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There are no words

They are among society’s most vulnerable — children with severe autism — and yet many endure abuse or neglect in the state-licensed residential schools that care for them. With not enough accountability and scant public disclosure, it is an invisible crisis.

Illustration by Hirotoshi Iwasaki for the Boston Globe

A caretaker at Sean’s group home insisted that he had caused his own injuries late that March night. That the young man himself was to blame for the shattered front tooth, the gash in his swollen lower lip that required seven stitches.

Sean is severely autistic and speaks only in one- and two-word clips, so he could not explain what had happened. His parents raised him at home until his needs became just too much. Enrolling him in a residential school, this one run by The Guild for Human Services in Concord, was the hardest decision they had ever made. But they dreamed Sean would become more independent, make friends, and in time discover meaningful work.


That dream became a nightmare — a nightmare captured on video.

When police officers and state investigators watched the group home’s security camera footage from that night last year, they saw no sign that Sean, 20, had hurt himself. Rather, what they saw was an eight-minute unprovoked assault by caretaker Jimmy Kimera during which he repeatedly tripped, knocked down, kicked, and stomped on Sean, according to investigation reports obtained by the Globe. The attack apparently began when Sean came to Kimera and a co-worker for help when he couldn’t sleep. In doing so, he kept them from sleeping. Fury followed.

A brutal assault in a state-licensed facility was shocking, but it did not come without warning. Massachusetts officials charged with protecting this vulnerable population have been repeatedly alerted to the hazards in these facilities in reports that have called for improvements.

Beginning a decade ago, members of a special commission on autism raised red flags that group homes for autistic people were substandard, warning that low pay, poor training, and high turnover among staff could create an “unstable and potentially dangerous environment.”

In 2017, the state’s Office of the Child Advocate focused specifically on residential schools, which include group homes for students, after families accused staff at a school that enrolled autistic boys in Great Barrington of repeated violence against students. Consultants concluded that regulators did not routinely collect and monitor certain key safety information, such as staff turnover, tenure, and excessive overtime. They still don’t. The child advocate agency promised that the significant workforce problems would be addressed later. But while state officials have taken some limited steps, there has been no comprehensive response to address the pervasive deficiencies.


And as families waited for answers, hundreds more students with disabilities have been harmed or put in harm’s way at group homes that are part of taxpayer-funded residential schools, according to a Globe Spotlight Team investigation, which gathered and analyzed information scattered throughout multiple agencies, police departments, and courthouses.

The details unearthed by the Globe publicly document for the first time the mistreatment students like Sean have experienced, information that his parents had no easy access to when making their decision to place him in the home. While such information is available in bits and pieces to people who file public records requests, or travel from courthouse to courthouse, the state provides none of it to families reviewing the suitability of residences.

The Globe examined 13 residential schools that specialize either solely or partly in students with autism, a diagnosis that has soared in recent years. State regulators have documented nearly 1,000 licensing and safety violations during almost 450 separate investigations at those schools’ residences since mid-2016, the Globe found. The vast majority of the violations were concentrated in half of the schools.


Furthermore, the state’s child-protection agency, the Department of Children and Families, supported allegations of abuse or neglect against employees at these schools in more than 80 investigations since mid-2018, according to data obtained by the Globe.

In numerous instances, regulators cited egregious misconduct by staff involving physical harm, including a case in which a house supervisor for the Evergreen Center based in Milford rubbed cayenne pepper into a student’s eyes, apparently hoping that the pain would deter him from his pattern of injuring himself.

Violations found by state investigators since mid-2016:

Source: Massachusetts Department of Early Education and Care investigations of 13 schools

At the Judge Rotenberg Educational Center based in Canton, a pattern of abuse appeared to flourish at one of the school’s nearby group homes. Police last year charged three employees, one a supervisor, with assaulting students in four separate incidents, including one beating that sent a student to the hospital.

In dozens of other cases examined by the Globe, caretakers were immersed in their personal cellphones or otherwise preoccupied, enabling unsupervised students to run away or engage in other harmful behavior. Conditions became so chaotic in some group homes that law enforcement was summoned. Police found one youth walking along a rural road at 4 a.m., stopping cars to say he was lost and thirsty. He had been missing for almost six hours before anyone in the autism program at Devereux Advanced Behavioral Health based in Rutland noticed.


