In a troubling case emerging from Ohio, a nursing home is accused of misleading a family about the dire condition of a 75-year-old woman who eventually succumbed to a severe Stage 4 pressure ulcer. Despite documentation claiming otherwise, the ulcer was severe enough to expose her muscles and bones, ultimately leading to her death, according to a lawsuit.

The lawsuit against Windsor House at Canfield alleges that staff routinely misinformed Judy Marsh’s family, falsely reporting that she had “no open areas” on her skin. Marsh, who was under a strict two-hour repositioning regimen, was reportedly left to manage her own movements without adequate assistance, and staff allegedly neglected to change her soiled diapers, the legal complaint states.

Judy Marsh had been admitted to the facility in December 2024 after an 11-day hospitalization for pneumonia, with doctors advising rehabilitation. At the time of her admission, she reportedly had no pressure wounds, according to the legal filing from Michael Hill Trial Law.

Tragically, by April 2025, Marsh had passed away. Her death was attributed to sepsis from decubitus wounds and E. coli infection in her pelvic bones, exacerbated by a Stage 4 pressure ulcer that developed into osteomyelitis—an aggressive bone infection due to exposure to air, as outlined in the lawsuit.

The complaint further details that Marsh, weakened by Multiple Sclerosis, had very limited mobility and required help for repositioning—a need that Windsor House at Canfield staff allegedly failed to meet. Instead, the facility relied on merely encouraging her to move, without providing the necessary physical assistance.

In the weeks leading to her death, the nursing home staff purportedly ignored the directives of Marsh’s healthcare providers, failing to follow through with her prescribed care. The lawsuit also accuses them of conducting inadequate skin assessments, inaccurately recording her skin as having “no open areas” despite the presence of significant pressure wounds, or neglecting to perform these assessments altogether.

“Windsor House at Canfield also continued to fail to timely change Judy’s adult diapers when they were soiled, leaving her skin exposed to urine and feces which rested directly on the open wounds on her buttock, causing worsening breakdown,” the complaint adds.

Marsh’s wounds developed “leathery scab-like tissue” on top of them that deteriorated over time and led to the Stage 4 ulcer that “tunneled deep” into her buttocks and pelvis, exposing the bones of her sacrum and gluteal muscles.

“Windsor House at Canfield had been telling Judy’s family that the pressure wound was improving with treatment when in fact, as can be seen from the photographs of the wound, it was steadily worsening to the point where it became a full-thickness Stage 4 pressure wound,” the complaint concludes.

Marsh’s family says she suffered a “continuous decline” until her death on April 6, 2025, including a refusal to eat and becoming “almost unarousable,” per the complaint.

“This case reflects an avoidable and incomprehensible breakdown in basic care,” said attorney Michael Hill, who represents the family, in a statement. “Our complaint alleges that a profit-driven business model led to chronic understaffing, and that Judy Marsh paid for that corporate decision with her life.”