Forensic pathologist Dr. Kris Sperry, former chief medical examiner at the Georgia Bureau of Investigation, reviewed Zeni’s autopsy report. He says he’s personally conducted more than 6,000 autopsies and has supervised more than 80,000 others.

“This is one of the most horrendous things I’ve ever seen in my career as a forensic pathologist,” Sperry said.

Sperry estimates hundreds of millions of mites were living inside Zeni at the time of her death. He doesn’t think it’s an exaggeration to assume she was essentially eaten alive and that she likely died a painful death.


“Having seen what I’ve seen with Ms. Zeni, I think that is frankly a good characterization,” said Sperry. “I would seriously consider calling this a homicide by neglect.”

Pruitt Health’s chairman, communications director and an attorney representing the company did not respond to request for comment. According to a response to the lawsuit, Pruitt attorneys denied all of the claims outlined in Zeni’s lawsuit, writing “[Pruitt Health] denies that it is a medical or healthcare provider and it, therefore, owed no legal duty to Plaintiff or Ms. Rebecca Zeni for which it could be held liable in this litigation.”

Missed Opportunities

According to records obtained from the Georgia Department of Public Health (DPH), state officials were notified of a scabies outbreak at Zeni’s facility in 2013 and 2015 before her death.

In its June 4th 2015 report, it shows at least 35 residents and staff were exposed to scabies. Instead of inspecting the facility in person, a state health department employee emailed a manual to the facility on how to treat scabies. Eleven days later, Zeni passed away.

According to DPH spokesperson Nancy Nydam, the agency isn’t required to inspect facilities when its notified about a scabies infestation. Despite the low reported outbreaks, Nydam says the agency considers scabies infestations “not necessarily uncommon” events at nursing homes.

While DPH records show no reported cases of scabies at Shepherd Hills in 2014, the facility’s own records show otherwise. According to the nursing home’s infection logs submitted into the case file, there were at least seven cases of scabies at the facility on October 22, 2014. DPH has no record of the facility notifying state health officials.

While DPH isn’t required to inspect facilities after learning about an outbreak, Nydam says its typical protocol to alert the Georgia Department of Community Health (DCH), which performs annual inspections of state nursing homes and responds when it receives a complaint from the public.

DPH says it has no record of staff notifying DCH regulators about the outbreak. When asked for documentation showing DCH was notified about scabies or inspection records related to any scabies outbreak at Shepherd Hills, DCH spokesperson Fiona Roberts emailed, “DCH does not have any records responsive to that issue.”