“The members of the grand jury heard repeatedly that AHCA is not in the business of closing facilities,” said jurors, adding that by “failing to take action, or even by taking action in an untimely manner, AHCA may be unwittingly putting other residents at risk of harm.”

The grand jury also went to great lengths to urge AHCA to make the ombudsman an intrinsic part of enforcement by reviewing the problems turned up by the trained volunteers during their visits to facilities — especially severe cases of abuse and neglect.

In fact, AHCA inspectors should go on their visits to homes armed with the ombudsman reports so that AHCA can better target specific problems, jurors said.

“Because ombudsman have more contact with the ALFs, have visited the ALFs on a more frequent basis and have investigated complaints from the residents of those ALFs, they have a more extensive knowledge of the performance of the ALFs over an extended period of time,” jurors said.

Though the grand jurors stressed the need for AHCA and the ombudsman to work together, getting them to do so could be a difficult hurdle.

The Herald found the ombudsman program had uncovered more cases of abuse and neglect in the past five years than it had seen in the previous three decades. But AHCA inspectors never investigated 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.

Larry Polivka, an expert on aging who chaired the governor’s task force, said he shared several concerns raised by jurors, especially the need to better track rogue operators — who often get fired and then simply move onto other homes.

“We need to know as much about the work history of these people as possible,” said Polivka, scholar-in-residence at Florida State University’s Claude Pepper Center. “We did hear evidence indicating that some folks who had records full of deficiencies, and worse, were still able to get jobs at facilities later. That’s putting people at risk.”

Jurors recommended the penalties be increased to a third-degree felony for caretakers who are caught punishing residents for complaining to inspectors.

Jurors also called for the state to increase educational requirements for administrators — now among the lowest in the country — especially for those who oversee specialized ALFs, like those for the mentally ill.

Citing the recent bust of a Miami ring that sold fake certificates to allow caretakers to work in ALFs, the panel strongly urged the state to examine all certificates of caretakers to make sure they weren’t forged. At least 20 people were arrested in the cash for credentials sting this week that showed caretakers were able to pay $20 to get certified in CPR, as well as Alzheimer’s and Down’s syndrome care.

In the end, “the constant message is that we have to stay vigilant,” said Rundle. “If we don’t have eyes and ears helping advocate for residents, it’s perilous to think what otherwise might happen.”