Mahoning Matters reported the sad and tragic death of Thomas Ward Sr. He was a resident of the Oasis Center for Rehabilitation and Healing nursing home for less than two months in 2018, but during that time developed an infestation of maggots between his nasal passages and throat, along with severe bed sores and other health complications that led to his death, according to a new lawsuit.

Ward was admitted to the facility to receive nursing care and rehabilitation following a stroke, according to the complaint. The neglect Ward suffered caused the development of an infected Stage 4 pressure injury.  Stage 4 is the most severe level indicating the wound is past muscle and exposing bone with visible signs of infection. Ward also suffered an infestation of maggots in his oral cavity and oropharynx, along with a urinary tract infection and “other health problems and infections that ultimately led to sepsis and septic shock.”

Ward was discharged the following October to two different hospitals before he began receiving palliative care from a hospice provider, according to the suit. He died about two weeks later, on Oct. 13, 2018.

Oasis, which currently has an overall “below average” rating of two stars on, has been a candidate for the state’s Special Focus Facilities list for six months, according to the most recent list released last month by the Centers for Medicare and Medicaid Services. The designation identifies nursing homes with the most health and safety citations, or which indicate a pattern of noncompliance with particular state standards.

According to the Nursing Home Compare website, Oasis has been cited by state inspectors for 58 health and safety deficiencies since December 2016 and fined more than $114,000, the most of any nursing home in Mahoning and Trumbull counties during those three years.

 More than 60,000 people die each year due to pressure injuries or bed sores, according to a journal entry found in the U.S. National Library of Medicine, which was last updated in September.

Unfortunately, despite awareness of the problem, the rates of pressure wounds remain high in long-term care facilities and nursing homes, where a lack of staff and optimal care is not always possible,” the entry states.

 Vivian Wright plans to seek justice against Heartland Health Care Center of Orange Park nursing home because staff neglected to treat her father’s pressure wounds and then tried to cover the smell with coffee grounds.  This is outrageous.  Vivian Wright’s father, Frank, entered Heartland Health Care Center in September 2019 after two strokes. Wright worked for the Department of Defense, as a boilermaker on the ships at Naval Station Mayport for more than 25 years.

She says that Frank has two bedsores, which are ulcers that form from pressure due to lying in a bed or sitting in a wheelchair for long periods of time, including one on his buttocks.  Bedsores typically begin as red areas that eventually turn purple. If left untreated, the bedsore can break open and become infected leading to sepsis and wrongful death.

One day, during a visit, she and her brother-in-law found piles of coffee grounds under his bed, First Coast News reported. The coffee grinds were used to cover the smell of an infected bedsore that staff had neglected. Coffee grounds contain nitrogen from caffeine, and the element helps to neutralize sulfur, which gives many unpleasant smells their stench. Staff used the coffee grounds to hide the odor of an infection from Frank’s bedsore on his buttocks.  Staff failed to make sure he had regular check-ups with his doctors and to take care of his wounds. lists Heartland’s quality of resident care as ‘below average’ and its health inspection rating as ‘much below average.’

When Krysten Schmidt visited her grandmother at Premier Genesee Center for Nursing and Rehabilitation nursing home, an aide quietly pulled her aside to share there were maggots on her grandmother’s foot.  Schmidt said that if it hadn’t been for the aide, she might never have known that maggots – fly larva that look like small worms – were infesting her grandmother’s leg wounds at Premier Genesee not only that day but also four days earlier.

Two nurses who responded to Schmidt’s demands for an explanation downplayed the maggots, the granddaughter said.

“My mother had just arrived for the visit and took off the shoe and sock and three or four maggots fell to the floor,” Schmidt said. “They proceeded to tell me the maggots were in her shoe and not her sock. I mean, does it really matter? Are maggots supposed to be anywhere? They were trying to downplay it.”

