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.”