Unsupervised students also have had sex with one another or sexually assaulted other students, in some instances at residential schools that treat children whose diagnoses include inappropriate sexual behavior and where the risks of leaving them unattended should be well known.

It is difficult to determine the exact number of children with autism who have faced mistreatment based on gaps in how the state provided records to the Globe. And the harm is not limited to students with this diagnosis; some of these schools also treat youth with intellectual disabilities and serious mental health problems.

In all, the state licenses 176 individual residences that are affiliated with 34 schools. They include a range of living arrangements; some students live in group homes near the school or in surrounding communities while others reside in dorms on campus. The Globe focused on schools with an autism specialty because of the increase in diagnoses, the discovery of several disturbing cases, and the unique challenges involved in investigating cases when the victim is nonverbal.

The agencies that oversee these schools and students fail to disclose these searing realities to families desperate for a top-notch program — families that might push for improvements, or accountability, if they knew more.

The Globe was able to compile data and detail cases only through dozens of public records requests and interviews with families and employees.

The perilous conditions in residential schools are in part the product of a complex bureaucracy that places few restrictions on who cares for students with challenging disabilities that include not only autism but mental health diagnoses, aggressive behavior, and trauma. While Massachusetts licenses these residences, which are part of schools run by private nonprofit agencies, it requires few minimum qualifications and no minimum pay for front-line workers. As a result, many are underqualified and underpaid. Meanwhile, school leaders earn salaries in the hundreds of thousands of dollars.


And as in other states, oversight is divided among many overlapping agencies in a way that can be confusing for families and can obscure accountability.

Certain residential schools the Globe examined appear to have stronger safety records than others. And parents emphasized that there are dedicated workers at every facility. Speaking publicly about problems was difficult for parents: After years of rejected applications, many were just thankful their child had a place to go, even if imperfect, they feared negative repercussions against their child, or they were fiercely protective of their child’s privacy.

In response to the Globe’s questions about safety concerns, school leaders emphasized that their students can exhibit very difficult behavior, including extreme aggression. However, as in Sean’s case, children and teens were often not combative at the time caretakers assaulted them.

The Department of Early Education and Care (EEC), which licenses the residences but not the schools themselves, acknowledged that “there are areas for significant improvement” and that regulations for these schools “have not been meaningfully updated since 2005,” said spokesperson Alana Davidson.

The Department of Early Education and Care (EEC), which licenses the residences but not the schools themselves, acknowledged that “there are areas for significant improvement" and that regulations for these schools “have not been meaningfully updated since 2005”

Spokesperson Alana Davidson

The agency has started a comprehensive review of its regulations under Governor Maura Healey’s administration “to ensure that residential students and families are receiving the safe and supportive educational services they deserve,” department Commissioner Amy Kershaw said in an email to the Globe.

Peg Doherty, who has searched for a residential school and adult group home for her severely disabled son several times, said it is very difficult for parents to compare providers without public quality and safety information. She also believes the state should demand more for its money. “It’s totally up to the providers to decide what they are going to do and who they are going to hire,” she said. “The state is paying for the service but has little control over provider operations.”

Sean’s family learned firsthand about the system’s failings.

In recent years, it had become increasingly difficult for Sean’s parents to monitor him while working full time and caring for another son. And though they were still in their 50s, they worried about what would happen to Sean when they were gone.

So they reluctantly enrolled him at the Guild school, hoping it would be a safe haven for him. It proved anything but.

Jimmy Kimera and Ismael Serunjogi had been hired by the Guild as staffers who would work through the night, but cameras set up in the home’s communal areas captured them setting up couches with pillows and blankets to sleep, according to state investigation reports. This is a breach of rules that one former Guild manager said was routine. “Some overnight staff think ‘my friends tell me I can sleep, it’s a good job,’ and aren’t really in it for the right reasons,” the manager said.

Sean, who suffers from insomnia, appeared to interrupt the employees’ plan when he wouldn’t go to bed and kept returning to the living room.

Sean with his mother.

