The Class AA fine, which is the most severe under California state law, arose from a 2008 injury and death of a 60-year-old long-term resident. The woman, who suffered from an inherited muscular disorder, fell from a lifting device while staff moved her from her wheelchair to her bed. She died four days later from a head injury. According to the state investigative report, the facility could not produce any evidence that the lifting device had been maintained or checked for safety. The lifting sling, which tore during the transfer, appeared to be worn “with what appeared to be bleached out blood stains at the center”.

The facility can appeal the fine but the nursing home Chief Operating Officer, Trevor Hammond, is unsure if they will do so. According to Hammond, “We’re mortified. We had a tragedy when a piece of equipment failed. It was a catastrophe.”