“For such a serious wound to develop undetected in the ALF … was inexplicable,” DCF agents wrote after she died.

The home’s only punishment: a $1,000 fine levied by the Agency for Healthcare Administration for failing to seek medical care or keep proper records.

Archer’s husband of 37 years, Theodore Robert Archer, said he’s still angry over the home’s treatment of his wife. “They never told me a thing about her condition,” he said. “Oh God, she was suffering.” Janice Merrill, an attorney representing the home, declined to comment.

Beyond problems at the homes, the DCF records reveal another troubling breakdown in the death cases: dozens of bodies found at the homes were sent to the grave without any forensic scrutiny.

The Miami Herald found 33 cases in which bodies were already embalmed or cremated by the time state agents found sweeping evidence of neglect.

Take the case of Muriel Christine Staab, a blind woman in a wheelchair, whose body was cremated before state agents found she had been a victim of neglect.

Clay County sheriff’s deputies responded three years ago to a call to the state’s abuse hotline: The 101-year-old woman developed a severe infection that went untreated and weeks later was found sprawled on the bathroom floor at Park of the Palms.

Under state law, sheriff’s deputies could have asked for an autopsy, but instead allowed a doctor to sign the death certificate saying the death was due to natural causes.

Dr. Daniel B. Cox told police he would simply declare she died from natural causes, even though he was told she had fallen and injured herself. “Dr. Cox said that he would not list the bump on the back of the victim’s head as a contributing factor to death because she probably had a heart attack and then fell to the floor,” a Clay County sheriff’s report states.

Two days later, her body was cremated at Watts Funeral Home in Keystone Heights with no autopsy.

In the end, DCF agents concluded Cox had “signed the death certificate with limited information.”

Agents later found the home had failed to call a doctor when Staab came down with a serious stomach virus, and then waited 15 minutes to call 911 after finding her on the bathroom floor the night she died.

“There is a strong possibility had medical attention been sought earlier in the day or evening, or 911 called immediately, [the victim] may have survived,” investigators wrote.

No red flags

Cox said the call from sheriff’s deputies the night she died “didn’t raise any red flags,” and he decided to declare her cause of death — without examining her. Home administrator Larry Henderson declined to comment, citing privacy restrictions.

Bentley Lipscomb, a former secretary of Elder Affairs, said the DCF files show for the first time the extent of neglect in homes, and the lack of criminal prosecutions that follow. “They just don’t value old people’s lives,” he said.

He and others spearheaded the changes 15 years ago that toughened state law to allow prosecutors to charge caretakers with neglect when people die under their care. “I was tired of seeing people die unnecessarily and no one doing anything about it,” he said.

George Sheldon, the former DCF secretary, said prosecutors are still failing to look for ways to hold caretakers accountable. He said his former agency — which investigates abuse of the elderly and children — has been frustrated by the number of cases turned over to law enforcement that don’t get prosecuted.

“A lot of attention is paid to children,” he said. “Somehow, we don’t have the same kind of outrage when a person is 70 or 80. There’s clearly a lack of justice.”

One of two cases that prosecutors took to court began on Mother’s Day in 2004 when Gladys Horta’s family got a call from caretakers: the 74-year-old had fallen in the shower, but she wasn’t hurt.

When one of her relatives arrived at The Gardens of Kendall that night to take Horta to dinner, however, she found the elderly woman in bed, curled up in pain.

By the time Horta arrived at the hospital, she was soaked in urine and unconscious, with blackened feet and deep bruises inexplicably circling her legs.

Though doctors performed emergency surgery, Horta died two days later.

In the ensuing weeks, investigators found there was more to the story than what the family was told on Mother’s Day.

Instead of a fall in the shower, Horta’s injuries were caused by a caretaker who had gone to extremes to keep the elderly woman from wandering: Horta was strapped down for at least six hours — so tightly she lost circulation in her legs, forming the blood clot that killed her, DCF reports state.

After an investigation by the attorney general’s office, facility owner Mayra Del Olmo was charged with aggravated neglect and later sentenced to one year of house arrest and five years’ probation in 2006, a state attorney general report said.

But to this day, there is no record of her conviction. The reason: Her case was later expunged.

Miami Herald staff writer Jared Goyette contributed to this report.