At 11:25 p.m., Kimera, seated on a couch, lifted his left leg and kicked Sean hard in his hip, the video showed, according to minute-by-minute descriptions obtained by the Globe through public records requests. The Middlesex County district attorney’s office declined to release the video to the Globe. Kimera then stood up, tripped Sean, and threw him to the floor. Sean had recently recovered from an unexplained broken arm that also occurred at the Guild.

At one point, Sean fell over onto a rocking chair. Serunjogi mostly watched. Court documents describe him as an $18 an hour overnight relief worker. Investigators said he did not stop the assault nor did he report it to his supervisors — a blatant violation of a job description that requires front-line workers to keep students safe and report abuse. State investigators have repeatedly found that workers at various schools have failed to report colleagues after seeing them mistreat students.

A state abuse investigator who watched the video of that night said the attack was unprovoked. He did not see “any aggressive, assaultive, or self-injurious behaviors of any kind” by Sean.

A Middlesex County grand jury last year indicted Kimera on four counts of assault and battery and Serunjogi on two counts, including assault and battery and permitting assault on a disabled person. Both were fired from their jobs at the Guild; they pleaded not guilty to the charges. Kimera’s attorney, Derege Demissie, told the Globe, “We look forward to defending our client in court.”

Connie Tran, Serunjogi’s lawyer, argued in a court filing that Sean had a history of aggression toward others. In a statement to the Globe, she described Serunjogi as a human rights activist who fled Uganda and “acted reasonably to protect himself.”

Guild chief executive Amy Sousa said she could not discuss specific cases or the training or work history of the two former employees. But she said that the organization does not tolerate abuse and is committed to strong training programs. When problems arise, she said, the organization is meticulous about notifying state regulators and police and those lapses are not representative of her program.

“Most people do the right thing most of the time,” she said.

“[Our son's assault] was horrific and has forever changed his life and ours.”

Sean’s parents

Sean’s parents wrote the Globe that the assault “was horrific and has forever changed his life and ours.’’ They asked that their son’s last name and their names not be used to protect his privacy.

It’s hard to know how Sean feels about what happened. A state investigator tried to interview Sean over Zoom last March. “How are you feeling? I heard that you got hurt,” said investigator Corey Young, according to a state investigative report.

Sean could not answer.

A fast growing need

After then-governor Deval Patrick created a special commission on autism in 2010, the group’s initial report cited a “staggering” increase in the number of Massachusetts children with autism.

Four percent of children here have autism, significantly higher than the US average and second only to Delaware, according to a 2019 national parent survey. The high prevalence could be because parents have ready access to pediatricians who are knowledgeable about the diagnosis and insurance coverage to pay for doctor visits. Some families also have moved to Massachusetts specifically to utilize the widespread autism services.

Percentage of Massachusetts children diagnosed with autism

Source: The National Autism Data Center

A little-understood brain disorder that stretches over a spectrum of severity, autism typically includes difficulties with communication and social interactions. Those with a milder form of the disorder once referred to as Asperger syndrome often have above-average intelligence. On the other end, 30 to 40 percent of autistic children have an intellectual disability. They also can have one or more specific characteristics; 25 to 30 percent are nonverbal, while 30 percent engage in self-injurious behavior. Anxiety, depression, ADHD, and aggression are also common.

In Massachusetts, more than 28,000 children with autism are enrolled in special education programs – six times the number two decades ago. The vast majority attend public schools or private day schools. But when a child is unsafe at home or has overwhelming educational needs, a residential school is one of the only options.

The cost to taxpayers is staggering: $200,000 to $400,000 a year per child. The price typically includes year-round classroom instruction in small groups and a home with around-the-clock staff who cook meals, teach personal hygiene and social skills, and drive students to school and other activities.

About 2,000 students attend residential schools here, a large portion with autism. Julia Landau, a lawyer with the Massachusetts Advocates for Children, said for certain children, these schools are “a lifeline.”

Cost of residential schools specializing in autism

Source: Massachusetts Operational Services Division tuition for fiscal year 2004

But for others, they have been places of peril and chaos.

Law enforcement officials launched an investigation in 2016 into the Eagleton School in Great Barrington, which enrolled boys with autism and other developmental delays, when students complained that staff were physically abusive. Police charged staff with assault and the EEC revoked the school’s license.

