he spent the kind of time nursing home neglect is built on: left in the same position. shift after shift. as a pressure ulcer slowly tore open skin over his tailbone until infection killed him.

In a lawsuit filed late last year. the family of Sam Frank Ray alleges that at the Arbors at Sylvania in Toledo. staff failed to reposition him and failed to take him to the toilet through 33 separate eight-hour shifts in September 2024. The suit says staff directed him to use adult diapers and wait to be changed. increasing his risk of infection as the ulcer worsened.

Michael Hill, a lawyer representing Ray’s family, said the family did not know anything was wrong until Ray was hospitalized as the infection spiraled.

“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.”

Pressure ulcers are considered highly preventable injuries. They can be avoided by repositioning an immobilized person once every two hours, and they can turn lethal if they’re allowed to progress.

Ray’s lawsuit argues that the same pattern led to another death in the Arbors chain. It points to Lucy Garcia. a patient at the Arbors at Oregon. a nearby nursing home also in the same company chain. A lawsuit filed by Garcia’s estate says she died in July 2024 after an infected bedsore developed into a fatal infection.

Garcia’s estate lawsuit alleges that tissue on her backside down to her bone had died off, including muscle. It says the open bedsore was exposed to Garcia’s own feces and urine from the Arbors at Oregon while she was placed in soiled adult diapers. and that the wound was infected with bacteria causing sepsis.

Garcia’s estate dropped the lawsuit against the Arbors at Oregon with prejudice, which means she cannot make the same claim again. Neither side confirmed the reason.

More than 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 operators pare staffing down to bare minimums—leaving residents vulnerable 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 paint a picture of care that sometimes 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 faulted three Arbors facilities in Ohio for contributing to the death of three patients via different sorts of medical errors.

And those complaints are only part of the broader record of incidents 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. and cases of residents going missing for days.

Administrators at several Arbors facilities named in a review 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 did not respond to written questions.

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

Penalties that don’t always land where the public expects them to

Regulators’ accountability, however, is uneven.

Control of the facilities is divided among different operating companies for each facility. related entities that own the land where the nursing homes sit. and Prestige Healthcare. The Ohio Department of Health considers violations on a one-by-one basis and does not consider that facilities are part 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—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 when facilities agree not to contest the penalty.

The fines are a small sum compared with facility revenue. Data provided by the Ohio Department of Medicaid shows Medicaid paid Arbors facilities a total of $233 million in revenue over the past three calendar years. That sum does not include payments from private insurers.

ODH spokesperson Ken Gordon added that the department can withhold future Medicaid reimbursement payments if facilities fail to remediate 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.

At the Arbors at Milford. CMS said 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, and the facility received $6.8 million through Medicaid reimbursement revenue that year.

At the Arbors at Minerva, CMS described staff’s failure to notify a doctor before a patient’s downward spiral and death, in an inspection report. The incident is dated January 2025, and records as of mid-June did not reflect any fine. CMS declined to comment or answer written questions.

When cases end, what remains is the question of quality

Wrongful death lawsuits filed against the Arbors all allege negligence tied to thin staffing leading to falls and bedsores that caused patients’ deaths.

Along with Lucy Garcia, estates of now-deceased patients of at least two other Arbors facilities filed wrongful death lawsuits since January 2024 and ended with plaintiffs dropping their cases with prejudice, suggesting 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. who 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 those lawsuits.

The families’ allegations across the pending cases share key similarities. 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. Gary Wade Conner died after allegedly falling while staying at the Arbors at Oregon.

Those cases are pending and have not 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—often tied to preventable problems like bedsores or falls.

“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.”

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

Eadie pointed to research showing that more nursing home staffing tends to produce better health outcomes for patients. He also referenced a recent white paper from the National Bureau of Economic Research that. relying on more detailed data required by regulators in Illinois. accused nursing home industry operators of “tunneling profits” to related entities to understate earnings. The paper said those “hidden profits” would equal a 36% increase in a ratio that measures staffing hours per resident.

In one CMS-inspected incident, the stakes weren’t always deadly—but they were still dangerous

Some of the problems flagged in CMS inspections were nonfatal yet still injurious and troubling.

One example described in a CMS writeup involves a field trip for 13 residents at the Arbors at Pomeroy in Southeast Ohio to the Columbus Zoo in June 2025. The heat index crept up to 90 degrees, and residents spent a long six hours at the zoo. The report says some complained about the heat and the duration.

The day began to sour on the drive home. Residents were boarded onto a bus that hadn’t been cooled down. The report says they ate fast food on board with the doors open.

An inspector quoted the administrator stating 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.”

One resident began “restless. jerking on other people’s seats” before opening the emergency window on the bus. then became unresponsive. CMS said he was unconscious for about 15 minutes until an ambulance arrived. The inspector wrote that the resident 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.

Another resident found unresponsive had a temperature of 104 degrees and was treated for heat stroke. CMS’ inspection states that the resident said she went to the hospital but did not remember much about the day, and that she was unable to recall when she got too hot.

Inspectors said they didn’t make it home until midnight. A custodian interviewed by inspectors said she was told by her superiors to “only say nice things and not be negative.” The custodian wrote a statement for inspectors. but CMS says 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.

Another case described a discharge that left a family stranded in winter

In another incident described by CMS. Sherry Kemp Woodyard said she knew her husband—71-year-old veteran Walter Woodyard. who had dementia and post-traumatic stress disorder—had been through a tumultuous few months at the Arbors at Delaware. She said the period included aggressive behavior, police intervention, and a trip to a behavioral health facility to stabilize him.

But she said she did not know the facility administrator refused to take Walter Woodyard back after his last hospitalization. Instead, Kemp said the administrator tried to drop him off at Kemp’s home without advance notice.

Kemp said Kemp wasn’t home and that she could only communicate with her confused husband and the 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.”

Kemp said Woodyard was instead taken to Grady Hospital, which does not offer behavioral care. She said a social worker called her.

“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 arranged for Woodyard’s transfer to a Veterans Affairs facility near Dayton, where he now resides.

After the episode, Kemp filed a complaint with the Ohio Department of Health, providing a copy. Kemp said the complaint triggered an unannounced inspection. State officials substantiated Kemp’s allegations and cited the facility for failing to ensure the safe discharge of Woodyard.

The state also found other problems in the facility, including several residents’ rooms measuring between 54 and 60 degrees Fahrenheit.

Angela Fox, a survey administrator, wrote to Kemp earlier this year in response to the complaint. The letter said the 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.

The chain’s corporate structure complicates blame

Corporate structure is a major theme in how responsibility is assigned.

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. The paperwork suggests a maze of entities.

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, according to a review of facilities by Signal Statewide, is true of several Arbors facilities.

CMS data analyzed by ProPublica lists major investors in the Arbors chain as B&Y Healthcare S Corp, B&Y Trust, Cody Healthcare S Corp and Craig Flashner 2007 Trust. It also says Craig Flashner and B&Y Trust are affiliated with Medilodge, another chain of 50 nursing homes around Michigan.

Hill, the lawyer who has sued the company, said the legal architecture has a purpose. He said each entity is built to limit tax liability or insulate owners from the financial risks of a lawsuit.

Hill said Arbors is probably not much better or worse than other major nursing home chains, and he said he has several pending cases against an industry rival in central Ohio, alleging 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.”

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

Ohio nursing homes Arbors at Ohio pressure ulcers bedsores CMS inspections Medicaid reimbursement Prestige Healthcare wrongful death lawsuits staffing levels