An Ohio nursing home is being accused of misleading the relatives of a 75-year-old woman regarding a deteriorating Stage 4 pressure ulcer, which ultimately led to her death. The facility’s records allegedly claimed she had “no open areas,” despite the ulcer exposing her muscles and bones, according to a lawsuit filed against them.

The family of Judy Marsh claims in a legal complaint that the staff at Windsor House at Canfield failed to adhere to a mandatory two-hour schedule for turning and repositioning her. They reportedly encouraged Marsh to reposition herself without providing the necessary assistance and neglected to change her soiled diapers.

Marsh was admitted to the facility in December 2024 for rehabilitation after an 11-day hospital stay for pneumonia, during which doctors noted she had no pressure wounds, as stated in the complaint from Michael Hill Trial Law.

By April 2025, Marsh had passed away, with the cause of death attributed to “sepsis due to decubitus wounds” and E. coli infection in her pelvic bones. These conditions were exacerbated by a Stage 4 pressure ulcer that resulted in osteomyelitis, a severe bone infection, the lawsuit details.

The complaint further elaborates that Marsh, who suffered from Multiple Sclerosis, was significantly weakened and had very limited mobility, necessitating assistance with repositioning. However, Windsor House at Canfield allegedly documented that they merely encouraged her to move rather than providing the actual assistance required.

Before her death, staff at Windsor House allegedly failed to consistently follow the orders of Marsh’s physicians and the wound care nurse. Additionally, nurses performed “wildly inaccurate skin observations and assessment,” documenting that she had “no open areas” in spite of there being “large pressure wounds” on her buttocks — or not performing skin assessments at all, the complaint says.

“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.”