As a result of the allegations at Eagleton and at a special education program in Holyoke, then-governor Charlie Baker directed state agencies to improve oversight of these schools to prevent harm to this “particularly vulnerable” group of students. The Office of the Child Advocate took the lead, gathering leaders of the agencies – five in all – responsible for the schools.

The group produced an 82-page report that included a plan to identify and assist troubled programs more quickly by working closely together. Leaders at these agencies now meet monthly to share information “to improve the safety and well-being of children served in residential programs,” said Executive Office of Education spokesperson Delaney Corcoran in an email.

But there is still no comprehensive plan to solve “significant workforce challenges” — too few qualified workers and inadequate training and supervision of those hired — that “are correlated with safety and quality in residential programs,” according to the 2017 document.

Crissy Goldman, legal counsel for the Office of the Child Advocate, acknowledged in an interview that serious problems continue, including high staff turnover, which leads to further havoc. Employees “pick up extra shifts and go beyond what they typically might do, go beyond their competencies,” she said. “A lot of relief staff are coming in and don’t know these kiddos. They are put in a situation where unexpected tensions can arise.”

When asked why the problems haven’t been solved despite at least a decade of warnings, she said “It’s not something where we can snap our fingers and say ‘fix this.’”

It was after the 2017 report that Jackie Bagunda’s son Nicky, who has severe autism, was mistreated at two residential schools, she said. He first attended Evergreen and lived at one of the school’s group homes in Northbridge. When she picked him up on Thanksgiving Day in 2018, she noticed a handprint on his face and that his jaw was swollen. Staff told her that Nicky had hit himself, but she thought the angle of the handprint made that impossible. Evergreen executive director Judy Hurlburt said she could not comment because of patient confidentiality rules.

Jackie Bagunda and her son Nicky.

Soon, Bagunda moved him to the League School in Walpole and a new group home. Unlike the Evergreen home, she said, this one had video cameras in the common areas. This time, in the fall of 2019, an administrator called her and said a video recording showed two staff members abusing Nicky. Police eventually charged them; one pleaded to sufficient facts and received two years probation, while the other was found not guilty by a jury.

“Nicky woke up at night and they wanted him to go back to sleep. One of the staff put his leg out to trip him. They want to sleep and not be disturbed so they can wake up and go to other jobs,’’ Bagunda said.

Nicky, 23, has since graduated and moved into a group home for adults - one run by Amego based in Attleboro - but the risks at homes for adults are no different. “Even where he is now, I can’t say he is 100 percent safe,’’ his mother said.

In its 2013 report, autism commission members cautioned that the quantity and quality of staff in adult group homes were inadequate.

“The exact same issues are there,’’ agreed Hillary Dunn Stanisz, a senior attorney for the Disability Law Center. “If you pay staff maybe a few dollars more per hour than minimum wage and throw them into a setting that is intense at times and with people who have high behavioral or medical support needs, it is not a good recipe. The staff may not last long, and we’re left with a revolving door of temporary, new, or relief staff who don’t know the residents.”

At the Massachusetts Disabled Persons Protection Commission, which investigates abuse and neglect complaints against victims age 18 to 59, allegations of mistreatment of individuals with autism have more than doubled — from 1,125 to 2,536 — in the last two years, according to data provided to the Globe. The reasons for the jump are unclear – whether it’s because more people are diagnosed with autism, better reporting, or more actual mistreatment.

But John Randall, chief executive of Amego, said workforce problems are “absolutely” contributing to abuse and neglect.

“We screen staff. They go through the background checks and still bad apples get through. We have to have better systems of monitoring in place to provide support, training, correction, and discharge,” he said. “Even some of our good staff, over the course of the pandemic, they’re tired. Because people are tired, they’re not paying attention as best they can.”

Lack of transparency and a confusing web of state agencies

Four months after Bagunda reported to police that her son was hit at the Evergreen home in Northbridge, police investigated another incident at the same mint-green one-story ranch.

A 16-year-old student had just returned from school to the home one afternoon when the assault began. It was a horrifying episode that highlights how the state keeps hidden even the most serious violations.

