On January 13, 2026, a Solano County, California nursing home negligence jury returned its verdict in excess of $15 million to the family of a 96-year-old woman who died on October 2, 2019 at home after developing pressure ulcers on her lower back and buttocks that allegedly were not properly diagnosed and treated during her stay at the Windsor Vallejo Care Center from August 3 to August 10, 2019.
The jury awarded $3,750,000 in compensatory damages and $12 million in punitive damages.
The California nursing home negligence and elder abuse lawsuit alleged, in part:
As of July 2019, Ruby Evans was living independently at home in her own apartment in San Francisco, CA. Ms. Evans made her own meals, exercised, dressed herself, went to the bathroom on her own, bathed herself, and managed her own finances and medications, among other things. Ms. Evans also enjoyed spending time with her devoted children.
On July 25, 2019, Ms. Evans experienced intracranial bleeding resulting from a hemorrhagic stroke. She was hospitalized at Sutter Solano. Sutter felt that Ms. Evans was not a candidate for neurosurgical intervention so the initial plan was to send her to a skilled nursing facility with hospice. However, on August 2, 2019, Ms. Evans showed signs of improvement. She was more alert and talking so her family rescinded the hospice decision and wanted her to get short-term rehabilitation. According to Sutter, Ms. Evans had no pressure ulcers on her body when she left Sutter on August 3, 2019.
Upon admission to Windsor Vallejo on August 3, 2019, Windsor Vallejo did not identify any pressure ulcers or skin breakdown on Ruby Evans’ body. According to Windsor Vallejo, Ms. Evans was at high risk for the development of pressure ulcers due to her decreased mobility and functional ability, which were the same reasons that brought her to Windsor Vallejo. In that regard, Ms. Evans was dependent on staff for her activities of daily living. Because she was at high risk for the development of pressure ulcers, Ms. Evans was to be repositioned every two hours.
On August 3 and 4, 2019, Windsor Vallejo rotely documented that Ms. Evans’ skin was “WNL,” or within normal limits. According to Windsor Vallejo, Ms. Evans’ skin was “warm and dry, skin color WNL, mucous membranes moist, turgor normal.” Ms. Evans’ skin was also documented to be intact. Ms. Evans had no skin issues according to Windsor Vallejo’s documentation. Windsor Vallejo documented that Ms. Evans was to be on a “turning/ repositioning program.” On August 4, Windsor Vallejo physician Gurpreet Singh, M.D. documented that Ms. Evans had no skin issues.
On August 5, 2019, Windsor Vallejo again documented in rote fashion that Ms. Evans’ skin was “within normal limits” and “warm and dry, skin color WNL, mucous membranes moist, turgor normal.” Ms. Evans’ skin was again documented to be intact, and she had no skin issues. On August 5, Windsor Vallejo assessed also Ms. Evans’s skin. Other than some discoloration on her arms and hips, Windsor Vallejo documented that Ms. Evans’ skin was intact.
On August 6, 7, and 8, 2019, Windsor Vallejo again rotely documented that Ms. Evans’ skin was “within normal limits” and “warm and dry, skin color WNL, mucous membranes moist, turgor normal.” Again, Ms. Evans’ skin was also documented to be intact, and she purportedly had no skin issues according to Windsor Vallejo.
On the morning of August 9, 2019, Windsor Vallejo first documented that Ms. Evans had a wound on her sacrum. According to Windsor Vallejo, Ms. Evans had “an abrasion on her sacrum, cleansed and pat dry and covered with foam dressing. No complaints of pain. No signs and symptoms of infection.” Despite this, a nurse at Windsor Vallejo repeated the same route entries from the prior six days, namely that Ms. Evans’ skin was “within normal limits;” “warm and dry, Skin color WNL, mucous membranes moist, turgor normal;” and her skin was intact and had no skin issues. Windsor Vallejo called Ms. Evans’ son that afternoon and told him that his mother had a small tear on her buttocks but not to worry.
On August 10, 2019, Ms. Evans’ took her and her belongings out of Windsor Vallejo. Entirely unaware of the severity of their mother’s sacrum wound, Ms. Evans’ family removed her from Windsor Vallejo because they were upset that they were not allowed to visit their mother after 8:00 p.m. and/ or stay overnight with her after her roommate told Ms. Evans’ children that she would call out their names throughout the night. Windsor Vallejo called Ms. Evans’ son around 8:00 p.m. and he advised the facility that his mother would not be returning.
On August 11, 2019, Ms. Evans’ family interviewed a potential caregiver for their mother. This caregiver examined Ms. Evans and saw the wound on her sacrum, which she then showed to Ms. Evans’ family. Ms. Evans’ family was shocked and horrified when they saw the wound on their mother’s sacrum as it was far more severe than described by Windsor Vallejo. Ms. Evans’ family had their mother immediately sent to the Sutter Solano Medical Center ER.
Although Sutter identified Ms. Evans’ pressure ulcer as a Stage 2 wound, it was more severe. The photograph taken in the emergency department shoes [sic] what is clearly a full thickness wound. Subsequent photographs also clearly demonstrate the wound was at least Stage 3 while hospice nurses continued to call it a Stage 2. One of the reasons Ms. Evans was deemed appropriate for hospice services at that time was the presence of her pressure injury. Mere repositioning caused Ms. Evans pain, and even treating the wound caused her pain. As a result of Windsor Vallejo’s reckless neglect, Ms. Evans was forced to live with the painful, severe pressure ulcer on her sacrum until she died on October 2, 2019.
If you or a loved one suffered injuries (or worse) while a resident of a nursing home in California or in another U.S. state due to nursing home pressure ulcer, improper nursing home discharge, improper nursing home transfer, nursing home fall, nursing home aspiration, nursing home neglect, nursing home negligence, nursing home abuse, nursing home understaffing, nursing home wrongful death, or the nursing home failing to properly care for a vulnerable adult, you should promptly find a nursing home claim lawyer in California or in your state who may investigate your nursing home claim for you and file a nursing home claim on your behalf or behalf of your loved one, if appropriate.
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