When understaffing becomes a liability: This $15.75 million verdict shows the risks

After a 96-year-old California nursing home resident developed a severe pressure ulcer during a stay in August 2019, her family filed a neglect lawsuit alleging chronic understaffing, inadequate care, and inaccurate documentation. A Solano County jury ultimately awarded the family $15.75 million.

What is a nuclear verdict?

Nuclear verdicts refer to exceptionally high jury awards—generally, those exceeding $10 million. These verdicts have become increasingly common in the past decade. In fact, communications firm Marathon Strategies reported that nearly 200 corporate lawsuits across 68 sectors resulted in nuclear verdicts in 2025, totaling $25.6 billion. This marks the highest number of such verdicts since 2009, representing a 40.7% increase in frequency compared to 2024. A variety of factors have contributed to the rise in nuclear verdicts, including increased third-party litigation funding and stalled momentum in tort reform. In addition, certain plaintiff-attorney strategies, such as anchoring damages discussions around exceptionally high award amounts and using “reptile theory” arguments centered on community safety concerns, may influence how juries evaluate liability and damages. At the same time, growing corporate distrust and heightened expectations around business accountability mean that juries may be more sympathetic to plaintiffs, particularly given the common perception that larger organizations have substantial resources to absorb sizable damage awards.

Nuclear verdicts can carry significant consequences for businesses of all sizes and sectors, causing lasting reputational harm, posing underinsurance concerns, and wreaking large-scale financial havoc. That’s why it’s vital for businesses to better understand these verdicts and how to prevent them. This case study summarizes a recent nuclear verdict, outlines the factors that led to it, highlights associated compliance considerations, and provides related risk mitigation measures.

Case details

In August 2019, a 96-year-old woman was staying at Windsor Vallejo Care Center in California after being discharged from the hospital following a stroke. During the woman’s stay, she developed a painful bedsore on her lower back and buttocks, which she lived with until her death in October from stroke complications. The woman’s family later filed a lawsuit against the care center, its owner, and the management company that oversaw it, alleging neglect. The jury found that the care center failed to reposition the patient consistently and inspect her skin for bedsores, despite having assessed her as high risk for developing pressure ulcers due to decreased mobility. Additionally, staff repeatedly documented the patient’s skin as “within normal limits,” and, when the wound appeared, noted it only as an abrasion with no signs or symptoms of infection. The woman’s family eventually removed her from the care center due to concerns over visitation restrictions. A new caregiver examined her shortly after and found the wound to be far more severe than the facility had claimed: It was stage 3, involved the loss of all skin layers, and exposed the fatty tissue underneath.

According to the family’s attorney, the care center owners prioritized profits over patient care, reportedly achieving profits up to eight times higher than those of comparable nursing facilities. The center was understaffed, leaving employees unable to provide adequate care. A separate state inspection had found that the facility failed to develop baseline care plans to prevent bedsores, left patients waiting hours for responses to call lights, and, in some cases, left residents in soiled clothing.

The Solano County jury found that the defendants failed to exercise the degree of care that a reasonable person in the same situation would have exercised, amounting to neglect. They awarded the woman’s family $12 million in punitive damages and $3.75 million in compensatory damages, for a total of $15.75 million.

Factors that led to the verdict

The main factors contributing to this verdict were a handful of institutional and clinical failures.

First, the care center’s understaffing was not an isolated shortfall but allegedly a routine business practice. According to the lawsuit, the facility’s owner—who operated about 40 care facilities in total—deliberately understaffed the facility to improve profit margins. This practice undermined the facility’s own care plan, since staff were unable to adhere to a repositioning schedule to prevent bedsores, despite assessing the resident as high risk for pressure ulcers. In addition, staff repeatedly documented the resident’s skin as “within normal limits” throughout her stay, even after noting skin discoloration and, later, an open wound, which created a discrepancy between medical records and the resident’s actual condition. Moreover, the severity of the wound was allegedly understated when communicated to the family, who were reportedly told it was only a “small tear.” Because care facilities are entrusted with the well-being of residents, this pattern of understaffing, inaccurate documentation, and minimized disclosure represented an institutional failure rather than a single lapse in judgment. This precedent may have influenced the jury’s decision to award $12 million in punitive damages, with the conduct potentially viewed as more serious than ordinary negligence.

