TUCSON, AZ — Miguel Moreno, 70, was the family patriarch so it was a difficult decision when his daughters had to place him in memory care.
Moreno’s daughters, Mina Hernandez and Adriana Moreno, had to get creative in moving their father to an assisted living facility in Tucson.
“I recall driving super slow,” said Hernandez, “He loved a filet sandwich from McDonald's, so we went through the drive-thru so that he could have something yummy to eat.”
The sisters arrived at Park Senior Villas, La Cañada on July 31, 2023, where they said they found a facility that was going to help him with a higher level of care for his dementia.
“He was my best friend,” Hernandez said.
Hernandez said he got out of the facility two days after he arrived at the La Cañada location.
“He got out of the gate, which was one of the most reassuring pieces of the facility that we have chosen because there's big wrought iron gates,” she said.
Her sister, Adriana, received a call that day that a worker from the care facility was following him and working to get him back to his new home.
According to the lawsuit filed by the family, Moreno got out of the facility on August 2nd, after he was able to lift a drop bolt for the gate.
Three days later, deputies with the Pima County Sheriff’s Department responded to that same location because Moreno got out again. This time, he was missing.
A sheriff’s report into Moreno’s death states that on August 5 he walked out of his assisted living facility without any staff noticing.
The Pima County Sheriff’s Department wrote, “It was determined that landscapers had left a gate propped open in the yard area which was the most likely avenue that Mr. Moreno left in.”
His daughters want to know how no one noticed.
“Never in my life did I [think] that day would end the way it did,” said Adriana.
It was 109º that day.
The sheriff’s department called for air support.
At one point, deputies were concerned that the helicopter could not launch because of the heat. But it did.
Hernandez, her sister, and other families took part in the search.
It was so hot, that the families felt guilty driving in their vehicles with air conditioning.
“It was a vulnerable adult that was out there by himself and confused,” Adriana said.
A deputy with air support found Moreno in a desert area about 250 yards from one of the villa units.
“Air support is who found him, in a wash, not under a bush, not under any shade, just where he gave out,” said Hernandez.
Park Senior Villas at La Cañada was fined $500 by the Arizona Department of Health Services, the state agency that licenses care facilities.
An investigation into the facility found that the manager failed to ensure that the premises and equipment were free from a condition or situation that may cause a resident to suffer physical injury.
A statement of deficiencies by ADHS said that the landscapers were scheduled to come on Wednesdays, and should not have been on the property on a Saturday – the day Moreno went missing.
The Scripps News Phoenix Investigators reached out to Park Senior Villas at La Cañada multiple times but did not hear back by our deadline.
It is unclear how long Moreno was missing before law enforcement was called.
The Scripps News Phoenix Investigators poured through hundreds of pages of police reports, medical examiner reports and state health department records. Scripps News Phoenix found at least a dozen cases of people who left their long-term care facilities or were left unsupervised outside and were all found dead in the heat.
The long-term care industry refers to unsupervised wandering that leads to residents leaving facilities as “elopements.” The exact number that occurs is unknown because no Arizona state agency tracks elopements.
Dev Sethi, attorney for the Moreno sisters, said elopements are a public health problem.
“One of the reasons we're not hearing about it is there's not a uniform reporting mechanism,” he said.
“Until there's a system-wide public health approach to protecting adults with memory care problems from elopement and protecting them from wandering away from their residences, we’re not going to have the knowledge we need to solve the problem.”
Sethi said that elopement deaths are preventable and that care facilities must have proper staffing and training.
“The more attention there is on this problem, the more resources that are devoted to it, the more we can prevent this from happening again,” said Sethi.
The Arizona Department of Health Services does not track these elopement cases by the numbers, but a spokesperson for the department said facilities should be documenting every instance of a patient leaving against medical advice.
ADHS, “does enforce the documentation requirement during inspections,” ADHS said by email.
This past legislative session, Arizona lawmakers raised the fines for care facilities from $500 to up to $1,000.
As for the Moreno family, they hope sharing their story will help bring change and accountability.
“Nobody deserves to die that way,” said Moreno.
