Three years ago, it looked like the Florida agency that oversees care for children and adults with disabilities had finally had enough.

It filed a legal complaint that outlined horrific abuse at Carlton Palms, a rambling campus of group homes and classrooms near the small town of Mount Dora.

What Happened to Adam It took one mother seven years to learn that the for-profit school she trusted with her son had strapped him down again and again, one time after not picking up his Legos. Read the story Help Us Investigate We’re looking for tips and stories from employees, former employees or families with experiences specialized schools or group homes for children with disabilities. If you have something to say, please email us at [email protected]. When sending tips, please include location.

A man called “R.G.” was punched in the stomach, kicked and told “shut your fucking mouth,” the complaint said. “R.T.” was left with a face full of bruises after a worker hit him with a belt wrapped around his fist. A child, “D.K.,” who refused to lie face down so he could be restrained, was kicked in the face and choked until, eyes bulging, he nearly passed out.

State officials wanted to bar Carlton Palms from accepting new residents for a year.

“[A] moratorium on admissions,” wrote a lawyer with the Agency for Persons with Disabilities, “is necessary to protect the public interest and to prevent the continuance of conditions that threaten the health, safety and welfare of Carlton Palm’s (sic) residents.”

Two months later, the state backed down.

Carlton Palms’ owner, the for-profit company AdvoServ, had deployed a Tallahassee lawyer and lobbyist who counted a former governor among his clients. The company admitted no wrongdoing and paid no fines when it settled with the state. It did agree to install more cameras to monitor workers.

The state of Florida — and its public schools — then went right back to sending Carlton Palms new clients.

AdvoServ’s homes and tens of thousands of facilities like them were supposed to be an antidote to the ills of institutional care for society’s most vulnerable: children and adults with profound disabilities like severe autism. Tucked away in neighborhoods across the country, the homes are often a last resort for overwhelmed families and schools, as well as state officials who shuttered their public asylums over concerns about mistreatment.

But the sprawling system of privately run residential programs is quietly — and with few repercussions — amassing a record as grim as the institutions it replaced, a ProPublica investigation found.

Particularly haunting are the deaths of children in residential facilities, often far from their homes. At least 145 kids have died from avoidable causes in such facilities over the last three decades, a ProPublica review of news accounts found.

In one group home, a worker strangled a teenaged resident during a struggle; at another, a boy died of an infection after employees taunted him and accused him of faking illness. Other children suffocated while workers held them down.

AdvoServ’s Carlton Palms is one of a dozen residential programs nationwide where two or more children have died in separate incidents from potentially preventable causes. Most recently, a 14-year-old girl died there after a night during which she was tied to a bed and chair. She’d entered the program just six months after the state dropped its call for a year-long moratorium.

Paige Lunsford, 14, died at AdvoServ’s Carlton Palms facility after a night in which she was tied to a bed and chair while vomiting. (Emily Michot/Miami Herald)

A deep examination of AdvoServ — a veteran industry player now owned by a private equity firm — shows how a powerful, well-financed provider can exploit a fractured system, using its deep pockets to beat back sanctions, bully regulators and shape the very rules it plays by.

The company’s ascension reveals, too, the fraught marriage of convenience that binds the growing ranks of private providers to the public agencies that rely on them, sometimes paying upwards of $350,000 a year in taxpayer money for each resident’s care.

Officials with Florida’s disabilities agency said the state sees itself as partnering with, as well as policing, Carlton Palms.

“Our approach has been very, very aggressive in working with Carlton Palms,” said Tom Rankin, a top official with the agency. “It’s also been very, very collaborative.”

