SAN ANTONIO — When Raul Rios Ordaz was having a schizophrenic episode, he believed he was either a boxer or president of the United States.
On March 2, 2025, he was the latter.
“Mom, come and see the news. They were talking a lot about the president and everybody getting fired,” he told his mother, Luisa Rios Macias, as he sat on the sofa that Sunday in the family’s home on the south side of San Antonio.
“Now I am the president. I am President Rowley,” he said, using a nickname bestowed by his young niece.
The 44-year-old Ordaz had a mild intellectual disability and had been diagnosed with schizophrenia when he was in middle school, his mother told Public Health Watch. But in recent years he’d been stable, working part-time jobs, shopping with his mom when she was off work, and spending his free days walking and riding the bus.
But that day in March, he knew he needed help. He told his mother he wanted to call his brother, Tony Rios Solis, to take him to Laurel Ridge Treatment Center, a psychiatric hospital in San Antonio where he had spent time the previous year. In recent weeks, Public Health Watch has reported on serious patient-safety violations at the hospital that led to the loss of federal Medicare and Medicaid contracts and the firing of its CEO.
“He knew that I could not help him and Tony couldn’t help him,” his mother said. “So he was asking for help.”
It took the family four hours to get him admitted to Laurel Ridge. Ordaz saluted, as a president would do, for his intake photo on March 2, 2025. His mother planned to return three days later, on visiting day.
“I will see you Wednesday, m’ijo [my son],” she said, as they left the building around 9:30 p.m.
It was the last time she saw him. Within 24 hours, he was dead. It was the first of three patient deaths at Laurel Ridge last year, according to police, state and federal records reviewed by Public Health Watch.
Last month, the hospital lost its federal funding for Medicare and Medicaid because of a stream of safety violations that put patients in “immediate jeopardy,” according to records obtained from the Centers for Medicaid and Medicare Services, known as CMS.
The hospital has notified employees that it plans to lay off 648 of the hospital’s 659 employees on June 26, and its CEO, Ashley Sacriste, was terminated on April 29.
A dozen former hospital staffers told Public Health Watch that the deaths came after a series of policy changes in 2024 that reduced staff-to-patient ratios. Ordaz, who had been placed in seclusion, should have been checked by staff every 15 minutes. But he was left unattended for nearly an hour, according to a state inspection of the facility in May 2025.
The upheaval has left the family demanding answers about why Ordaz was left after being given psychiatric medications outside his usual regimen. They want to know what happened in the 20 or so hours after they left him in what they thought were safe hands.
“I just want nobody else to die there,” Macias said. “We want them to be held accountable for what happened to Raul, because Raul mattered. Raul was a loving caring, person. He mattered. He was so important. Maybe not to them, but to me. He was a big part of my life.”
Universal Health Services, the parent company of Laurel Ridge, told Public Health Watch that patients remain the top concern.
“The safety, dignity and well-being of our patients remain our highest priority and guide every decision, action and policy we implement,” according to a statement sent by email. “We have a robust pre-employment screening process for all employees, along with continuous training and education, as well as supervision of all staff to help ensure patient safety. Should we become aware of an allegation of wrongdoing, we cooperate fully with all relevant authorities throughout the investigative process.”
The facility is now working to regain federal Medicare certification.
“Laurel Ridge is committed to continuing to provide services to individuals in the greater San Antonio region and is pursuing the process of certification with CMS,” according to the statement.
‘Unresponsive’
Ordaz was a walking jungle gym for his two nieces, a regular Texas Lottery player, a hard worker, an encyclopedia of sports knowledge and a fan of every Texas team, according to his family.
Sometimes, when the two Texas teams played on the same day, Raul would wear his Dallas Cowboys jersey for the Cowboys game and then change into his Houston Texans jersey for the Texans game.
To this day, a grey San Antonio Spurs blanket covers the bed in his blue-walled bedroom at the family home.
He attended Harlandale High School in Bexar County, and played basketball in the Special Olympics. He was picked as the school’s homecoming king the year he graduated, and would volunteer every year in Harlandale’s Alumni Basketball Tournament.
Ordaz was also a planner. By the time he was admitted to Laurel Ridge in March 2025, he had already bought pajamas for every member of his family to wear on Christmas. He had recently seen the new “Beetlejuice” sequel and wanted a big Beetlejuice-themed party for his 45th birthday on October 15. He had already found a DJ and invited a few people.
He was always buying gifts for others.
“He had the biggest heart,” his brother said. “He was different because his world was different — better, I think.”
But on March 2, he was struggling with his schizophrenia. After being admitted to Laurel Ridge, he smashed a finger in a door and was taken to a nearby hospital for sutures and a tetanus shot, the family was told in a phone call that evening.
His blood pressure, oxygen levels and heart rate were in order, he was cooperative and was discharged after midnight to go back to Laurel Ridge, according to medical records obtained by the family and reviewed by Public Health Watch.
His mother received another call from Laurel Ridge about 4 a.m. on March 3. Her son was back, the staff said, and she could hear him in the background saying, “You are fired,” a favorite phrase when he believed he was president.
Later that day, however, staffers reported that Ordaz was being aggressive — behavior the family described as uncharacteristic. At about 3 p.m. he was administered the antipsychotic medication haloperidol, known as Haldol, and the tranquilizer lorazepam, or Ativan, according to police records.
At that point, he was considered to be in seclusion, which under Texas law would require him to be monitored at least every 15 minutes. But records show he was not checked again for another 55 or 60 minutes, when he was found “unresponsive and bleeding from his mouth,” records show.
