The same trend took place with investigations of serious incidents like deaths and injuries — known as adverse incidents — which were slashed by 90 percent between 2002 and 2008.

Regulators never investigated Isabel Adult Care III after the owner reported that Aurora Navas, an 85-year-old grandmother with dementia, had quietly wandered from the Miami-Dade home and drowned in a pond in the backyard in 2008.

“Her lack of ability to find her way back caused her accidental death,” wrote the home’s administrator, Isabel Lopez, in a report to AHCA. “We found that all procedures were followed. The facility has door alarms, proper door locks, and a fenced backyard.”

But records show that if regulators had carried out what was once a routine exercise, they would have found just the opposite: The door alarm and video cameras weren’t working, the back gate was unlocked and an attendant had fallen asleep, Miami-Dade police records show.

Navas, who had a history of wandering, was found floating in 18 inches of water, clad only in her lavender sleeping gown, a blue slipper on the ground nearby.

To this day, Alfredo Navas says he’s enraged the state never investigated his mother’s death at the quiet suburban home just north of Kendall.

“You don’t follow up when it comes to human beings who are supposed to be watching other human beings. They get nothing,” said Navas, 59, adding that his mother was afraid of water most of her life. “The safeguards you thought in place weren’t in place.”

In an interview, Lopez said she was ordered by fire inspectors to remove the locks from the rear door. But county records show that was not the case: Inspectors simply told her to get new locks.

Cases skyrocket

While inspections of homes were dropping across the state, another troubling trend was under way that would set new records.

The state Department of Elder Affairs ombudsman program was uncovering more cases of abuse and neglect than it had seen in the last three decades, with numbers doubling in the past five years.

Though the program sends its findings to AHCA, regulators failed to investigate the vast majority of the cases, records show. In fact, a state audit in 2008 found that AHCA couldn’t locate two-thirds of the complaints sent to the agency.

“It’s baffling to me,” said Brian Lee, the ombudsman program’s past director. “We find things, and it’s like, how did they not see the same things?”

Even when AHCA does find problems — including people dying from abuse and medical neglect — it rarely moves to close homes, allowing the same dangerous violations to turn up again.

Though Briarwood Manor has been the target of more than 1,200 police and rescue calls in the past five years — with residents stabbing, fighting and suffering psychiatric breakdowns — the Broward County facility has been allowed to stay open.

The drab, stuccoed home in the heart of Lauderhill has been slapped with scores of violations by AHCA — 100 in the past five years — including an episode in which a man slashed his roommate with a knife during a crack binge while the night caretaker was nowhere to be found. Twice in the past five years, the state could have revoked or suspended the home’s license, but did neither.

Instead, AHCA allowed Briarwood to operate for four years while it owed massive fines that peaked at more than $370,000, with AHCA eventually agreeing to reduce the amount by 74 percent in 2008.

Briarwood is among the hundreds of ALFs that opened their doors in the past decade, driven by the closing of state mental health institutions.

But as the industry boomed, AHCA failed to keep up with the growth, with state agents taking longer to respond to dangerous breakdowns. A Miami Herald analysis shows it took inspectors an average of 37 days to complete complaint investigations in 2009, 10 days longer than five years earlier.

At least five times, other agencies were forced to take the lead in shutting down homes when AHCA didn’t act.

One Hardee County sheriff’s detective said he was unable to prod AHCA to shut down Southern Oaks Retirement Center last year after he found residents sleeping on torn, urine-soaked mattresses surrounded by moldy, cracked walls and boarded-up windows.

Though AHCA had turned up the same hazards at the Central Florida home for eight years — including just a month earlier — the facility stayed open until fire officials ordered the evacuation of all 49 residents on June 22, 2010.

Not until the home made critical repairs five weeks later was the order lifted.

For Rosalie Manor, it was a longer battle.

For years, Pinellas County sheriff’s deputies had been forced to round up dozens of residents with mental illnesses found wandering the small town of Dunedin, breaking into a school and homes, and shoplifting from businesses.

When deputies finally investigated, they found Rosalie Manor owner Erik Anderson had placed a 53-year-old man just released from a psychiatric ward in charge of dispensing powerful psychotropic drugs to others in the home.

When two residents suffered breakdowns after not getting their crucial medications, detectives sent a warning to AHCA: Shut the place down.

But regulators dropped the case a month later, citing a lack of evidence — prompting an angry response from Sgt. J. Michael Daily, who slammed AHCA for its “inability to take action on this and other valid complaints at Rosalie Manor,” records show.

During the next two months, deputies joined prosecutors in a rare effort to close the 34-bed facility.

