At a nearby hospital, the child had to be resuscitated more than once, and doctors found parts of a diaper in the youngster’s throat, as well as a Christmas tree light in the child’s lungs.

Westminster, which is now called Orlando Health and Rehabilitation Center, agreed to pay a $3,750 fine in a settlement with the state.

A 2008 complaint claimed Westminster had failed to follow a doctor’s orders that a child with cerebral palsy be given extensive physical therapy to ensure the resident did not suffer any deterioration in the use of his or her arms and legs. The child was supposed to be given a detailed regimen of restorative therapy to the arms and legs five days-per week, and be allowed to stand up three days each week. But notes and interviews showed the child had been given such therapies only once, an AHCA report says.

At Grandma’s House — which advertises on the Internet that it provides a “homelike atmosphere that fosters intergenerational healing” — one child who has autism and a cognitive disorder suffered an injury to the hand when nursing staff failed to remove protective mittens at the required interval. The 9-year-old’s left arm was swollen, discolored and bruised from the elbow to the fingertips where the hand mitt had been in place, a July 2009 report said.

Some nursing home mishaps involving children are never documented by the healthcare agency.

In 2008, a pediatrician with the Department of Health’s Child Protection Team in Miami, which investigates some allegations of child abuse and neglect, wrote a scathing letter to then-Gov. Charlie Crist, accusing an AHCA inspector of botching an investigation into reports that a severely disabled foster child had been burned at Florida Club Care.

In his letter, pediatrician Michael D. Strong said he was “shocked” by the AHCA inspector’s “apparent lack of due diligence” in a probe of the case that found no fault in the nursing home’s actions. The 12-year-old girl, who suffers from cerebral palsy and cannot communicate, had sustained second-degree burns to her hand and thigh — and no one at the home had taken responsibility for the injuries.

The death of Marie

The greatest tragedy involved Marie Freyre, a curly-haired cherub with a huge smile — but enormous challenges.

The backdrop to Freyre’s story is displayed in 40 color photos at the youngster’s online memorial: Marie as a smiling infant wrapped in a white gauzy blanket and surrounded by white teddy bears and a white reindeer; a smiling Marie in a tangerine-colored dress, with Minnie Mouse — her arms outstretched in a welcoming gesture — in the background; a smiling Marie, bows in her hair, so covered with stuffed toys that much of her body has disappeared; a smiling Marie in a lavender party dress, her hair festooned with ribbons, dwarfed by a yellow birthday cake and a candle shaped in the number 3.

“She was a very happy baby,” her grandfather said, “because she was loved by all.”

But the photos reveal another truth: Marie is never standing. Her hands are clenched in a fist, victims of the cerebral palsy that devastated her life.

Born with fluid surrounding her brain, and a seizure disorder in addition to the crippling cerebral palsy, Marie lived with her mother until a series of setbacks brought her to Tampa General Hospital, where a Hillsborough County judge — asked to determine custody of the girl — ordered that she be returned to her mother, Doris Freyre. Almost a month later, said the family’s Tampa attorney, Peter J. Brudny, the hospital placed her in an ambulance for what became a bumpy, five-hour, trip to the Miami Gardens nursing home — the only one that would accept Marie, her grandfather said. Her mother and grandfather pleaded in vain with hospital staff not to take her.

“When they took Marie out of my arms, it destroyed everyone in the family,” said 59-year-old Doris Freyre.

Joe Follick, a spokesman for the Department of Children & Families, said he does not know why a private foster care agency under contract with the state sent Marie to a Miami-Dade nursing home in violation of a judge’s order. The agency, Hillsborough Kids, no longer works with the state. “The priority of the department,” he said, “is always to keep families together, keep children in family settings and consider the best needs of a child and their family in often difficult and complex situations.”

Marie arrived at Florida Club Care Center on April 26, 2011 at 5:30 p.m. on a stretcher. “Patient was screaming,” records say.

At 9 p.m., the next note in her chart said Marie was given applesauce and “comfort measures.” At 11 p.m., Marie was noted to be screaming, as she was in the next notation, at 2 a.m.. At 5:40 a.m., notations say Marie’s breathing was labored, and she was “warm to the touch.” Five minutes later, Marie was “unresponsive.”

The 14-year-old died of a heart attack at 6:54 a.m. at Jackson North Medical Center. Health regulators faulted the nursing home for a spate of lapses:

•  Marie’s condition was not assessed by nurses until three hours after she arrived.

•  There’s no record that the nursing home ever told a doctor she was struggling to breathe.

•  Records suggest Marie did not receive life-saving anti-seizure drugs — prescribed for three times each day — past 9 or 10 a.m. the day before she died.

•  Despite the enhanced funding for pediatric residents, the nursing home acknowledged it had no policies for treating children differently than frail elders.

•  Even after Marie died, the home failed to notify the state, as required by Florida law. When questioned about the lapse, the home’s administrator took no responsibility for the girl’s death. “She did not expire in the facility,” he said. “She expired in the hospital.”

Federal regulators assessed a $300,000 fine, the largest by the feds against a nursing home in recent years. AHCA imposed a fine of $7,500, a spokeswoman said, but the fine has yet to be collected. The home currently cares for 37 children.

“We are still hurting — very, very much,” said Jose Freyre, the girl’s grandfather. “This is something we will never forget, and we will never forgive — including the state of Florida.”