A tragic incident at a nursing home in California has led to a lawsuit filed by the family of a centenarian with Alzheimer’s dementia. The family alleges that the facility allowed the 100-year-old woman, Mildred Hernandez, known for her tendency to wander at night, to exit through a door that locked automatically behind her. This incident resulted in her being unable to re-enter the premises, ultimately leading to her freezing to death.

In February 2019, Hernandez was discovered outside Greenhaven Estates Assisted Living and Memory Care in Sacramento, in a dire state. According to her family’s legal complaint, she was “cold to the touch,” struggling with “agonal breathing” and had a significantly low heart rate. These critical conditions were detailed in the complaint as part of a wrongful death and elder abuse trial currently underway.

The complaint further describes how emergency room professionals at Kaiser Hospital were unable to detect a body temperature or pulse, and unfortunately, Hernandez succumbed to hypothermia.

Greenhaven, which has since been rebranded as Spanish Vines Assisted Living and Memory Care, is accused of neglecting Hernandez’s known conditions. The lawsuit claims that her tendencies to forget, become disoriented, and wander, along with being a high fall risk, were well known to the staff but were not officially recorded.

The family’s legal action criticizes the facility for failing to document Hernandez’s wandering behavior in her assessments or care plans. The complaint highlights that this risk was not adequately addressed or mitigated in her individualized care plan with effective interventions to safeguard her from harm.

The family’s lawyer, Ed Dudensing, told local ABC affiliate KXTV that Hernandez was “out there for several hours” before she was found.

“There was no kind of silver alert,” he said. “There was no alarming of any doors, and she was found by a caregiver, but she couldn’t be saved.”

The family’s complaint says Greenhaven staff “failed to adequately provide and supervise the care required of residents” and did nothing to ensure that Hernandez would not wander outside. The family is seeking damages for negligence, wrongful death and elder abuse.

A total of 12 entity defendants were named in the complaint, with at least five of them having “previously settled” or been dismissed from the lawsuit, according to court filings. Lawyers for them have said that Hernandez’s family has not proved that “negligence caused the decedent’s death,” and that the evidence proving that they caused Hernandez’s fatal injuries is “insufficient.”

According to KXTV, state inspection reports from the California Department of Social Services show the facility has been cited for deficiencies related to staffing, training, and resident supervision. Citations have been filed as recently as 2025, KXTV reports.