New York State and the federal government provided $1.4 million annually per person to care for Jonathan and the other residents of the Oswald D. Heck Developmental Center, a warren of low-rise concrete and brick buildings near Albany.
Yet on a February afternoon in 2007, Jonathan, a skinny, autistic 13-year-old, was asphyxiated, slowly crushed to death in the back seat of a van by a state employee who had worked nearly 200 hours without a day off over 15 days. The employee, a ninth-grade dropout with a criminal conviction for selling marijuana, had been on duty during at least one previous episode of alleged abuse involving Jonathan.
"I could be a good king or a bad king," he told the dying boy beneath him, according to court documents.
In the front seat of the van, the driver, another state worker at O. D. Heck, watched through the rear-view mirror but said little. He had been fired from four different private providers of services to the developmentally disabled before the state hired him to care for the same vulnerable population.
O. D. Heck is one of nine large institutions in New York that house the developmentally disabled, those with cerebral palsy, autism, Down syndrome and other conditions.
These institutions spend two and a half times as much money, per resident, as the thousands of smaller group homes that care for far more of the 135,000 developmentally disabled New Yorkers receiving services.
But the institutions are hardly a model: Those who run them have tolerated physical and psychological abuse, knowingly hired unqualified workers, ignored complaints by whistle-blowers and failed to credibly investigate cases of abuse and neglect, according to a review by The New York Times of thousands of state records and court documents, along with interviews of current and former employees.
Since 2005, seven of the institutions have failed inspections by the State Health Department, which oversees the safety and living conditions of the residents. One was shut down altogether this year.
While Jonathan Carey was at O. D. Heck, Health Department inspectors accused its management of routinely failing to investigate fractures and lacerations suffered by residents.
Similar problems can be found across the state. The Broome Developmental Center in Binghamton has been cited for repeatedly failing to protect residents from staff members. One employee there was merely reassigned after encouraging adolescent residents to fight one another.
Patterns of abuse appear embedded in the culture of the Sunmount Developmental Center in the Adirondacks. Last year, one supervisor was accused of four different episodes of physical and psychological abuse of residents within a span of two and a half months; another employee bragged on Facebook about "beating retards."
The most damning accounts about the operations come from employees - thwarted whistle-blowers from around the state - and the beleaguered family members of residents.
Dozens of people with direct experience in the system echoed a central complaint about the Office for People With Developmental Disabilities: that the agency fails to take complaints seriously or curtail abuse of its residents.
"I've never seen any outfit run the way this place is," said Jim Lynch, a direct-care worker in Brooklyn. "You report stuff, and then you get retaliated against. They want everything kept quiet. People that are outspoken attract the heat. I don't know who to talk to when I see a problem. Nothing ever gets done."
Paul Borer, a dietitian who works for the agency in the Hudson Valley, said he saw another employee punch a resident twice in the face in 2008, but little ever came of the many complaints he made about the episode, to his supervisors, to the commissioner of the agency at the time, Diana Jones Ritter, and to the office of Gov. David A. Paterson.
"You can see a person get hit, then you can go through three years of writing back and forth and nothing happens, so why even report it?" Mr. Borer said.
Mary Maioriello, who worked at O. D. Heck, reported seeing several cases of abuse, including the repeated beating of a resident with a stick that staff members called "the magic wand."