The lack of prosecutions come as the number of assisted-living facilities rises in Florida 408 new ones in the past three years.
During the past decade, the DCF death cases reveal a stunning sequence of fatal mistakes made by caretakers who are supposed to protect their vulnerable wards.
In more than 40 percent of the death cases reviewed by The Miami Herald 29 in all the people who died of neglect or abuse were suffering from dementia.
At one West Melbourne home, caretakers were supposed to follow a simple rule when the homes exit alarm was triggered: do a head count and call 911.
But when 74-year-old Waymon Cross slipped out the door of Alterra Clare Bridge in the early hours in 2003, his caretaker shut off the alarm and went back to work.
It was hours before another employee spotted his cap floating in a pond near the home, his body drifting nearby.
Her job is to protect and take care of [Cross], and she didnt do that, recalled West Melbourne police Detective Barbara Smith, adding the caretaker twice changed her story before admitting to what happened.
The homes administrator did not return repeated phone calls.
For a month in 2008, workers at Living Legends Retirement Center were finding Frances Tremblay sprawled on the floor, her body covered in cuts and bruises.
Instead of taking steps to protect her, administrators at the Deerfield Beach home ignored warnings from a staff nurse that the woman was constantly falling.
The end came after the 11th fall.
When a Broward County sheriffs deputy showed up, the 98-year-old grandmother was lying in a puddle of blood in a locked room, screaming for help.
At the hospital, doctors found she had two black eyes, a gash over her nose and a fractured neck. She died months later without ever recovering from her injuries.
What they did to her was criminal, said William Dean, an attorney who represents Tremblays family.
Though charges were never filed in the case, the details of her death emerged for the first time this year, when a Broward County jury found sweeping negligence in Tremblays death, awarding her estate $2.39 million in one of the countys largest jury awards ever rendered against an ALF.
As people were dying in homes across the state 40 in the past five years another agency joined regulators in probing deaths: the state attorney generals office.
In the past eight years, the office reviewed more than half the death cases turned up by DCF including drownings, medical neglect and drug overdoses but made just one arrest.
The DCF files show that even when caretakers were caught destroying evidence in death cases shredding and in some cases falsifying key medical records the attorney generals office didnt act.
When Dorothy Archer arrived at a Pasco County hospital two years ago, rescue workers discovered a blackened hole the size of a baseball festering on her back.
Egregious neglect was how the wound was described by DCF agents investigating her treatment at Edwinola ALF.
But when agents tried to find out how the 90-year-old developed the septic sore, they hit a barrier: Key records describing her final two months at Edwinola had disappeared. Worse, nurses notes detailing the wound appeared fabricated.