Nursing home abuse and neglect put vulnerable residents at serious risk, leading to malnutrition, dehydration, infections, and preventable injuries. When facilities fail to provide adequate care, residents suffer, and families are left feeling helpless. Lack of supervision, improper medical treatment, and unsafe conditions can result in devastating harm. Understanding the warning signs, knowing your legal rights, and holding negligent facilities accountable are crucial steps in protecting your loved ones. Learn how to take action and seek justice.
November 5, 2024
3 min
WARNING: This article contains graphic photos that may be disturbing to some readers.
Following an autopsy and a review of Lucy Garcia’s medical records from both the hospital and the Arbors at Oregon facility, the Lucas County Coroner’s Office ruled her death a homicide, citing complications from a Stage IV sacral pressure ulcer caused by medical neglect as the primary cause. Although records from Arbors at Oregon indicated that Lucy was at moderate risk for bed sores, the facility failed to implement essential preventive measures. Instead, they falsely documented her wound as a minor “abrasion,” concealing its severity from both her family and Medicare to avoid a lower facility rating. Over a period of three months, Arbors at Oregon continued to falsify records and withheld the truth about Lucy’s worsening condition, allowing her bed sore to progress into a large, open wound exposing muscle and bone, leading to severe infection. Lucy endured significant suffering until her death on July 2, 2024.
Michael Hill, Matthew Mooney, and Molly Morris of Michael Hill Trial Law are pursuing a lawsuit on behalf of Lucy Garcia’s family against Ohio-Based skilled nursing facility Arbors at Oregon located in Oregon, Ohio. The case alleges negligence, wrongful death, and violations of nursing home resident rights laws. The lawsuit is Estate of Lucy Garcia v. Arbors at Oregon aka Oregon Opco, LLC, et al. and is pending in Lucas County, Ohio.
The lawsuit states that Lucy Garcia became a resident of Arbors at Oregon on January 25, 2023 following complications of a stroke. Upon admission, the facility was aware that Lucy needed the assistance of staff to get in and out of bed, to move herself around in bed, and to get to and from the toilet due to her left-sided weakness from the stroke. Lucy maintained the majority of her mental cognition while she was at the facility, but did suffer from a degree of cognitive decline due to her stroke. This further increased her dependence on Arbors at Oregon staff to assist her with her activities of daily living and to protect her from potential harm. The Garcia family discussed Lucy’s care needs with Arbors at Oregon, and the facility assured them that it could meet her care needs and keep her safe.
The lawsuit further alleges that Arbors at Oregon was aware that its residents’ needs were routinely unmet, leading to preventable injuries such as bed sores, infections, falls, and even death, due to insufficient staffing levels and a lack of properly trained, compassionate nursing staff equipped to meet individual needs. Despite being investigated and cited for multiple health and safety violations—and having a recent history of criminal neglect and abuse by nursing staff that resulted in a resident’s homicide—the facility assured the Garcia family it could provide the necessary care for Lucy but failed to disclose these serious issues. The Garcia family trusted that the Arbors at Oregon’s representations were truthful and that Lucy would be taken care of.
Arbors at Oregon performed a Braden Scale assessment of Ms. Garcia to determine her risk of pressure sores (aka bed sores) the day after she arrived at the facility. It was revealed that Lucy was at moderate risk for developing bed sores. In order to prevent bed sores from developing, it is necessary for the staff to implement a turning schedule where they rotate the resident in their bed every two hours. It is also important to not let the resident sit in soiled adult diapers for extended periods of time to prevent breakdown of the skin, which can further expose the individual to bed sores.
The lawsuit states that Arbors at Oregon forced Lucy Garcia to wear adult diapers despite the fact that she was not incontinent and could use the toilet to relieve herself with the assistance of nursing staff. The facility made Lucy soil herself in her adult diapers and wait for the staff to return to change her versus getting her out of bed and assisting her to the toilet. This resulted in Lucy laying in soiled adult diapers for extended periods of time and exposing her skin to bodily waste which caused breakdown of the skin on her bottocks and coccyx. In combination with failing to turn and reposition her in her bed regularly, it was foreseeable that Lucy would develop severe bed sores on her back side.
On March 5, 2024, Arbors at Oregon staff documented a new sore on Lucy’s coccyx, measuring 1.5 cm by 1 cm, describing it as an “abrasion” rather than a bed sore. This distinction is significant, as skilled nursing facilities are required to report new bed sores to the Centers for Medicare, which can negatively impact their publicly accessible “Quality Measures” rating. This rating, visible on Medicare’s Nursing Home Compare tool, helps consumers make informed decisions when selecting a nursing home.
By March 13, 2024, the “abrasion” was documented as worsening, now measuring 2.3cm by 2.7cm. Despite the facility’s labeling, this wound was in fact a bed sore that continued to deteriorate. The documentation in the medical records shows that the Arbors at Oregon nursing staff has been trained by the facility’s administration and corporate agents to document bed sores as other types of wounds to avoid mandatory reporting to Medicare, protecting the facility from a negative rating on Medicare’s Nursing Home Compare tool. This pattern of failing to report bed sores results in inflated ratings that mislead the public about the quality of care provided at the facility. Lucy Garcia’s family was told that the wound on her back was just an abrasion. A photo of the wound on March 13, 2024 is shown below.
On March 25, 2024, Arbors at Oregon’s nursing staff documented that the wound on Lucy Garcia’s back had “resolved,” but it had not.