Restraint Chair State records show many of AdvoServ’s Florida residents have been injured during “behavior interventions” that turned physical, typically involving restraints. Teeth were knocked out, noses pushed out of joint. Cuts needed stitches. Arms, collarbones and jaws broke. The person sits in the chair His wrists are secured to the arm rests His ankles are strapped in place A lap belt is fastened A shoulder harness is applied The person can’t get up from the chair Credit: Hiram Henriquez for ProPublica

State and federal officials often give operators like AdvoServ wide latitude on key decisions such as figuring out how to control unruly patients, meet medical needs and staff homes. When problems occur, the limits of regulators’ power can become starkly clear.

One infamous program for instance, the Judge Rotenberg Educational Center outside Boston, has been condemned for its use of electric shocks to halt residents’ undesirable behaviors. At least two states tried and couldn’t get Rotenberg to stop. The facility continues to receive more than $60 million a year in mostly public money to care for 240 people with developmental, intellectual or emotional disabilities.

Calls for federal action have failed. A bill first introduced in 2008 would have required the federal government track abuse complaints and create a website listing residential providers for kids nationwide. It has gone nowhere.

Even some in the industry say more oversight is needed. “We definitely support regulation because bad things have happened to kids in residential programs, and not just 10 years ago,” said Kari Sisson, executive director of the American Association of Children’s Residential Centers, which promotes best practices. “They happen to kids today.”

Florida’s aborted effort to sanction AdvoServ surprised few who knew of its nearly five decades of dealings with regulators. The company cares for roughly 700 people with intellectual and developmental disabilities and behavioral problems in Delaware, where it is headquartered, as well as New Jersey and Florida.

“I always got the feeling they were pretty untouchable,” said Kevin Huckshorn, a national behavioral health consultant.

An examination of news reports by ProPublica shows that at least 145 children died at residential programs across the country in the last 35 years from avoidable causes. Because there is no federal oversight of abuse or neglect at residential facilities, it is impossible to know how many children across the country have died or been mistreated while under the care of such providers. Credit: Annie Waldman/ProPublica, Meral Agish for ProPublica

AdvoServ executives say there is no pattern of abuse in its facilities and that employees who mistreat residents are disciplined. “In a program like ours in which we serve individuals with significantly challenging behaviors, incidents are going to be inevitable,” said Robert Bacon, the company’s chief operating officer and a 29-year AdvoServ veteran.

“We acknowledge we are not perfect,” CEO Kelly McCrann told ProPublica. “But what we do does not allow perfection.”

In a written statement, top officials at AdvoServ also said they are proud of the company’s record and that they “responsibly” address problems when they arise. AdvoServ supports strong oversight and clear standards, the statement said, “because they help us deliver the highest quality care.” (Read the full statement.)

The parents of five teenagers and adults living at AdvoServ homes praised the company, which provided ProPublica their contact information.

“We have had nothing but unbelievably good experiences with Carlton Palms,” said Ginny Robinson of Kennesaw, Georgia, whose son Jonathan has an intellectual disability and can have violent tantrums. He first entered the program 19 years ago. “I truly believe had we not found them he would be either in jail or dead.”

But a more troubling picture emerges from thousands of pages of public records reviewed by ProPublica, as well as from the accounts of current or former residents laid out in lawsuits and in interviews with relatives. Many complaints have centered around the company’s aggressive use of mechanical restraints, such as leather cuffs, chairs with straps, and a “wrap mat” akin to a full-body straight-jacket. Such tactics, records show, have resulted in broken arms, collarbones and jaws, knocked-out teeth and cuts needing stitches.

In late June 2013, Carlton Palms’ staff members assured Paige Lunsford’s parents in emails that their daughter, a waifish girl with brown eyes, “was having a nice day in class today” — even though she had begun vomiting and clashing with staff just days after arriving. Lunsford had autism, was bipolar and schizophrenic, and couldn’t speak. She struggled with compulsions to bite her skin or bang her head. Workers tied her down when she ran from them, threw things or tried to hurt herself.

A Carlton Palms doctor saw her but, despite her worsening condition, chose not to send her to the hospital. The next morning a 911 call brought medics to Lunsford’s bedroom, where they found her dead of dehydration brought on by her stomach illness.

