Villas at Saratoga: Dementia Resident Eloped Twice - CA
The second elopement happened on May 13, at 7:45 in the evening. She was noted missing and found on Oak Street again at 8:15 p.m. She was alert to her own name only, had a diagnosis of dementia, and could not recall the incident afterward.
Federal inspectors who visited the facility on June 30 found three exits on the resident's unit with no alarms connected to the wander guard system: the elevator on the second floor, a second-floor door leading to stairs, and a first-floor exit that opened to a gate roughly 20 feet from a parking lot. To reach Oak Street from that gate, a person had to travel down a hill more than a block long. The maintenance director acknowledged during the inspection tour that the resident had been trying to get into the elevator frequently, and that there was no elevator alarm.
The wander guard was supposed to alert staff when she approached exits. It was not linked to the elevator she kept approaching.
After the first elopement in April, the facility's own elopement evaluation, completed four days later on April 10, identified the resident as high risk, noted her history of wandering, and called for frequent location monitoring, a behavior log, and staff notification. A care plan was developed that day. But no interdisciplinary team meeting was ever held to discuss the April 6 incident. The medical record director, interviewed on July 30, said there should have been a care plan developed by April 7 and an IDT note addressing the elopement. She said her job included auditing medical records for completeness.
The director of nursing said the same thing: a care plan should have been developed when a problem arose.
The medication administration record showed the resident was monitored once per shift from April 11 through May 2025 and that the wander guard was on her left wrist. The record did not specify when during a shift the checks were to happen, including at mealtimes, which the care plan had flagged as a higher-risk period.
After the second elopement in May, the interdisciplinary team finally met on May 15 and noted the resident had been found trying to open doors and exiting from the elevator. They placed her on hourly monitoring and directed staff to assess for triggers like pain and loud noises. The wander guard was described as active and linked to the unit exit door.
Not the elevator.
When inspectors returned and asked for the behavior log and the frequent monitoring documentation referenced in the April 10 evaluation, and the trigger assessments referenced in the May 15 team notes, the facility did not provide them.
The maintenance director told inspectors on July 3 that the facility had just started a wandering log to check the alarms, and that there was no policy or manufacturer's instructions for maintaining and testing the wander guard system.
The facility's own care planning policy, last revised in March 2022, assigned the interdisciplinary team responsibility for developing resident care plans but did not specify any timeframe for doing so after a problem was identified.
The resident was found on Oak Street twice. The elevator she kept walking toward had no alarm both times.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villas At Saratoga Skilled Nsg & Assisted Lvg from 2025-08-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
THE VILLAS AT SARATOGA SKILLED NSG & ASSISTED LVG in SARATOGA, CA was cited for violations during a health inspection on August 12, 2025.
The second elopement happened on May 13, at 7:45 in the evening.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.