The wound on Lucy’s backside was again documented on May 30, 2024, with nursing staff notes stating that it developed on May 29, 2024. However, the documentation revealed a large open hole exposing the underlying layers of tissue, with visible tunneling. Such deterioration would not occur within a single day, indicating that this was the same bed sore from March that had progressively worsened over time. Despite this, the Garcia family was still not informed that Lucy had a bed sore on her back, even as the facility described the wound as “new.” The facility left the classification of the wound blank, further avoiding the identification of it as a bed sore to continue to circumvent reporting requirements. A photograph of the wound on May 30, 2024 is included below.
For the next several weeks, the wound on Lucy Garcia’s back side continued to grow wider and deeper as the tissue beneath her skin began to die, exposing the muscle and bone underneath. The wound on her back was first documented in the medical records as a “pressure wound” on June 13, 2024. However, Arbors at Oregon still did not inform the Garcia family about Lucy’s condition. The progression of the bed sore from its condition on May 30, 2024 to June 13, 2024 is illustrated in the photograph below.
The Garcia family was contacted by Arbors at Oregon on June 19, 2024, with reports that Lucy was at the end of her life and needed to be placed on hospice care. Upon arriving at the facility, family members found their mother barely responsive. The unit manager brought Lucy’s sons to another area of the facility and insisted on making their mother a hospice patient. When questioned about how her condition had deteriorated so rapidly, given that she was well enough to attend church just a few weeks prior, the facility could not provide an explanation. The family was still not informed about the large bed sore on Lucy’s back.
While Lucy’s sons were meeting with the unit manager, other family members noticed a strong foul odor coming from Lucy while visiting her in her room. After turning Lucy over on her side, the family saw a loose bandage hanging from her backside, which revealed the bed sore and caused pus to flow from the wound. The Garcia family insisted Lucy be taken to the hospital. Arbors at Oregon was hesitant to call an ambulance and continued to try to convince the family she was a hospice patient.
Eventually, Lucy was taken to MercyHealth St. Charles Medical Center, where the extent of her Stage IV bed sore was fully revealed to the family. A Stage IV bed sore indicated that all the tissue on Lucy’s backside, down to the bone, had died, including the muscle. The bed sore was exposed to feces and urine because Arbors at Oregon consistently left her in soiled adult diapers. As a result, the wound became infected with bacteria, leading to sepsis—a systemic infection throughout Lucy’s body. The wound was so deep that it exposed the bones in Lucy’s back, which were also infected, causing osteomyelitis. The wound is photographed below.
While at St. Charles Medical Center, Lucy endured intensive treatment, including IV antibiotics and surgical debridement of the wound. She underwent multiple painful bedside wound treatments, with nurses packing dressings deep into the exposed cavities of her body in an attempt to heal the wound. However, despite the best efforts of Lucy and her care team, she succumbed to the infection caused by the bed sore and passed away on July 2, 2024.
The lawsuit claims that Arbors at Oregon failed to ensure the facility was sufficiently staffed with properly trained and informed personnel to meet the individual needs of Lucy Garcia during her residency. It further alleges that the facility and its corporate agents were aware that inadequate staffing led to increased falls, bed sores, infections, and injuries among residents. Despite this knowledge, the facility chose to engage in a systemic practice of manipulating data sent to Medicare by underreporting such injuries to inflate their “Quality Measures” ratings, thereby misleading the public about the facility’s actual capabilities in providing care.
Additionally, the lawsuit states that Arbors at Oregon knew Lucy Garcia required significant assistance with all activities of daily living upon her admission and that she depended on the facility to provide this care. It claims that Arbors at Oregon failed to deliver the proper care and treatment that Lucy required, which they knew or should have known. The lawsuit further asserts that these failures were the direct and proximate cause of Lucy Garcia’s untimely and wrongful death.
“Today we take the first step towards bringing Lucy Garcia’s killers to justice. With the filing of this Complaint, the truth about how the Arbors at Oregon neglected Lucy and deceived her family comes to light. We will stop at nothing to hold the Arbors and its corporate controllers accountable for creating a system of putting profits over people–a system that they knew caused horrific injuries and death to their residents like Lucy. Arbors tried to hide all this from the people they served, but a righteous reckoning is coming. We look forward to exposing the truth about the Arbors to a Lucas County jury,” says Matthew Mooney–the Garcia family’s attorney.
The lawsuit requests compensatory damages as well as punitive damages to deter similar conduct in the future.
Lucy Garcia’s tragic death and the neglect she faced at Arbors at Oregon have attracted significant media attention, with reports highlighting the severe bed sores that contributed to her suffering. Outlets such as 13abc, Cleveland 19, USA Today, and the Daily Mail have covered the allegations against the facility, emphasizing the systemic issues in nursing home care. For more details on Lucy’s story, please refer to the coverage by 13abc, Cleveland 19, USA Today, and Daily Mail.
The Arbors at Oregon facility is part of the Arbors at Ohio chain. There are numerous Arbors at Ohio-owned facilities located throughout the State of Ohio.
Michael Hill is a nationally recognized attorney who handles exclusively cases against long term care facilities. Michael and his firm, Michael Hill Trial Law, handle cases across the country. If you have any questions about cases involving Arbors at Oregon, Arbors at Ohio, or any other nursing home, assisted living facility, or group home, you can contact Michael Hill Trial Law at www.protectseniors.com, by sending an email to info@protectseniors.com, or by calling (800) 659-2712.
