**Editor’s Note: Readers may find some details in this story disturbing. Discretion is advised.**

LIBERTY, Mo. — Bradford Williams was alone when the 79-year-old died, seemingly forgotten outside on a hot August day.

He was found on the ground next to his wheelchair with scratches and bruises and bugs crawling over him, according to the findings of a state investigation.

Now his family has filed a lawsuit, demanding answers from Liberty Health and Wellness, the nursing home that was supposed to be caring for him.

The family’s attorney, Paeten Denning, alleged in a wrongful death lawsuit that Williams, who had difficulty seeing and was partially paralyzed on his right side, had been upset that August morning in 2022 and had wheeled himself to the front desk, where he demanded his money back and asked to leave.

Instead of letting Williams out the front door, a staff member assisted him outside into the nursing home’s inner courtyard, according to a witness interviewed by state investigators.

The lawsuit alleged that by the time staff found him, more than 4 hours had passed. He was found lying on the ground face down in tall grass.

According to the lawsuit, the director of nursing declared him dead, never initiating CPR or calling 911. Instead, they called a funeral home while nursing home staff brought Williams back to his room and cleaned him with ice water. Williams’ skin was “fire hot,” according to the lawsuit.

The funeral home director was so alarmed at the condition of Williams’ body that he alerted the family, Denning said.

“He had bugs on his face that were crawling in and out of his mouth and nose,” Denning said, in addition to the cuts and scrapes on his arms.

“You can imagine the type of reaction you’d have if that were your family member.”

In response to the lawsuit, the nursing home has denied all responsibility.

Marissa Chrisco, a former nurse at Liberty Health and Wellness, said she was off work the day Williams’ body was found outside, but she wasn’t surprised to hear that a patient could have been forgotten in the courtyard, as the lawsuit alleged.

“Staffing was terrible, absolutely terrible,” said Chrisco, who at the time FOX4 interviewed her still worked at Liberty Health and Wellness.

“Your nurses are just worked ragged because they are working so many halls and they are trying,” she said. “We want to take care of people. We just can’t do it.”

Chrisco said it’s not only patients who are at risk — so are employees.

She has hired attorney Antonette Dupree and plans to sue Liberty Health and Wellness after she said she was injured on the job and discovered the nursing home had no workers’ compensation — something required under Missouri law.

Chrisco stopped working at the nursing home in November.

Liberty Health and Wellness is no stranger to federal and state investigators. On its last available inspection in May, it had 28 violations. That’s more than three times the number of a typical nursing home.

The report itself cited so many problems that it’s 138 pages in length. Among the findings, federal inspectors found a resident who had “dried blood in their hair,” wearing heavily soiled clothes.

Residents told investigators they went without showers for up to eight weeks. Medicine also wasn’t being regularly delivered – something Chrisco confirmed.

“I contacted the medical director and I said, ‘Look, we are dying here. I’m doing the best I can, but they are not getting their medicine,'” she recalled.

Investigators cited complaints of food carts being left in hallways with residents expected to collect their own meals and water. Those unable to do so would rely on other residents for help.

They knew that asking for staff was hopeless.

“The residents would turn their call lights on, and it would be hours before it was answered,” Chrisco said.

Liberty Health and Wellness is so troubled it’s on a list titled “Special Focus Facilities,” comprised of nursing homes at potential risk of losing federal funding unless they clean up their act. Some facilities go off and on the list on a regular basis.

Despite increased oversight by regulators, Chrisco said problems are still rampant at the facility.

“Changes seem to be made then it goes right back,” Chrisco said. “Like I said, it’s this terrible roller coaster.”

So, who is in charge at Liberty Health and Wellness?

At the time of Williams death, the nursing home was operated by 27-year-old Sam Goldner and Goldner Capital Management. Goldner is no stranger to FOX4 Problem Solvers.

Last year, a nurse at another Goldner-operated nursing home called Problem Solvers after discovering her life insurance policy had been canceled for nonpayment, even though the premiums were being deducted from her paycheck.

That nursing home, Meadow View of Harrisonville, no longer lists Goldner as an owner/operator.

Last year, Goldner was the second-biggest owner of nursing homes in Missouri with 15 facilities. That’s something that didn’t surprise attorney Antonette Dupree.

“This company has an owner that is acquiring these assisted living facilities at a crazy rate all over the country,” Dupree said, adding that Goldner’s pitch to a group of potential investors in Ohio revealed how the company makes money.

“The way he intended doing that is the same way he is operating his facilities in Missouri — to take benefits away from his staff, cut down on staffing, cut down on dietary needs of the patients,” Dupree said.

“He put this in writing, and this is exactly what you see translated into what he is doing and how he is operating these facilities, and it’s dangerous.”

In the last three years, at least four wrongful death lawsuits have been filed against Goldner-operated nursing homes in Missouri.

Besides Williams’ case, other wrongful death lawsuits were filed against Royal Oak Nursing and Rehab in St. Louis, Abbey Woods in St. Joseph and at Redwood of South Kansas City.

Two of the suits were settled out of court. The other two are still pending. Goldner was dismissed from one of the settled lawsuits because no one could find him in his home state of New York to serve him court papers.

FOX4 Problem Solvers tried calling Goldner on the only phone number we could find listed, but never got a call back. We also asked a St. Louis attorney, representing Goldner on a different matter, to let his client know we wanted to talk to him.

We have never heard from Goldner.

We then paid a visit to Liberty Health and Wellness. That’s where we met administrator Amy Bax. She told us she could not comment about Williams’ death, the dozens of violations the nursing home faced or the allegation that it has no workers compensation coverage for its employees.

She claimed, however, that the nursing home is no longer affiliated with Sam Goldner or Goldner Capital Management, but she would not tell us who the new owner is. According to federal records, it’s Vertical Health Services based in Puyallup, Washington.

CEO William Miller said the company took over operations last summer and is making improvements. So far, violations at the Liberty nursing home have dropped from 27 to 17 – although it’s still listed as a troubled facility in state and federal databases.

Williams also told us that Sam Goldner, as of this year, no longer operates any nursing homes in Missouri. News that Goldner is no longer in charge has given at least some hope to Chrisco that no more patients or staff will suffer.

“You’re just devastated when you go home,” she said. “You’re in tears every day.“