This case reflects a pattern that extends well beyond elder care. When staffing levels fall below operational needs, both service quality and documentation can suffer. Similar risks can arise in any industry where a company is responsible for people’s physical safety, and staffing decisions can undermine its ability to meet that responsibility. Examples include assisted living and home healthcare, childcare and adult day programs, hospitality and security services, and manufacturing and warehousing operations.

Compliance considerations

This case also raises compliance considerations regarding several federal and state regulations, including the following:

• California’s Elder Abuse and Dependent Adult Civil Protection Act (EADACPA), Welfare and Institutions Code § 15600 et seq.—This law establishes a distinct pathway for pursuing elder abuse and neglect claims, providing remedies that are generally unavailable in standard negligence lawsuits. Under EADACPA, a defendant may face greater liability when neglect is accompanied by recklessness, oppression, fraud, or malice, raising the stakes for elder-care providers. In the case of Windsor Vallejo Care Center, the plaintiffs alleged that chronic understaffing and documentation discrepancies reflected broader organizational failures rather than a single negligent act.
• Welfare and Institutions Code § 15657—This provision of EADACPA establishes the enhanced remedies available in certain elder abuse and neglect cases. In addition to compensatory damages, plaintiffs may recover attorney’s fees and litigation costs. The statute also permits recovery for a victim’s pre-death pain and suffering in circumstances where those damages might not otherwise be available. In this case, that framework likely contributed to the family’s ability to recover damages related to the pain the resident endured from the pressure ulcer, even though her death was attributed to stroke complications, rather than the ulcer. The case also illustrates how alleged systemic failures, such as chronic understaffing and inaccurate documentation, can substantially increase liability exposure when they are viewed as reckless rather than merely negligent.
• Corporate liability considerations—California law allows liability to extend beyond the licensed facility itself to any parent companies or management firms overseeing it. Instead of treating the neglect as a facility-level failure, the Windsor Vallejo Care Center lawsuit also named owner Lee Samson and corporate overseer S&F Management, illustrating how plaintiffs may seek to hold multiple parties accountable when they believe decisions are driven at the corporate level rather than being isolated facility-level failures.
• Recordkeeping requirements and documentation practices—Skilled nursing facilities are required to maintain accurate records of residents’ conditions, including skin assessments and care logs, as part of routine regulatory compliance. In this case, the plaintiffs alleged that the facility’s records did not accurately reflect the woman’s condition as her wound progressed. Documentation discrepancies can escalate from a compliance issue into a significant source of litigation risk.

Risk mitigation measures

To help reduce the risk of nuclear verdicts like this one, businesses should consider the following strategies:

Align staffing with operational risks

Businesses should establish staffing levels based on actual safety risks, rather than on budgetary targets, to reduce the likelihood of missed tasks or inadequate oversight of established procedures. Staffing levels should be reviewed periodically to determine whether resources remain aligned with operational needs.

Treat written safety plans as binding

Businesses should implement procedures to verify that established safety plans and inspection, monitoring, and maintenance activities are being completed as intended and appropriately documented. Strong supervision can help ensure that written procedures are consistently followed in practice rather than existing only on paper.

Verify documentation accuracy and completeness

Businesses should regularly review documentation, including inspection reports, maintenance logs, incident reports, and other records, to ensure they reflect actual events. Internal audits can help identify documentation gaps before they become compliance concerns.

Communicate known incidents accurately

Businesses should ensure injuries, incidents, and other safety concerns are communicated accurately and reported promptly to affected parties, stakeholders, and regulators, as appropriate. Timely and transparent communication can reduce the risk that an incident will later be perceived as having been minimized or concealed.

Such risk mitigation practices apply broadly to any organization whose operations depend on adequate staffing, effective oversight, and accurate documentation, as failures in any of these areas can increase litigation exposure.

Businesses should periodically assess whether their liability coverage keeps pace with their actual risk, since a policy that was adequate previously may fall short of a large verdict today.

Contact us today for additional risk management guidance and insurance solutions.

This document is not intended to be exhaustive, nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel or an insurance professional for appropriate advice. © 2026 Zywave, Inc. All rights reserved.