A large, strong boy who didn’t speak, the teenager found transitions hard. And it was times like these that he would bang his head on the floor. Police and court officials redacted his name from records because he is a minor.

Staff were supposed to follow specific protocols when the boy, who has autism, began to injure himself, according to police interviews with staff. These included quickly strapping a protective helmet on his head and laying cushioned mats on the floor. Instead, Maime Roberts-Saka, a supervisor at the house, made up her own rules that day in March 2019.

As her co-workers restrained the boy, Roberts-Saka mixed cayenne pepper in a cereal bowl, dipped her fingers into it, and rubbed the mixture into the student’s eyes, according to a police report.

Unbeknownst to her, a colleague who had concerns about her approach to managing students had pressed “record” on his phone to capture the incident. Staff can be heard yelling about “the pepper” as the boy groans, according to a police description of the 19-second recording. The next day, a different employee recorded three male staff members saying that Roberts-Saka almost got caught — a manager had arrived at the house just as they were trying to get the boy into the shower to wash off the pepper, according to investigative reports.

That night, the boy briefly called his mother on Facetime. He was crying and she noticed that his eyes were red. She was concerned and called the staff. A worker involved in the incident reassured her that her son was fine.

The Globe reconstructed the assault using police reports, state records, and court documents.

During its investigation of this case, triggered when school administrators reported the incident to the state, the Department of Early Education and Care found eight separate licensing violations at the home. Because Roberts-Saka’s coworkers did not immediately report her to administrators or to state oversight agencies and the program had prior violations of mandated reporting requirements, the department determined that Evergreen was “not administratively sound.” That designation indicates, beyond this incident, the program was ignoring its own policies meant to safeguard students, a far more serious finding. The agency required numerous improvements.

If the state agency had registered a similar finding against a child care center, the investigation and violations would have been listed on its website. But no such requirement exists for residential schools.

If the agency had registered a similar finding against a child care center — a sector it also oversees — the investigation and violations would have been listed on its website. But no such requirement exists for residential schools. Families considering Evergreen have been left in the dark, not only about this case but about the 40 licensing violations the program has amassed in recent years. None of the agencies that oversee residential schools and disabled students provides any information to families on the quality of the homes and dorms.

Davidson, the spokesperson for the Department of Early Education and Care, said the agency is required to make information about child care organizations public as part of a federal grant. Nothing prohibits the agency from making similar information available about residential schools, but it has not done so. Davidson said the agency is committed to improving “what information is publicly available, while also ensuring the safety and confidentiality of the children served,” but she declined to be specific.

When asked about this case by the Globe, Hurlburt, the Evergreen executive director, acknowledged the incident in an email but disputed the state agency’s determination that the program was not properly administered. Just a week before the assault, during a routine licensing visit, state regulators complimented various aspects of the program, she said. Evergreen has since improved its oversight of staff, and the number of violations “has steadily dropped” since 2016, she added.

The mother of the 16-year-old student said she is “completely satisfied with how seriously Evergreen took the 2019 incident.”

The only state report on residential schools comes from another agency — the Department of Elementary and Secondary Education — but it oversees only the educational portion of these schools. During its review of Evergreen in 2021, the agency gave the school a perfect grade on its educational program. When asked why its reports do not reflect EEC violations, department spokesperson Jacqueline Reis said her agency’s reviews are independent from ECC reviews but that “any EEC findings of noncompliance help inform our reviews.”

That split has created significant dissonance at other schools, too. On its website, Devereux Advanced Behavioral Health in Rutland boasts that the Department of Elementary and Secondary Education found its educational programs “fully acceptable with no corrective action needed” during its last complete review in February 2021. Yet, in the past six and a half years, Devereux has had more EEC licensing violations than any other residential school with a specialty of autism – 301, the majority coming between 2018 and 2021 and many for negligent supervision. That is not mentioned by the Department of Elementary and Secondary Education or Devereux in public reports.

The cayenne pepper case, and the attack on Sean, also highlight holes in a state system that is supposed to stop abusive or neglectful workers from caring for people with intellectual and developmental disabilities in the future.

