After he suffered a stroke, he was treated at Kenmore Mercy Hospital, according to medical records. He was transferred to Safire Northtowns on Sept. 9, 2016.

Public records do not provide many details about his stay at Safire Northtowns, but his son provided an account.

"He was placed in long-term care for three days. I had to tell them he was a rehab patient. They didn't have a bed for him in rehab. The place smelled of urine and it was hot. There were no open windows and my father was sweating," Mark Williams said.

With assistance, Williams could walk. But when he was in bed, the son said, caution was necessary. His father was restless.

"He liked to roll. I'd asked them to place rails on the sides of his bed," Mark Williams said.

The request, he said, was not addressed.

"One day when I came in, he had a big old bump on his head. I asked, 'What happened to you?' He said, 'Oh, I fell out of bed.' The nursing home never told me about that," the son said.

Mark Williams said the nursing home staff informed him in early December 2016 that his father had developed a bedsore in the groin area.