Detectives brought forward reams of paperwork in 2006 detailing abuse and neglect inside the cluster of cottages near downtown Dunedin — including violations turned up by AHCA year after year.

They found Anderson had covered up crucial evidence in death investigations of the home’s residents.

In one case in 2003, he threatened to fire any employee who called police after finding blood splattered on the walls of a 72-year-old man’s bedroom and a suicide note on the dresser.

In 2005, he drove a male resident with a criminal history to a pharmacy to fill a prescription for powerful narcotics, but failed to collect the drugs from the man, who then fed them to a 20-year-old female resident with mental illness. She was then raped by the man and died in her bedroom from an overdose.

Administrator charged

In the end, prosecutors charged Anderson, 60, with neglect, witness tampering and falsifying medical records. He pleaded guilty and surrendered his ALF license. His sentence: probation.

Caretaker Mary Pressley, 47, who worked at Rosalie for nearly a decade, said she couldn’t understand why AHCA never moved to close the home. “I don’t know how he got away with what he did,” she said.

Since 2005, Rosalie was among more than 40 homes found to be placing residents in immediate danger — the most serious breach of Florida’s ALF law — with a quarter of the homes going on to do it again.

Even after AHCA inspectors warned their own agency that Bruce Hall was running a dangerous facility in 2004, he was allowed to renew his license and expand the home to make room for eight more beds.

It was the third time the troubled facility was granted a renewal by AHCA, despite breaking the state’s ALF law 51 times.

The next year, Hall fell asleep on night watch duty just long enough for 71-year-old Elnora Shuler to wander out the door with her baby doll and slip into a pond on the premises.

When AHCA investigators asked Hall why the fence around the pond was only half finished, an inspection report states he responded: “My complacency is the reason… I knew I’d find [Shuler] down there in that pond someday.”

When agents visited the ramshackle 52-bed home in North Florida to investigate a tip that Hall threatened residents with a gun, he flew into a rage, referring to the residents as “deranged, mental retarded sons of bitches,” while lashing out at state agents, reports showed.

In the end, inspectors Patty McIntire and Kara Cowart, along with a Washington County sheriff’s deputy, left the property without completing their investigation, citing “safety concerns.”

For his tirade, Hall was fined $1,756 and ordered to visit a therapist because of his anger. But just 17 days later, he shoved a woman diagnosed with mental retardation to the ground, sending her to the hospital with a sprained ankle and cuts on her arm, elbow, knee and shin.

Hall told regulators he was protecting his wife after the resident grabbed her arm, but state agents cited him for abuse.

In an interview with The Miami Herald, Hall said regulators were “bureaucrats” who didn’t understand the challenges of dealing with people with mental disabilities — and that he had a right to impose force on residents when they got unruly.

“If one of them jumps on you and you got to beat the hell out of them to get them off you, then you get held responsible,” he said. “I’m the damn culprit that’s the bad guy in all this?”

He blamed residents and his neighbors for bringing unwarranted scrutiny to the facility.

“These mentally handicapped residents, they know the game,” he said. “They will play you. They are of the system, they know the system — just like a prisoner. They know what they can get away with.”

He said if he hadn’t imposed discipline on his residents, they would have taken control of the facility. “They’re going to realize they can continue to treat you like a dog,” he said.

During a state inspection in 2006, 14 residents at Sunshine Acres refused to give their names to AHCA agents, saying they feared retaliation.

Between 2007 and 2008, five employees quit their jobs, saying they were tired of the abuse at the home, state reports show.

During that same period, sheriff’s deputies and rescue workers were called to the home more than 400 times for, among other things, fights between residents and people suffering psychiatric breakdowns.

“It was like a damn nightmare,” said Dewayne Anderson, a next-door neighbor who joined the community coalition to close the home.

In 2008, Hall ran AHCA agents off the premises a second time after berating an elderly female resident who was trying to talk privately to them.

Hall “dropped to his knees in front of the resident” and with “flushed face, clenched jaw, rapid, loud speech, flaying [flying] arms,” he said he was throwing her out for complaining about him.

“The survey was discontinued at this point due to a fear for the safety of the surveyors,” inspectors wrote.

After the event, the state threatened to kick Hall out of the business.

In April, agents sent a letter saying Sunshine Acres’ license would not be renewed. But it was. In October, regulators told Hall to get out — but once again, bargained the punishment down, giving him a year to sell the troubled home.

Through it all, agents continued to find more problems: Six residents were illegally given powerful drugs known as “chemical restraints,” designed to keep them under control — without a doctor’s consent, agents wrote.

Finally, after more than 115 citations from AHCA, Hall sold the home in September 2009 — still holding the mortgage in a deal that will earn him $1.1 million during the next 10 years.