A recent case at the Monroe Developmental Center in Rochester, which failed a December inspection by the Health Department, highlighted the lax practices. Inspectors found that an allegation of physical abuse was substantiated against an employee who yelled at a resident, lunged toward him and “pushed him into the wall.”

Inspectors discovered that the same employee had previously been fired in 2007, after being involved in a case of misconduct and for threatening a supervisor. The employee also had been convicted of criminal mischief, a misdemeanor, not related to her job. In her personnel file, there were “do not rehire” recommendations from “numerous supervisors and administrators at the facility when she was terminated in 2007,” inspectors found. And yet she was hired again.

Ms. Burke, the agency’s commissioner, said in a statement that despite the past practice, she “will do everything in my power to not allow the rehiring of employees who have been previously terminated.”

The Sunmount Developmental Center in the Adirondacks, a repository for residents deemed more challenging, also failed an inspection last year. The supervisor accused of four episodes of abuse of residents continued to have contact with them even as the investigations took place, inspectors found.

Inspectors also found that a resident had claimed that a caretaker had called him a “retard” and threatened to have another resident “beat him up.” When the resident was indeed assaulted by the second resident, inspectors found that Sunmount officials did not investigate whether the employee had instigated the fight. In another episode, an employee dumped ketchup, salt and pepper on the head of a resident during dinner. The agency’s response was to transfer the employee to another unit.

Around the same time, one Sunmount resident, Eddie Adkins, was set upon by several staff members after he grew upset that he was not allowed to go to the bathroom, according to an internal report provided to The Times by Mr. Adkins’s family, who were able to get the report because of a disclosure law passed in the wake of Jonathan Carey’s death.

A deaf resident told state investigators that he saw four state employees punching Mr. Adkins while he was sitting on a couch — “I did not like that,” he told investigators, adding that he was so disturbed that he turned his hearing aid off during the melee.