The sole concession Florida regulators wrung out of AdvoServ after dropping the admissions moratorium — that the company improve video monitoring — did little to bring about accountability.

When detectives went to examine video from cameras where Lunsford lived, they discovered all but an hour or so was gone. Company officials said the footage was mistakenly erased.

In recent decades, states have largely outsourced the day-to-day care of people with developmental and intellectual disabilities. Group homes are now overwhelmingly run by private organizations, and while nonprofits rule the sector, for-profit investors have increasingly taken interest. AdvoServ founder Kenneth Mazik was at their vanguard.

Mazik opened the Au Clair School for autistic children in 1969 in a stern-looking 28-room mansion in Bear, Delaware. A broad-shouldered University of Delaware graduate who had worked at a state institution, he said a particularly gruesome encounter had inspired him: A boy he was counseling had pulled out his own eye. “So, following my usual pattern, I overcompensated,” he told a reporter at the time. “I threw myself into autism - which was what was wrong with the boy.”

He took in castaways — his first patients were teenage boys who had been kicked out of another program — and Au Clair soon had 30 children. It received national attention in the early 1970s when “Silk Stockings,” a racehorse owned by Mazik and his then-wife, started winning harness-style races, infusing the school with prize money. The media loved the tale of how the horse saved the little school for autistics.

AdvoServ started out nearly five decades ago in a 28-room mansion in Bear, Delaware, in 1969 as the Au Clair School for children with severe autism. (Melissa Steele/The Cape Gazette)

Another source of cash for Au Clair appeared when Congress mandated in 1975 that public schools take responsibility for educating all children with disabilities. Local classrooms still sometimes couldn’t handle children with the most serious impairments, so families implored local officials to pay tuition for special private schools. Mazik’s Au Clair, and schools like it, took the cases no one else would.

But signs of trouble began soon after the glow from Silk Stockings’ wins faded, when former workers said they had witnessed children being beaten at Au Clair as part of their treatment.

Articles in the Wilmington News-Journal in 1979 described children hit with plastic bats and dunked in a dirty swimming pool. Mazik himself, the newspaper said, had repeatedly whipped a 16-year-old boy with an intellectual disability across his backside with a riding crop.

Mazik acknowledged in the story that he had struck the boy, but said it didn’t constitute abuse. The employees who complained were disgruntled, he said.

We found at least 62 children at programs across the country died after being restrained. Although the use of restraint and seclusion can cause injury or trauma, over 80 percent of residential treatment facilities have recently used the techniques on children. Credit: Annie Waldman/ProPublica, Meral Agish for ProPublica

Delaware officials considered shutting down the school, but instead chose to work with it to improve conditions.

The company continued to grow, opening a second Au Clair in 1987 in Florida, northwest of Orlando. That school — later rechristened Carlton Palms — took root on the isolated lakeside campus of a former retirement community, tucked between orange groves.

The company had told local officials the school would house 20 to 30 children, ages seven to 18. But within three years, it had grown to 48 students coming from 28 states.

Keeping large numbers of disabled children under one roof was exactly the model the country was moving away from. The goal was to replace big institutions with a network of community-based homes.

But in Florida, a lobbyist for the company urged legislators to carve out an exception for “transitional” programs with tiered levels of care and more people living together than was typically allowed. The change — which only benefited Au Clair — also later helped justify higher rates of pay from the state than what other programs received.

By 1997, Au Clair had changed its name to AdvoServ and expanded to about 130 children at schools in Delaware and Florida. That year, it faced two crises.

On April 2, Mazik telephoned relatives of a 14-year-old student to tell them the boy had died of an apparent seizure at Carlton Palms.

A caller to the state’s abuse hotline a few months later reported that the boy, Jon Henley, hadn’t received immediate medical care for the seizure, and that staff had neglected him.

