By the time Melvin Hearld was rushed from Grandview Adult Care II to an Abingdon hospital, his heart was racing, his kidneys were failing, infection raged in his body and his right leg was cold and dead. Doctors didn't believe that the 85-year-old man would survive the double amputation he needed. An intake nurse labeled his case "suspected neglect/abuse."

When he died 24 hours later on May 5, 2002, a doctor termed it a "wrongful death." Doctors said Hearld's massive gangrene had spread from bedsores that would have taken weeks to develop, and state inspectors said caretakers should have sought medical treatment sooner.

The inspectors contacted the Washington County Sheriff's Office, which dispatched a deputy to investigate. He interviewed a nurse at the hospital and looked at photos of Hearld's wounds. He then closed his investigation and the brief effort at prosecution died.

State records show about 4,400 cases of abuse, neglect or exploitation in assisted living facilities since 1995, but those responsible are rarely prosecuted.

Just 43 times between 1994 and 2002 have people been prosecuted under a state law prohibiting abuse and neglect of the incapacitated or elderly, according to a review of computerized court records statewide. And those cases were not necessarily in assisted living facilities.

In a handful of other cases, adult home employees were prosecuted under other statutes, including sexual assault.

Unprosecuted neglect and abuse of the elderly and disabled is "a huge problem that is widespread," said Joseph Soos, a former Alexandria police detective who trains others how to investigate these cases. Soos said law enforcement officials are often reluctant because they lack the expertise and determination to investigate and prosecute this type of case. Also, the mental or physical disabilities of the victims can make them poor witnesses.

Some cases are missed altogether, he said, because social workers, not police or other trained officials, are expected to make critical decisions about what constitutes a crime and whether to contact police. State officials said new requirements that abuse, neglect and certain deaths be reported and reviewed should bring many more cases to light.

In Hearld's case, state inspectors concluded that staff members failed to detect the worst of his three bedsores and, when they did, "failed to obtain proper medical attention for the resident."

Washington County Detective J.S. Blevins said he decided that there was no criminal intent, so he closed the case. "I did that one interview . . . and I pretty much turned it back over to Social Services," he said.

Washington County Commonwealth's Attorney Jeffrey Coale, who left office in 2003, said neither the sheriff's office nor licensing inspectors contacted his office about Hearld's death.

Dexter Ramey, who operated the home at the time, declined to be interviewed, but in state records he denied that the home neglected Hearld. The facility remains open under new management and a new name.

At Brighton Gardens of Richmond, prosecutors had witnesses who saw Louise Elliott Jonas, 81, being abused March 3, 2002. A caretaker slapped Jonas on the arm and said "that [expletive] gave me a hard time today," co-workers told licensing inspectors. After dinner that day, the staff saw the same caretaker pin Jonas to the bed with her elbow and wrestle her into her pajamas.

About 2 a.m., Jonas was found collapsed in her room, suffering from a massive head injury. She died five days later of a subdural hematoma, an autopsy found.

The medical examiner said the cause of the hematoma was "undetermined."

"The injury that was rough handling, that was described in the evening, did not involve her head," said Marcella F. Fierro, Virginia's chief medical examiner. Fierro noted that Jonas had Alzheimer's disease, which made her brain more susceptible to injury. Jonas could have fallen and "could have severely banged her head on something with no fault to anyone," Fierro said.

The caretaker was found guilty of misdemeanor assault and given a suspended sentence. Inspectors fined Brighton Gardens $500 but drew no connection between that and the death. The executive director of the facility said the employee was fired.

"Personally, I feel like that [caretaker] is responsible," said Dick Cecil, Jonas's grandson. "She was fine before. She lost all of her dignity."

Jane Trotta, 61, a resident of Cary Avenue Adult Home in Gloucester, was sent to the hospital in 2001 with multiple bed sores, one so deep that the infection reached the bone, prosecutors said. Licensing inspectors found that the home violated regulations in her care.

Prosecutors said they wanted to avoid debate about who should be held accountable, so they charged the corporation that ran the facility.

"Rather than pin a conviction on some poor nurse's aide who is making little more than minimum wage, find the corporation responsible," said Gloucester County Commonwealth's Attorney Robert D. Hicks.

One of Trotta's sores was "extremely bad" when she was sent to the emergency room, owner Benny Stokes said. But Stokes contended that the injuries were self-inflicted with a heating pad. "She didn't want to be helped, basically," Stokes said.

The trial lasted one day. The judge noted that nobody could say for certain how long it took for the injuries to develop and how long they had gone undetected. He dismissed the case.

"It's a criminal case . . . and I have a reasonable doubt," Judge William H. Shaw III said in court.

Staff researcher Bobbye Pratt and database editor Dan Keating contributed to this report.

Virginia Commonwealth's Attorney Robert D. Hicks and Assistant Commonwealth's Attorney Nanci Reaves review Trotta's files. Trotta's bedsores were so bad that she had to be hospitalized.Benny Stokes, owner of Cary Avenue Adult Home in Gloucester, says Jane Trotta's bedsores were her own fault: "She didn't want to be helped."