Later that same day, Schmidt said, she filed a complaint with the state Health Department, which initiated an investigation in early October.  Staff at Premier described the Sept. 25 incident to a state Health Department investigator in graphic terms. On Mary Ellen Sharp’s left foot, there was “something wiggling between her toes,” a nurse’s aide told investigators.  In the state investigation report, the director of nursing told an investigator that the licensed practical nurse who initially discovered the maggots has been banned from working at the facility “for lack of nursing supervision notification.” The licensed practical nurse, however, told the investigator she not only recorded the incident in Sharp’s file, but also informed a registered nurse and tried “many times” to alert the nursing supervisor by phone, pages and texts, but could not reach her. The state cited Premier Genesee for violations but incredibly did not fine the nursing home.

An inadequate pest control program to prevent flies from entering and spreading maggots at the 160-bed nursing home was cited by the Health Department as the culprit.  A maggot infestation on a nursing home resident’s body is a very disturbing violation of minimum care standards.  An adequate pest control program includes making sure screens remain properly fitted in windows and eliminating gaps in doors to block flies from entering, making sure bug light traps are plugged in and that monthly recommendations for repairs from a pest control company are promptly addressed.  The best intervention would be to care for and treat the resident’s wounds every shift.

The state cited other problems:

• An unsanitary situation occurred when a wound doctor, after treating one of Sharp’s wounds, failed to place a dressing on it. For hours, the wound was openly exposed, making it a target for flies.

• Officials at the nursing home failed to comply with a federal regulation requiring they immediately notify a physician and relatives when there has been a change in a resident’s condition.

• Breakdowns in communication among employees, ranging from the nursing staff to maintenance workers.

“What happened is inexcusable and horrifying,” said Lindsay Heckler, supervising attorney at the Center for Elder Law and Justice in Buffalo. “Had staff followed basic standards of care and timely notified the physician, maggots would not have infested the resident’s leg for additional multiple days. Maggots should not have infested her leg on Sept. 21, and the resident should not have been left to suffer from further infestation.”

“You don’t really think it could be true or it could ever happen,” Schmidt said of the maggots. “How would anyone feel having that happen to a loved one?”



Rosalind Agatha Bell died less than two months after developing a bed sore on her left ankle while at the Evergreen Health & Rehabilitation Center.  Marjorie Ann Bell, Rosalind Bell’s daughter, is suing the nursing home for compensation. The suit alleges that the facility should have prevented the bedsores because when Rosalind Bell was admitted to the facility, the staff knew or should have known that she was a high risk for developing bedsores (also known as pressure ulcers) and needed interventions to avoid them.

“Bell depended completely on the defendants for responsible pressure ulcer and wound prevention and treatment, to include care as basic as turning and re-positioning,” attorney Robert W. Carter Jr. wrote. “The defendants permitted Bell to develop a left outer ankle wound as early as Sept. 26, 2017.”

Carter said in an interview that Evergreen has a history of improperly treating bedsores, a common complication among neglected residents. Evergreen was cited by the Department of Health in 2016 for several problems including substandard treatment of bed sores and failure to maintain proper infection control.
In a settlement in March, the family of a 90-year-old woman who died after developing bedsores was awarded $300,000. The family, which sought $2.5 million, alleged the bedsores were caused by the staff failing to properly rotate the woman in bed.

“The staff was insufficient in number or had knowledge deficits about the proper means to care for Ms. Bell,” he said. “The development and deterioration of the wounds got as bad as it gets for wounds.”

McKnight’s reported on a recent appeal of an arbitration decision in favor of the nursing home resident.  I find it funny that the nursing home industry pushes for arbitration because it is “cheaper” “faster” and “will provide closure” but still appeals the arbitrator’s decision!

Villa Huntington Drive Healthcare Center neglected Patricia Porter’s avoidable pressure injury causing her wrongful death.  Her doctor had ordered a low-air mattress to help prevent and heal a severe pressure ulcer. The order was made on July 4, 2012 but the mattress did not arrive until July 12. Caregivers failed to alleviate the pressure by turning and repositioning Porter adequately, and left her sitting in a wheelchair for six hours, further worsening her injuries. She died in November 2012 from a septic sore and urinary infections.