Despite the brutality of the attack, Roberts-Saka does not qualify for the state’s new abuser registry overseen by the Disabled Persons Protection Commission. That registry applies only when the victim is at least 18 years old, and when the caregiver works in a program under oversight by the Department of Developmental Services. Because it is part of a school, the Evergreen home where Roberts-Saka worked falls under the Department of Early Education and Care.

She does qualify for the Department of Children and Families registry because her victim was under 18. A DCF spokesperson said the agency is prohibited by law from disclosing whether Roberts-Saka is listed on the registry, which is intended to provide information to other agencies and, in some cases, employers.

Sean’s alleged abusers won’t appear on either registry, because he was 20 when he was assaulted and lived in a home licensed by the Department of Early Education and Care.

Even criminal record background checks don’t always reveal past abusers.

Roberts-Saka admitted to sufficient facts in her case in return for being allowed to avoid jail time. A judge assigned her three months probation and required her to write an apology letter to the victim. The felony charges against her won’t show up on all levels of criminal record checks since she was not convicted.

Overwhelmed low-paid staff and high executive pay

On their websites, schools deliver an upbeat message about the care they provide students in their group homes.

Devereux “offers youth and their families a cohesive, supportive and evidence-based model of treatment.” The Guild for Human Services describes “consistent support from our warm and caring staff.” And the Judge Rotenberg Educational Center says that at its “unusually attractive residences … experienced supervisory staff monitor and supervise all staff members at the residences, in real time and throughout the night” using video cameras.

But executives acknowledge that they are struggling to find high-caliber staff committed to their mission. In fact there are few limitations on whom they can employ to care for the state’s most vulnerable students.

Cara Falconi, a special education and therapeutic consultant whose son has attended several residential schools, believes that “a lot of these schools are taking students they are not equipped to manage, treat, and educate” at the same time they are short on employees. “When there is not enough staff, that means there is not proper training or accountability happening,” she said.

“I’ve been in the field for 20 plus years and I have never seen as much negligence happening in residential schools as I see today.”

Cara Falconi, a special education and therapeutic consultant

“I’ve been in the field for 20 plus years and I have never seen as much negligence happening in residential schools as I see today,” she added. “These students’ basic needs are not being met consistently, never mind the programs are so short-staffed that staff are not even able to work on the reasons why students are there in the first place.”

Massachusetts state agencies require few qualifications, and no minimum experience or pay for direct care staff at school residences, leaving that almost entirely up to the private contractors that run them at taxpayer expense. Nor does the state limit overtime to ensure the residents aren’t being overseen by exhausted workers. Front-line workers are typically paid $16 to $23 an hour — minimum wage is $15 — and many work two jobs to pay their bills.

Meanwhile, compensation for top executives at these schools ranges between $250,000 and $700,000 a year. Several executives also oversee schools or educational programs in other states, which may account for some differences in pay.

EEC officials said that requiring more qualifications for staff would have cost implications for the programs and for other state agencies and school districts that fund these schools.

The state requires agencies to conduct criminal record checks, train staff before they start work, and give refresher courses, including lessons on how to verbally deescalate aggressive behavior and avoid power struggles. In case those methods fail, employees also learn special safe techniques to restrain students and control their behavior, some of which are controversial or considered over-used. Residential schools typically use physical restraints; the Department of Elementary and Secondary Education publishes online the number of restraints and restraint-related injuries annually for individual schools.

The Rotenberg center is the only school in the country that uses electric skin shocks, which is allowed through a Massachusetts court consent decree.

Glenda Crookes, Rotenberg’s executive director, said police were right to criminally charge the three employees who mistreated students at one particular group home last year. But she said administrators found no connection between the cases other than it “is our most difficult house. For anything like this to happen is just terrible to us.’' She said Rotenberg has many safeguards in place, including extensive training and supervisors who review video camera footage live at all times.

Several employees at residential schools told the Globe that in most cases the state-required training does occur, but it can be shallow and lacking in real-world application. And communication among the staff and residents can be challenging, not just for those students who can barely form words, but for some staffers who are new immigrants and for whom English is their second language.

