Inset: Mildred Hernandez. Background: The California nursing home that Mildred Hernandez allegedly walked out of before freezing to death (KXTV).
A California nursing home let a 100-year-old woman with Alzheimer”s dementia who was known for “wandering” at night walk out of an exit door “that automatically locked” behind her, preventing her re-entry and causing her to freeze to death, her family says in a lawsuit.
Mildred Hernandez was “cold to the touch” and suffering from “agonal breathing,” as well as a low heart rate, when she was found outside of Greenhaven Estates Assisted Living and Memory Care in Sacramento in February 2019, according to her family’s legal complaint. A jury is hearing testimony this week as part of a wrongful death and elder abuse trial brought on by the lawsuit.
“Emergency room health care practitioners at Kaiser Hospital were unable to obtain a body temperature, or palpate a pulse,” the complaint says. “Hernandez died from hypothermia.”
Staff at Greenhaven, which now operates as Spanish Vines Assisted Living and Memory Care, allegedly knew that Hernandez was “often forgetful, had become confused with times of day and night, required redirection, and was a high fall risk,” the complaint says. But her behavior was never officially documented, despite staff knowing about it, according to the family.
“Wandering was known,” the complaint charges. “Hernandez’s known wandering was not stated in written assessments or reappraisals of her condition, nor was this risk of harm identified or addressed in Mildred Hernandez’s individualized care plan with meaningful interventions to protect 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.