Investigators from the county sheriff’s office and state Department of Children and Families discovered a roommate had told staff that Henley was shaking their bunk bed early that morning, but workers had done nothing to help him. One staffer said she just told the boy — who was face down — to be quiet because she thought he was masturbating. Workers were supposed to check on his wellbeing every 15 minutes all night. But he was found dead at wake-up time, 7:30 a.m., still face down.

Henley had autism and took medication to prevent convulsions. But an autopsy found it present in his blood at levels far below the “therapeutic range” typically needed to control seizures.

Ultimately, despite signs of potential lapses in care, the sheriff’s office did not file criminal charges and state investigators closed their inquiry with no finding of mistreatment. The facility faced no repercussions.

Henley, a joyful child whose loved ones called him “Prince Jon Jon,” had gone to Carlton Palms because his St. Thomas, Virgin Islands, school district wasn’t equipped to teach him. “If they had the accommodations on the island for him we would have never sent him there,” his aunt Laurice Simmonds-Wilson recalled.

When he died, she said, Carlton Palms officials said the company would pay for a casket and arrange to return his body to St. Thomas.

Family members only recently learned through ProPublica’s inquiries about the state investigation and allegations that Henley had not received proper care. The family didn’t even know an autopsy was conducted. “We feel we were lied to and fooled for all of these years,” Simmonds-Wilson said. “Jon Jon deserved justice. Period.”

Jon Henley, 14, died of an apparent seizure overnight at Carlton Palms in 1997 after a worker simply told him to quiet down. Courtesy of Laurice Simmonds-Wilson

A former staffer said Carlton Palms administrators had offered little information about what happened to the well-liked student, even to workers. “I was confused,” said Susan Knoll, who was a behavior analyst there at the time. “They didn’t tell us, which seemed strange.”

AdvoServ officials, in a statement, said Carlton Palms cooperated with the investigations, which found no wrongdoing, and that “[w]hen incidents like this occur, we responsibly address them.”

Just a month after Henley’s death, the next crisis hit: The New York Times published a scathingstory on Mazik’s schools and his influence on federal welfare reform.

The story — which didn’t mention Henley’s death — revealed New York inspectors had once discovered children at the Delaware Au Clair school living in trailers that smelled of urine and feces. One weeping deaf boy, the story said, had been confined for hours in a wrap mat that had cut off his circulation.

“I cried all the way back on Amtrak,” a New York official told the Times.

The story also detailed how Mazik had maneuvered to dip into a stream of foster care funding by urging federal lawmakers to strike the word “non-profit” from a section of the 1996 welfare reform legislation signed by Bill Clinton.

Mazik quickly sent a letter to Delaware officials blasting the story. “Because of your involvement,” he wrote a top licensing official, “I want to provide you with some facts to help alleviate any discomfort you may feel as a result of the Times piece.”

But any worries Mazik might have had proved unfounded. The company experienced no major fallout and proceeded with plans to enter a new market. AdvoServ would soon become the largest provider of group homes for developmentally disabled adults in New Jersey.

Mazik’s circumstances seemed to reflect the company’s growing prosperity. He kept homes in Delaware and Florida, shuttling between them in his private plane. He collected fine art, cigars and wine and increased his real estate holdings. He also developed other business ventures, launching a video surveillance company that supplied his group homes and schools.

AdvoServ’s expanding portfolio of programs routinely used mechanical restraints, such as the wrap mat or cuffs — which other operators were abandoning — to manage agitated residents. The company battled fiercely to fend off any limits on such measures.

In 2003, New Jersey lawmakers introduced a state bill to curtail restraints in residential programs, particularly those serving people with developmental disabilities or brain injuries. The measure was inspired by Matthew Goodman, a 14 -year -old who had died of pneumonia after being repeatedly restrained while living at another operator’s group home.