At Devereux, students have struggled under woefully deficient staffing, state reports reveal. The night in July 2019 when Spencer police found a student on a rural road stopping cars, one recently hired employee was on duty with six residents in the autism program on the Rutland campus. There was supposed to be one employee for every three residents at that time. The staff member did not check that residents were in their beds as often as was required and falsified a log to make it appear that he had done so, according to an EEC investigation. At one point, he apparently watched a movie.

As a result of this and other supervision problems, Devereux froze admissions to the autism program on campus.

Two months later, however, in a Devereux group home for children with autism, another child ran away when a new staff member did not properly supervise him; the student was soon found, barefoot, at a gas station on a busy street. The same child ran away again a couple weeks later. The relief agency employee on duty that night was not given any information or training about the child’s history as she should have been, investigators found.

EEC required a range of improvements, including better training for overnight supervisors, but problems continued.

In another instance in 2020, a student sitting in the staff office at the autism program on campus injected himself with Windex and aftershave, requiring a trip to the emergency room. The unit was understaffed that day. One of the few caretakers on duty was sitting in the office with the student, but was absorbed in his computer and paperwork.

Investigators also have questioned Devereux’s hiring practices. Two years ago, after a resident lit a fire in his room, state investigators said they were concerned about the ability of the facility’s employee in charge to care for children because she “seemed confused” and was slow to respond to questions.

In an email to the Globe, Nadyia Abbas, executive director of Devereux Advanced Behavioral Health Massachusetts and Rhode Island, said it is difficult to compare Devereux to other residential schools in Massachusetts because of its large size and the complex needs of its residents; about half have a diagnosis of autism, and half have psychiatric disorders.

She said the organization has strengthened its safety practices, enhancing staff training, hiring a chief safety and risk officer, and installing 300 additional video cameras. These and other measures have led to a 70 percent reduction in licensing violations since 2019, from 71 that year to 14 in 2022, Abbas said.

“Caring for someone’s child is a sacred trust,” she said.

Tere Ramos, whose daughter has autism, believes problems at residential schools go beyond momentary eruptions and one-time lapses by individual staffers. A lawyer who has helped families evaluate residential schools, Ramos has seen staff who lack enough training and on-the-job support from supervisors to talk down students during a crisis. “Instead they sometimes resort to physical and verbal responses that are inappropriate,” she said.

Photo in court records of Nasir's injuries. (Court Document)

“You have to understand, these are positions that require skill and patience,’’ said Ramos, adding that employees themselves are at risk of injury when faced with a combative student.

At the Guild, inattentive and unqualified staff contributed to a serious injury for Nasir, a severely autistic boy who was nonverbal, according to state investigators.

On a Thursday afternoon in September, 2020, an employee can be seen on a video pushing Nasir, 16, kneeing him in the torso and putting his hands around the boy’s neck. A police officer who watched the tape said he was concerned about the worker’s aggressiveness.

But the real damage happened when the pair moved into Nasir’s bedroom — out of the range of video cameras. A couple minutes later, the teen emerged from his bedroom with blood on his mouth, holding two front teeth.

That night, a Guild nurse directed staff to put Nasir’s teeth in a baggie, which prevented them from being saved. Even a Google search, investigators said, advises one to submerge teeth in milk to preserve them. “The nurse stated she never heard of this,” their report said, concluding that she was not prepared to handle the emergency.

In this case, the employee was not convicted. There was no video camera in Nasir’s bedroom, and the teen was unable to testify about what happened. A judge issued a not guilty finding. The family was able to reach a settlement with the school for $450,000.

Nasir’s mother, Nicole Daye, said the settlement includes a confidentiality agreement that prohibits her from discussing the case. But according to a police report, she and her brother went to meet with Sousa, the Guild chief executive, and watch the video of that night. Daye could not watch and left the room crying.

Globe reporter Stephanie Ebbert contributed to this report. Illustrations by Hirotoshi Iwasaki for the Boston Globe. Photo credits: Bagunda and her son Nicky, Sean and mother (family photos); Nasir (court document)

Tips or feedback to the Globe Spotlight Team can be sent to spotlight@globe.com or at 617-929-7483. Mail can be sent to Spotlight Team, the Boston Globe, 1 Exchange Place, Suite 201, Boston, MA. 02109-2132.

Liz Kowalczyk can be reached at lizbeth.kowalczyk@globe.com.