Villas at Saratoga: Dementia Patient Escaped Twice - CA
Resident 3 first disappeared on April 6 at 4:01 p.m. when a family member spotted her walking outside the facility. She was found on Oak Street and brought back to the nursing home. Despite this alarming incident, staff failed to convene the required interdisciplinary team meeting or develop an immediate care plan to prevent future escapes.
Four days later, on April 10, administrators finally acknowledged the resident had "a history of elopement at home" and "wandering behavior likely to affect safety or well-being of self and others." They classified her as high risk for elopement and developed a plan requiring a personal safety alarm device, behavior monitoring, and frequent location checks.
The plan proved inadequate.
On May 13 at 7:45 p.m., Resident 3 vanished again. Staff discovered her missing and found her wandering Oak Street around 8:15 p.m. — a full 30 minutes after she had escaped undetected.
Federal inspectors discovered the facility's wander guard system was fundamentally broken. During a June 30 tour, maintenance director and environmental services staff revealed that four of the facility's exits lacked functioning alarms, including the elevator from the second floor and multiple exit doors. The elevator that Resident 3 "was trying to go into frequently" had no alarm whatsoever.
The first-floor exit led to an unalarmed gate just 20 feet away, opening directly to a parking lot. To reach Oak Street — where Resident 3 was found both times — she had to travel down a hill over a block long while completely unmonitored.
"There currently was no elevator alarm," the maintenance director admitted during interviews. He also revealed the facility had no policy or manufacturer's instructions for maintaining and checking wander guard function. Staff had only recently initiated a wandering log to check alarms.
The medication administration records showed Resident 3 was supposedly monitored "once a shift" for elopement from April 11 through May, but the records failed to specify when these checks occurred. The facility's own interdisciplinary team notes from May 15 described her as "alert to self/name only" with a dementia diagnosis and "previous attempts to leave the facility including trying to open doors."
Staff noted she was "found exiting from the elevator" and that her wander guard was "active and linked to the unit exit door" — yet the maintenance director confirmed no elevator alarm existed.
The medical record director acknowledged during a July 30 interview that "there should have been an elopement care plan developed by the next day" after the April 6 incident. She said auditing medical records for completeness was part of her job responsibilities.
The director of nursing agreed that "a care plan should have been developed when a problem arose such as a change in condition."
When inspectors requested documentation of the behavior monitoring logs and assessment of elopement triggers that staff had promised in their May 15 interdisciplinary team notes, the facility failed to provide any records.
Federal inspectors also documented that Resident 3 had been "swiped food from another resident's room," but no care plan addressed this wandering behavior either.
The facility's Care Planning policy, revised in March 2022, assigned the interdisciplinary team responsibility for developing resident care plans but failed to specify any timeframe for action when problems were identified.
Resident 3's case illustrates the dangerous consequences when nursing homes fail to properly assess and monitor vulnerable residents. Both escapes occurred during evening hours when staffing is typically reduced, and both times she was found on the same street after wandering undetected from a facility that knew she was at high risk.
The inspection found the facility placed few residents at minimal harm, but for Resident 3 — a person with dementia wandering alone on public streets — the potential consequences were far more severe than the regulatory classification suggests.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 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.
Resident 3 first disappeared on April 6 at 4:01 p.m.
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.