At an assembly committee hearing on the bill, then-AdvoServ CEO Judith Favell passionately defended the tactics. “I believe that restraints should be used to assist in decreasing a behavior problem,” she said. “In my experience, the abuses involved in restraint are, indeed, rare.”

Favell also met with the committee’s chairwoman, Democrat Loretta Weinberg. Two weeks later, one of Mazik’s companies donated $2,200 to Weinberg’s campaign. Mazik gave another $25,000 to the state Democratic Party’s senate political action committee — the first installment of nearly $125,000 he would give the party over the next four years.

38 children at programs across the country died of asphyxiation after being restrained. In 1990, Diane Harris, 17, died as a result of asphyxiation after staff at a Texas residential treatment center restrained her in a “five-man basket hold.” In 1993, Casey Collier, a 17 year-old boy with autism, suffocated to death following a “six-point” restraint in Colorado Springs. In 2004, a 13-year old boy with autism choked on his vomit and suffocated to death after he was restrained by six staff members at a facility in Virginia. Credit: Annie Waldman/ProPublica, Meral Agish for ProPublica

Weinberg’s assembly committee went on to pass a weakened version of the measure with fewer limits, and a restraint bill did not gain traction in the state senate.

Weinberg, now a state senator, told ProPublica she agreed to the compromise bill not because of AdvoServ, but because she didn’t think stronger legislation could pass and had heard from parents who supported restraints. “I have never in my 20-some years in public life sold a vote,” she said.

In the end, the company got its way: The effort at reform fizzled.

A few years later, the restraint issue resurfaced — this time on the national level. In 2009, Congressional lawmakers introduced the first of what would become a series ofbills to restrict the use of restraints on public school children.

AdvoServ pushed back, using heavyweights such as former HealthSouth lobbyist Eric Hanson — who was later joined by former Congressman Jerry Weller. The company has paid the lobbyists’ firm nearly $1 million over the past decade.

The legislation was reintroduced repeatedly but stalled, never achieving significant Republican support.

Two opponents of the restrictions were the most vocal, a former Senate staffer said: One was the controversial Rotenberg Center. The other was AdvoServ.

AdvoServ has proven as adept at working over the state agencies that deliver it clients — and the millions of dollars that follow them — as it has the political process. The company’s relentless advocacy in Delaware kept a stream of residents flowing to its facilities even after two sets of regulators raised alarms about children hurt in its care.

In 2011, Delaware’s agency for foster care and children’s mental health took a bold step: It decided to stop sending kids to AdvoServ.

The Wrap Mat Nearly every day at AdvoServ, residents are strapped into mechanical restraints, which were considered so inhumane that the United Kingdom banned them in asylums in the 1800s. They have also been mostly abandoned in the U.S. Workers force a person trying to hurt themselves or others to lie down. Workers force a person trying to hurt themselves or others to lie down. Workers force a person trying to hurt themselves or others to lie down. They tie down the person's wrists and ankles with straps. They tie down the person's wrists and ankles with straps. They tie down the person's wrists and ankles with straps. They fold big flaps across the person’s body. They fold big flaps across the person’s body. They fold big flaps across the person’s body. They use seatbelt-like straps to close the mat, and turn on a fan so the person won’t asphyxiate. Credit: Hiram Henriquez for ProPublica

Agency officials objected to mechanical restraints and thought kids were staying too long in what should have been short-term placements. AdvoServ had also resisted even telling regulators about all restraints — a move that one official in an email called an effort “to prevent any oversight of their practice.”

AdvoServ leaders responded to the agency’s decision with “intense outreach,” emailsshow, urging it to reconsider and promising the company was making improvements. But state workers saw no such improvements.

“I have checked with others here in the Kids Department, who have been on site there in recent months,” wrote Vicky Kelly, director of the agency’s family services division, in 2012, “and they don’t report evidence of these changes.”