After listening to all the relevant evidence introduced, the arbitrator awarded the resident and her family $1 million.  California’s  arbitration awards can be reviewed by a court in limited circumstances, but the California Court of Appeal, Second District, deemed that the case did not meet those requirements. That’s because AG Arcadia did not identify any unwaivable statutory rights that the $1 million award violated, Bloomberg reported.

An appeals court ruled that an arbitrator did not exceed her authority by awarding the patient damages in excess of the $250,000 cap contained in the state’s Medical Injury Compensation Reform Act, Bloomberg Law reported.

According to court documents, the facility had argued that the arbitrator exceeded her powers by awarding non-economic damages in lump sums, rather than in proportion to each defendant’s percentage of fault. It also contended that the arbitrator failed to make any findings against parent company AG Arcadia and its facilities.

Huntington Drive Health also asserted that the arbitrator was prejudiced in the matter and did not grant the SNF added time to present testimony from treating nurses and its medical expert, according to court documents.


The Buffalo News reported the tragic and preventable death of Frank Williams.  Frank Williams died Dec. 21, 2016, from sepsis from pressure ulcers or bedsores he suffered at Safire Rehabilitation at Northtowns.  Williams didn’t have any skin breakdown or bedsores when he left Kenmore Mercy Hospital and entered the nursing home for rehabilitation after a stroke. Williams’ case illustrates how vulnerable individuals who go to poorly rated and understaffed nursing homes for rehabilitation can quickly succumb to preventable but lethal ailments like bedsores.

Four months later, when he returned to Kenmore Mercy, the retired ironworker had seven bedsores on the lower half of his body. He died 14 days later from sepsis – an extreme response to infection – according to his death certificate. Hospital records cite infections from bedsores as the most likely cause of the sepsis.

After he arrived, hospital records note, Kenmore Mercy staff discovered bedsores on the lower half of his body, including one with “foul smelling drainage” and greenish gray and black spots, along with dead tissue.

According to hospital medical records, there were bedsores on his lower back, right ankle, right and left heels and right big toe. There were two lesser wounds on his right pelvis and scrotum. 

“The sore on his right ankle looked like it was down to the bone,” Mark Williams said.

“They told me this is the worst case of bedsores they have ever seen from that nursing home,” his son, Mark F. Williams Sr., recalled doctors and nurses telling him in the emergency room. “The sores were black. I’d never seen that before. I was shocked. I thought it was the black plague.”

Bedsores, also known as pressure ulcers, occur when a section of the body is pressing against a surface for too long and not repositioned to alleviate the pressure. Several other factors, such as nutrition, the surface on which the body is pressing and moisture also contribute to bedsores, according to experts in the prevention of  these injuries. Yet there is consensus among nursing homes and other health care providers that the vast majority of pressure injuries can be prevented.  In fact, the nationwide average for pressure ulcers is less than 5% in most facilities.


Willie Johnson suffers end-stage dementia and now lives in the Laurellwood Nursing Center in St. Petersburg, Florida.  His daughter, Tonya, has been his advocate for years but is troubled by the customs and practices at the nursing home.

“I’m so hurt, I’m so disappointed in that place,” Tonya said.  “In my dad’s room, they have a white sheet to the window as a cover, as a blind or as a curtain. It’s a white sheet,” Tonya stated.  On December 31, Tonya decided she’d seen enough when she spotted a large bed sore on her father’s backside. According to Tonya, her father didn’t have that bed sore when he arrived.

“I said, ‘Roll my dad over a little bit’ and that’s when I discovered (it.) I sort of stepped back, I said, ‘What is this?'” Tonya recalled. “And she said, ‘Oh, well, it’s a sore.’ And I’m like wow. I said, ‘Where’d this come from?'”  “I said, ‘Well how come nobody contacted me?’ She said, ‘Nobody ever called you?’ I said no,” Tonya said.

In addition, she was concerned about an ulcerated heel.

“I asked them to lift my daddy’s foot up. They lifted up in the air and I noticed my daddy’s foot under the bottom, like he’s got a hole and it’s spreading and it’s spreading,” she said.

In September, Laurellwood was issued 12 citations for health violations and 10 more for fire safety problems, according to Medicare’s website.