An autopsy performed by the Bexar County Medical Examiner’s Office concluded that Ordaz died from natural causes, with hypertension and heart disease exacerbated by diabetes, obesity and his “psychotic episode.”
The same autopsy, however, did not report finding severe medical conditions. The report concluded that his heart was enlarged but barely met the threshold for a diagnosis of an
enlarged heart, known as cardiomegaly. Hardening of the arteries and aorta around his heart were “moderate” and “mild.” The autopsy also reported “slight” hardening of the arteries to his kidneys.
A former staff member who was an admissions nurse when Ordaz arrived told Public Health Watch that he should have been monitored more closely after being put in seclusion.
“Someone should have been there in that room checking his blood pressure every 15 minutes,
but no,” Linda Appiah-Siriboe said. “I strongly believe that it was staffing that caused that poor man’s death.”
Appiah-Siriboe — who was not on duty when Ordaz was found dead — was among several staffers at the facility fired after his death.
Appiah-Siriboe believes she was wrongly fired, but that staff was blamed by hospital officials for the death. Federal records noted that the hospital did not have enough medical personnel to meet staffing requirements on the day he died.
On March 15, 2025, less than two weeks after Ordaz’s death, a 42-year-old patient was also found dead in his bed. His death, too, was attributed to natural causes — hypertensive heart disease — with no contributing factors from the medication found in his system, according to the medical examiner’s office.
Seven months later, on the morning of October 12, 2025, a 26-year-old woman who had been struggling with heroin withdrawal was found unresponsive in her bed, according to a November report obtained from CMS. She had been admitted two days earlier with thoughts of suicide, and was reported to have high blood pressure at 7 p.m. the day before she died.
Staffers at Laurel Ridge did not check the woman regularly throughout the night, however, according to the report. She was checked only twice and was found dead at 9 a.m. the next day. Her death was also attributed to natural causes.
Officials with the Bexar County Medical Examiner’s Office did not respond to requests for comment about the three deaths.
‘Tell him I love him’
It was Ordaz's second trip to Laurel Ridge.
In the fall of 2024, he began hallucinating frequently. He would give his brother messages from their grandmother, who died in 2013, and seemed withdrawn. His regular doctors said they couldn’t help him.
“He might need to be admitted somewhere,” one of the doctors said, according to Solis.
Macias took him to Laurel Ridge in October 2024. Another patient hit him while he was there, and a scan revealed he had a non-cancerous brain tumor that doctors removed through his nose. If it had grown, the tumor could have caused him to lose his eyesight and balance, but it was not affecting his behavior, doctors told Macias.
He still had frequent episodes his mother said she couldn’t handle.
On March 2, 2025, his brother got a call that Ordaz needed help. He picked up his mother and brother, and the three of them drove the 29 miles from their home to Laurel Ridge in the northeast part of town.
They arrived about 5 p.m., and Ordaz was calm. He kept making them laugh, Solis said, describing the exchanges with staff.
“Hi, nice to meet you,” the admissions woman told them when they arrived.
“Hi,” Ordaz said. “I am the president.”
“Wow, I have never met a president before,” she said.
“Well, now you have,” he said.
The next morning, Macias called the hospital repeatedly to find out how her son was doing after the overnight incidents, but couldn’t reach anyone. Someone finally called her about 6 p.m.
“I just want to let you know that Raul is having cardiac arrest,” the woman on the phone said. “We are doing mouth-to-mouth on him and we are going to take him to the hospital.”
Macias and Solis drove straight to Laurel Ridge, where they arrived to find an ambulance outside and an area of the hospital secured with yellow tape. Macias begged the people at the reception to let her see her son, to no avail.
“I kept telling them, ‘Can you please let me go and just hold my son’s hand and just tell him I love him?’”
They weren’t allowed in. A couple of hours later, she said, a doctor came out to confirm what they had feared. Ordaz had died, the doctor said, noting that he had “underlying conditions.”
The explanation didn’t sit right with the family. Ordaz wasn’t perfectly healthy, but he was in Laurel Ridge because of mental, not physical, problems.
“My son has never been sick from his heart,” Macias said.
‘It was just not right’
The family is still working through the grief.
Macias couldn’t work for three months after Ordaz’s death. She keeps thinking about how she couldn’t hold his hand the day he died.
The family is suspicious about the circumstances of his death, and are looking for a lawyer to represent them. The recent news reports about the troubles at Laurel Ridge make her feel that “everything is happening all over again.”
“It has been miserable without him,” she said. “Our family will never be the same.”
Her son spent so much time with her that people often thought he was her husband. She worked from home, and Ordaz would sit next to her during the day, and would make her coffee and toast. They would also spend her days off together.
Now, she can’t stand going alone to stores she and her son used to visit. Sometimes she asks Solis to go with her. She has decided to retire at the end of May because she can’t concentrate on work. She keeps thinking of what happened, and can’t sleep at night.
Solis’s six-year-old daughter, who had given her uncle his nickname, sometimes prays for God to bring “Rowley” back.
“For 44 years he lived with me,” Macias said. “I took care of him and he took care of me. It was just not right what happened to him and the way it ended.”
Last October, Macias decided to throw her son the party he had so eagerly planned. She had a “Happy Birthday Raul” Beetlejuice sign made. She invited his friends and family, and some dressed up as Beetlejuice to honor him.
Macias dressed as Beetlejuice’s mother, wearing a wig and a black-and-white dress. When the time came for cake, Solis played a YouTube video of Marilyn Monroe singing, “Happy Birthday, Mr. President” to John F. Kennedy.
Macias burst into tears.