Even the state psychiatric center for adults was cutting back on restraints at federal officials’ insistence. But AdvoServ was “unbending” in its commitment to them, another of Kelly’s emails from that year said. “So the state is in a precarious position right now,” she wrote, “in agreeing that restraint is prohibited for adults, yet still allowed for youth with serious disabilities.”

As foster care officials continued to avoid placing kids with AdvoServ, Delaware lawmakers took up a bill to prohibit using mechanical restraints on public school students and limit holds with bare hands.

That posed a problem for AdvoServ because Delaware public schools referred more children to the company’s homes than the state’s child welfare agency did, sending about 20 boarding students and 10 day students a year. Each student brought in substantial revenue: Six-figure bills are typical and, for one AdvoServ student, the state and local agencies paid a combined $383,000 per year.

AdvoServ — whose Delaware lobbying firm was led by prominent former state Rep. Bob Byrd — pushed for a loophole in the restraint measure involving schoolchildren: The company wanted providers to be able to seek waivers if they thought mechanical restraints were needed for a particularly challenging resident.

A state lawmaker told an education official that because of AdvoServ’s intervention, the bill would go nowhere without the waiver provision, according to state school officials and the director of the state Developmental Disabilities Council.

In June 2013, the restraint bill passed with the exception AdvoServ had sought. (It has not, to date, sought a waiver.)

Soon after it won that battle, the company faced a new one with state education officials. They, too, had objected strongly to mechanical restraints on students, which the company was phasing out. While officials hadn’t barred schools from sending kids to AdvoServ, company executives perceived a downtick in the number of schoolchildren referred to the company’s program in 2013.

AdvoServ responded by ramping up pressure on state bureaucrats.

“One of my clients represents AdvoServ,” former Delaware Controller General Russell Larson wrote in an email to top education leaders in August 2013. “I would love to meet with you to find out if there’s anything I can tell my client to help them improve their service.”

Education officials told him they were already talking with AdvoServ directly. Unsatisfied, AdvoServ brought its concerns to Gov. Jack Markell’s office two months later — threatening to leave the state if school referrals didn’t pick up, emails show.

As AdvoServ tried to muscle state leaders into line, rank-and-file staffers at Delaware’s education department expressed frustration.

“They HAVE gotten new referrals,” one education official wrote to another after learning of the company’s complaints to Markell. “I wish they would own the problems they caused for themselves and acknowledge the inordinate amount of time we have devoted to them to help them remain open!”

Amid the wrangling between the company and school officials, a rash of complaints about mistreatment in AdvoServ homes rolled in, with seven landing between November 2013 and July 2014. “It is out of control,” a state licensing official lamented to another.

In one case, an AdvoServ worker threw scalding water on a resident, causing first-degree burns. Employees, including a supervisor who had left the home to play video games with a friend, sought to cover up what happened by claiming a cup of hot water had fallen off a dresser when the resident was trying to injure herself, records show. Workers didn’t take her to a doctor right away. Instead, they popped her burn blisters and falsified an injury report.

They later told authorities what they had done was “typical” behavior at AdvoServ. The workers resigned or were fired. The company said they lacked credibility.

In another case, a Delaware worker covered a boy’s face with a folded-up pillowcase to prevent him from spitting, leaving him gasping for breath. That led to one of three citations from the state last year for improper restraints.

In August 2014, the state education department approved keeping AdvoServ on the list of places public schools could send schoolchildren for the next three years.

Education officials said last week the decision was based on improvements the company had made, as well as parents’ and school districts’ positive comments.

After the scalding incident and other problems, Delaware’s foster agency gave one AdvoServ school a “warning of probation,” an action two steps before license suspension. The agency required AdvoServ officials to hire a consultant to help it improve safety at all its Delaware facilities.

Though the agency still wasn’t referring kids there, AdvoServ met all the requirements. This past May, state licensing authorities lifted their warning.

AdvoServ was, once again, a residential school in good standing.