Tonya complained to the Department of Children and Families, Elder Abuse and Florida’s Agency for Health Care Administration about her father’s treatment.  DCF confirmed it received a complaint from Tonya and stated it is investigating.

The Buffalo News reported the jury verdict in a nursing home neglect case.  Shirley Burrows needed follow-up treatment for three “superficial” bedsores when she was discharged from the hospital to Newfane Rehab & Health Care Center nursing home. Her wounds were on her sacrum and backside.  Bedsores, also known as pressure sores, are mostly preventable but occur when a section of the body is pressing against a surface for too long and not repositioned to alleviate the pressure. Medical protocol to prevent sores calls for repositioning at least every two hours. Instead of getting better, Burrows’ sores worsened, became infected, and a bone in Burrows’ lower back was exposed.

A jury compensated her with $1.25 million to the 72-year-old woman, after determining Newfane Rehab & Health Care Center was negligent in its care of her.

“She had gone to the nursing home for wound care treatment and they horribly neglected her,” said Brian R. Hogan, one Burrows’ attorneys at Brown Chiari law firm. “What makes this egregious is they knew she had sores and she was not seen by a doctor at the nursing home. It took two years of treatment at the wound clinic and she still has an open wound, but it is a lot smaller and her daughter is caring for her,” Hogan said.

The federal government rates Newfane Rehab as a two star, or “below average,” facility in its five-star rating system.

Of the verdict amount, the jury awarded $475,000 for past pain and suffering, $300,000 for future pain and suffering, and an additional $475,000 for violating a state public health law that requires special protections to nursing home residents, for the total of $1.25 million.



Glennie Hood’s children say she was loved not only by them, but also her community. They told stories of kids from the neighborhood visiting her home and calling her grandma. No one wanted to place her in a nursing home, but it became less and less of a choice as she began developing symptoms of dementia. They chose Essex of Tallmadge because they were nearby and seemed trustworthy. As they visited and toured the facility, they were made promises that Glennie would be in safe and loving hands. Of course, that was not the case.

Hood died after the Essex of Tallmadge nursing home allowed a blister on her foot to become infected and rot. Though it was a major concern, her family and other visitors were not allowed to see the deterioration of the wound while her caretakers often insisted that it was healing properly. Then, one day, when the smell of it was overwhelming, her son asked to see his mother’s foot unwrapped, and he finally saw the damage that had been done.

A doctor was brought over to look at the blister, which had by then turned the foot into an infected, rotting, and black mass of flesh.  The doctor said it was “too far gone.” Mohing could be done and she died from the injuries.

Those representing the facility say no correlation exists between the blister and the elderly woman’s death, but her family disagrees.

Stories like this break your heart because of the trust that was abused in the process. People loved Glennie Hood. She was important. She was human. It could have been any number of things at that nursing home that led to her injury and death, but none of those things should have happened in the first place. If the home and, more broadly, the industry truly cared about Glennie Hood’s humanity, they never would have caused her so much pain.

Newson6 reported on a resident’s family seeking answers in a lawsuit against Grace Living Center. Twila Knight was 57 when she checked in at Grace Living Center to recover from a fall.  At the facility, Twila suffered from falls, custodial neglect, and a pressure ulcer injury.  The family of a former resident is suing Grace Living Center claiming the staff failed to monitor, treat, diagnose and care for their loved one.

The center’s Medicare health inspection rating is one out of five stars.  The health inspection report shows the rating is the lowest possible score. And it’s rate of long-stay patients developing pressure ulcers is 12.6 percent more than double the national average.

Knight’s family is suing the nursing home for negligence claiming the staff also failed to properly treat bed sores she got in their care. The family is also claiming the staff was verbally abusive and failed to address her dietary needs, weight loss, and medication needs.

“There has to be special mattresses put in place, there has to be turning that’s done, you have to make sure that people are getting up,” said the family’s attorney Mark Edwards.

“We rely on these places to take care of our most fragile. And what’s happening is we have businesses that are putting profits over people,” said Edwards.