Pictures of Rebecca Zeni during her younger years showed her with flawless skin, well-defined eyebrows and long, thick lashes. Her hair, parted in the middle, was neatly tied with a bow behind her ear.
Her beauty could capture a room, her daughter said, but she was more than just a beautiful face.
She was a modern-day woman of the 1940s and 1950s, headstrong, career-oriented and hard-working, said Mike Prieto, a lawyer representing Zeni's family. At a time when women were expected to marry young and have children, the small-town girl from North Carolina moved to Norfolk after high school to work at the naval base, her daughter, Pamela Puryear, said. She later became a model in New York City and worked as an assistant for CBS News' Mike Wallace before she married and became a stay-at-home mother.
"Her life just became exciting," Puryear said. "She thought in her mind that everybody's life is just like this."
But the once-vibrant woman later found herself living in a nursing home, where she suffered a long, painful death, her family's attorneys said. Parasitic mites had burrowed under her skin, living and laying eggs all over her body. By the time she died, vesicles and thick crusts had formed on her skin. Her right hand had turned nearly black, and Prieto said her fingers were about to fall off.
The scabies that infected Zeni's body had become so severe that bacteria seeped into her bloodstream. She died in 2015 at age 93.
Zeni's death is now the subject of a lawsuit filed against PruittHealth, a for-profit company that owns dozens of nursing homes, including Shepherd Hills in LaFayette, Georgia, where Zeni lived for five years.
Shepherd Hills had multiple scabies outbreaks in recent years and a history of health violations. It failed to follow policies and procedures to prevent the occurrence and spread of the highly contagious disease, documents say. Instead of providing the care Zeni desperately needed, the lawsuit alleges, the nursing home allowed her to die an agonising death.
"The last six months of her life, she was in constant pain," Prieto said. "She was literally being eaten alive from inside out."
Questions over for-profit nursing homes
Zeni's death raises crucial - and familiar - questions about for-profit nursing homes that have long been accused of sacrificing patient care to minimise costs and maximise bottom lines. Nursing homes owned by big corporations and private investment firms consistently performed poorly in terms of quality of care and are more likely than nonprofit and government facilities to be cited for "serious deficiencies" that harm residents, according to 2011 and 2016 reports by the Government Accountability Office. Staffing levels are usually lower, meaning trained nurses spend less time with residents each day.
"You must consider that the reimbursement rate from [Medicare] continues to fail to keep up with rising costs associated with care," said Prieto, who focuses on nursing-home litigation. "The only variable that's available for these for-profit facilities to ensure they continue to maximise their opportunity for profiting is staffing. Purposefully understaff facilities in an attempt to ensure maximum profit."
Avi Mukherjee, a professor at Marshall University who focuses on health-care management, said high staff turnovers, diminishing morale, and meagre pay and benefits often result in low-quality care.
"The key is to understand that low service quality and negative outcomes for patients and residents is not in the interest of the long-term survival of these companies," Mukherjee said.
PruittHealth and its attorneys did not respond to calls or emails seeking comment.
Federal health inspection records paint a troubling picture of the company, which describes itself as the "regional leader" of providing long-term health care to the elderly in the southeast.
Shepherd Hills was ordered to pay $337,786 in penalties over the past two years and has a one-star rating - the lowest - from Medicare based on health inspection results, staffing and quality of care.
In 2016, for example, the facility was penalised for several staff medication errors, some of which resulted in life-threatening situations. One resident was mistakenly given morphine twice within a half-hour one morning and continued to receive the medication every two hours later that night and the following day, records show. The resident overdosed and was rushed to the intensive care unit.
State health inspection records obtained by 11Alive, which first reported on Zeni's case, showed nearly three dozen violations in 2014, 2015 and 2016. The NBC affiliate reported that state officials threatened to withhold federal funding if the violations weren't addressed.
Many PruittHealth-owned facilities have similarly dismal records. Nineteen facilities in Georgia, seven in South Carolina and one in North Carolina received one- and two-star ratings from Medicare.
According to the Government Accountability Office's 2016 report to Congress, skilled nursing facilities received $28.6 billion in Medicare funds in 2014. About 70 per cent of these facilities are for-profit nursing homes.
Zeni was admitted to Shepherd Hills in 2010. By then, the 87-year-old had been diagnosed with dementia, diabetes and other illnesses. She was completely dependent on others and was no longer legally qualified to stay at an assisted-living facility.
Puryear, who lives in LaFayette, was close enough to visit often.
Zeni's rashes began to appear in fall 2013, around the time that a scabies outbreak at the facility was reported to the local health department. Ten residents and 10 staff had rashes; some were diagnosed with scabies, according to Georgia Department of Public Health records.
Attorneys for Puryear said the nursing home did not take the necessary steps to keep the outbreak contained and to properly treat residents. Sheets used by those infected were washed along with those of the general population, and medication was shared among residents. Families were not informed of the highly contagious disease, said attorney Stephen Chance; instead, vague signs about a rash were posted at the facility. Residents with scabies were not quarantined, and infected staff returned to work.
"Once you got a number of people that are carrying scabies, and they go home and they have it at home and they're coming back to work, going from one patient room to another patient room, that sort of approach is not going to eradicate scabies," said attorney Lance Lourie.
Lourie added: "Nursing homes in this chain in particular, they're under a tremendous pressure to keep the facility full. Telling all your residents that you got an outbreak of scabies in the facility would hurt your ability to get more residents and families will leave."
Another outbreak in 2014, Chance said, was not reported to the health department. A third outbreak happened in spring 2015. Twenty residents and 15 staffers were infected, state records show.
By then, Zeni's condition had dramatically worsened. Rashes had spread to her scalp, neck, chest, shoulders, back and arms. A doctor had ordered that she be given Ivermectin, a tablet used to treat worm infections, and Elimite cream, which is used to treat scabies. But the treatments and medications were at times not given as ordered, court records say.
Zeni died June 2, 2015. An autopsy found that she died of Staphylococcus aureus septicaemia due to Norwegian crusted scabies, a severe form of scabies that affects people with weak immune systems, such as the elderly. Scabies can spread rapidly in crowded places, such as nursing homes, extended-care facilities and prisons, according to the state health department.
An affidavit by Debi Luther, a Florida nurse who reviewed Zeni's medical records, stated that the nursing home's failure to recognise her deteriorating condition and to prevent the spread of scabies resulted in her death.
Nancy Nydam, spokeswoman for the Georgia health department, said the agency provides guidelines to prevent and control scabies outbreaks and follows up with facilities, but it does not have regulatory control.
A separate agency, the Georgia Department of Community Health, inspects facilities and could set rules that a facility must follow. But that agency said it does not have records showing it was notified of the scabies outbreaks, 11Alive reported.
"Our client trusted them and her trust was betrayed," Prieto, one of the attorneys, said of Puryear.
Puryear said she watched helplessly as she visited her mother every day, unable to touch or hug the woman she loved and admired.
"It's a nightmare," she said, adding later: "There was no dignity."