While AdvoServ largely succeeded in smoothing over conflicts in Delaware, it faced what looked like a greater threat in Florida: 14-year-old Paige Lunsford had died from a treatable medical condition and state investigators wanted to know why.

A tip to the state’s abuse hotline five days after Lunsford’s death on July 6, 2013, implicated Lunsford’s care at Carlton Palms, as well as workers’ use of restraints on her.

The caller said Lunsford had been in “too much restraint for longer than necessary” and that the restraints may have made her underlying medical problems worse. Records of her care, the caller said, went missing the morning after she died.

Carlton Palms hadn’t notified the agency of Lunsford’s death, though it was supposed to immediately report any incident where abuse or neglect was suspected.

Child welfare investigators and detectives descended on the remote campus to interview employees. They discovered a tangle of conflicting accounts.

Lunsford’s parents said Carlton Palms’ doctor, Dr. Robert Lynch, had initially told them she was rushed to the hospital, where she collapsed and died, state records show. Yet medics said that when they arrived at Carlton Palms, she was already dead.

Tom Shea — the center’s director — told investigators that overnight, Lunsford had rocked herself to sleep in the restraint chair and staffers carried her to her bed.

But workers said Lunsford had endured multiple mechanical restraints on her last night while vomiting as many as 25 to 30 times — “like water out of a sink,” one staffer told investigators. Workers tied her arms and legs to a bed while she lay on her back.

11 children at programs across the country died from heat stroke or exhaustion. In 2002, Erica Harvey died from heatstroke and dehydration during a wilderness trek at a program in Nevada. “Erica’s eyes rolled into the back of her head and she fell off the trail head-first into rocks,” as Erica’s mother recently recently recounted. Credit: Annie Waldman/ProPublica, Meral Agish for ProPublica

Then, in one of the night’s most harrowing moments, they decided to move her to a restraint chair in the hallway. They said Lunsford, down to 69 pounds, fought back so hard it took six of them to wrestle her into the chair — where she was bound in six places. They said she never slept.

Her caregivers said they sought help from the program’s top nursing and behavioral staff, but no one directed them to call an ambulance.

After a nearly eight-month investigation, state child protection officials cited Carlton Palms for medical neglect and for inadequately supervising Lunsford, singling out Lynch and head nurse Bonnie Clugston.

“[W]rongful death due to medical neglect is probable,” one state report concluded.

The state health department found Clugston, the facility’s head nurse, had violated state law by failing to get Lunsford emergency medical help. (The department has not made a similar finding for Lynch.)

In its statement, company leaders said they “fundamentally disagree” with the child protection agency’s conclusions and are awaiting the health department’s determination in Lynch’s case. AdvoServ also said it stands by Shea’s account of Lunsford’s last night and that the video deletion was accidental.

“Paige’s death was very tragic and heart-wrenching for us all, and it still hurts quite a bit,” said Bacon, AdvoServ’s chief operating officer. He declined to answer specific questions about Lunsford.

Clugston and Lynch resigned, the company said. Shea retired in the spring. Lynch did not return messages left at his office. Clugston could not be reached.

Lunsford’s parents filed a lawsuit in May 2015 against Carlton Palms and certain staff members, alleging negligent medical care.

The job of figuring out what sanctions, if any, should be levied against Carlton Palms fell to the Agency for Persons with Disabilities, the same department that had sought, then dropped, a year-long moratorium.

As before, officials there chose not to halt admissions or levy fines.

“[A]s my staff previously discussed with you, the Agency is willing to forego the imposition of administrative fines at this juncture and allow your facility to apply those resources instead to complying with the expectations outlined herein,” the agency’s director, Barbara Palmer, wrote in a letter to AdvoServ almost 10 months after Lunsford’s death.

