A lawsuit claims that a 100-year-old woman with Alzheimer’s disease, who was prone to nighttime wandering, was left to freeze to death after a California nursing home allowed her to exit through a door that automatically locked behind her, preventing her from re-entering. This incident, according to her family, occurred at Greenhaven Estates Assisted Living and Memory Care in Sacramento.

The family of Mildred Hernandez alleges in their legal complaint that she was discovered outside the facility in February 2019, showing signs of severe hypothermia, including being “cold to the touch,” having “agonal breathing,” and a slow heart rate. This week, a jury is hearing the wrongful death and elder abuse lawsuit related to her case.

The complaint details that when Hernandez was taken to the emergency room at Kaiser Hospital, medical personnel could not record her body temperature or detect a pulse. Tragically, Hernandez succumbed to hypothermia.

The lawsuit asserts that staff at Greenhaven, now Spanish Vines Assisted Living and Memory Care, were aware of Hernandez’s cognitive challenges, including her forgetfulness, confusion about day and night, and her high risk of falling. Despite their awareness, her wandering tendencies were reportedly never documented in her care assessments or plans.

“Her tendency to wander was known,” the complaint states, criticizing the facility for not documenting her wandering in written assessments or care plans, nor implementing protective measures to ensure her safety.

Ed Dudensing, the family’s attorney, told local ABC affiliate KXTV that Hernandez was left outside for “several hours” before being discovered.

“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.