Range of Motion Restraint AdvoServ officials say mechanical restraints are only used as a last resort and can be safer than holds done with bare hands. Staff have employed the devices at the company’s 200-bed Florida program nearly 28,000 times in less than five years, state records show. The belt is tightened around the person’s waist The belt is tightened around the person’s waist A clip is looped on the wrist cuff A clip is looped on the wrist cuff The wrist cuffs are secured to the belt, forcing the person’s hands to his sides The wrist cuffs are secured to the belt, forcing the person’s hands to his sides Credit: Hiram Henriquez for ProPublica

The state required more upgrades to the facility’s video monitoring, including letting regulators call in for access to remote feeds, and an overhaul of how the program managed medical cases. Officials also mandated that the company retrain workers on restraints and that company officials meet regularly with regulators.

Three months after Palmer’s letter, as the Miami Herald prepared to publish a story about Lunsford, another alarming incident took place at Carlton Palms.

A boy broke his arm while staffers were restraining him in a wrap mat, according to state records. They didn’t take him to the hospital for five hours. He had surgery to insert pins in his upper arm, then landed back in the hospital days later with an infection after Carlton Palms workers didn’t properly care for the wound.

The Agency for Persons with Disabilities finally imposed an informal moratorium, pledging not to refer any residents to Carlton Palms.

The ban lasted five months, during which the state agency still allowed the facility to admit an out-of-state resident, according to the company.

“It is important to understand that the moratorium was not a punitive measure, it was done out of an abundance of caution to allow the agency and AdvoServ to work through any potential issues,” the company’s statement said. “We fully support the process.”

AdvoServ also paid a $10,000 penalty, the maximum allowed by law.

Today, AdvoServ appears poised for more growth. The company is expanding into Virginia.

In 2009, Mazik sold a majority share in the company to California-based GI Partners — which recently sold the company again to another private equity firm, Wellspring Capital Management in New York. AdvoServ says Mazik no longer has any ownership stake in the company.

Mazik did not respond to questions sent to him. In a letter, his lawyer said that since the 2009 sale, Mazik “has had no operational or managerial role regarding day to day operations” of the company.

Critics of Carlton Palms worry it has grown so big that regulators can’t effectively oversee it. The facility cares for nearly 30 percent of all Floridians who need such services. Finding so many beds elsewhere would be difficult.

When the Agency for Persons with Disabilities filed its complaint asking for a moratorium in 2012, it acknowledged a concern that suspending or revoking Carlton Palms’ license “could unnecessarily disrupt the lives of the existing residents.” The agency shut down two residential providers for people with similar disabilities to those at AdvoServ in the past year. But Carlton Palms dwarfs them in size and influence.

In a statement, the Agency for Persons with Disabilities objected to the idea that it is unable to properly oversee Carlton Palms. It said, however, “closure of a facility is always the Agency’s last resort … and is only done in cases where a provider is either unwilling or unable to correct identified problems.”

When AdvoServ executives gave me a tour of Carlton Palms last summer, the placid campus gave no indication of the previous year’s turmoil.

We traveled in a golf cart over wide grassy lawns past skinny palms and live oaks draped in Spanish moss, visiting tidy classrooms and silent halls in dorm-style buildings. Only about 20 of the facility’s roughly 200 residents were in view.

Company officials said the rest of their clients were at vocational assignments or off-campus trips such as to a bowling alley. About 80 residents do landscaping and janitorial work for minimum wage at sites, it turns out, that include buildings owned by Mazik’s leasing company in downtown Mount Dora.

The golf cart rolled past a chapel by a fountain, a field where residents play flag football, and a squat modular unit that serves as the administrative building. We saw teenage boys listening to a lesson about managing money, and, in another building, girls with more severe physical impairments doing crafts.

We didn’t stop at the site where Lunsford’s parents had been told Carlton Palms would plant a tree in her memory, just as it had planted one for Henley.

Update, March 28, 2017: AdvoServ has a new leadership team and changed its name to Bellwether Behavioral Health earlier this year.

Meral Agish contributed research for this report. Production by Emily Martinez, Rob Weychert, and Hannah Birch.