Jacquelyn Kaminski's hair was often greasy, her weight dropped dangerously, and she had bites and bruises from attacks by other residents at her group home for adults with intellectual and developmental disabilities.

The staff didn't change Jacquelyn out of wet undergarments or wipe her thoroughly. The house where the 34-year-old lived in Wayne, run by Broadway Group Home LLC, was dirty and unkempt, with feces on the floor, and windows open to mask the smell.

And after caregivers repeatedly failed to give Jacquelyn her epilepsy medication, she landed in the hospital.

Initially, state investigators did not conclude that neglect caused her hospitalization -- but they reversed that decision 15 months later when Jacquelyn's parents pressed for more information.

State officials had been aware of serious concerns at Broadway for some time. But the company's licenses to run group homes are unblemished -- and the state has allowed Broadway to expand.

Jacquelyn's story highlights the many failings in New Jersey's group home system, where the state reacts slowly, if at all, to problems and troubling lapses in care.

Previously, NorthJersey.com detailed how some residents of state-licensed group homes and supervised apartments die alone, unsupervised -- and in avoidable ways. It has also identified problems with medication and showed the dangers of a low-paid workforce plagued by churn.

Now we explore an estimated $1.5 billion system where providers largely police themselves, where consequences are few, and where a lack of accountability can have devastating results for vulnerable residents such as Jacquelyn.

Our investigation, which included the review of thousands of state, family and law enforcement records, found that:

The best glimpse into abuse and neglect in the group home system is New Jersey's incident database that tracks concerns reported by providers and the public. The data includes situations ranging from unplanned hospitalizations to serious injuries and attacks.

But NorthJersey.com found that few allegations called in to the department's abuse and neglect hotline make it into this system, which was launched in mid-2018. Of more than 5,000 calls, the state created 354 incident reports.

Even so, most group home companies have cases where residents were put in harm's way, according to investigation results through 2024.

The state substantiated 412 cases of neglect, 267 cases of abuse, and 111 cases of exploitation.

In the investigations done by group homes themselves, they substantiated more than 5,100 cases of neglect, 2,000 cases of abuse, and 180 cases of exploitation.

The specifics of the incidents are confidential.

'Where are folks going to go?'

The state Department of Human Services oversees the group home system. Its commissioner, Sarah Adelman, maintains that "all allegations of abuse and neglect are taken seriously." She insists they "take aggressive steps" against providers.

But Adelman also argues that her agency needs more powers and supports a package of bills that would more stringently regulate group homes, by imposing fines on companies for the first time and setting limits on executive pay and profits.

The bills, which have not yet moved out of legislative committee, are hotly contested by providers.

But many families with loved ones in the system say the proposed bills do not go far enough. They say it's time for investigations to move out of Adelman's department -- and especially out of the hands of providers. Instead, one bill creates a committee to study the system. The bills also don't address a push for cameras in common spaces spearheaded by the mother of a man who died unexpectedly in his group home.

NorthJersey.com spoke with nearly 100 family members or guardians. Some asked that their names not be published, fearing retribution against their loved ones living in group homes. They also worry about being branded troublemakers, hindering their chances of finding them a better, safer home.

Adelman said she could not comment on individual cases, but when NorthJersey.com asked the commissioner about residents' basic needs not being met -- a concern raised by all family members or guardians of residents interviewed by NorthJersey.com -- Adelman said, "That is not a complaint I have ever received directly."

"That concerns me a great deal," she said.

But it's something the ombudsman for individuals with developmental disabilities hears every day.

"Daily, we are told by individuals and family members about poor living conditions and about basic needs not being met," said Paul Aronsohn, the ombudsman. "Dietary restrictions or preferences being ignored. Medications being wrongly administered. Filthy clothes. Residents effectively trapped in their homes, because staff shortages prevent them from going outside. Residents not being treated with care and dignity -- not being treated like human beings."

Today, more than 2,000 group homes and apartments are nestled into neighborhoods across the state. The number nearly tripled after the 1999 landmark U.S. Supreme Court case Olmstead v. L.C., which spurred the shift of housing people with disabilities away from large institutions and into the community.

The needs are great. Thousands of people with developmental disabilities are on a waiting list for funding, many for group home slots. Hundreds more languish in nursing homes. About 1,000 people still live in five large institutions -- among the most of any state in the nation.

Tom Baffuto, who leads The Arc of New Jersey, thinks some changes can be made in the system, but believes "most providers are doing a good job."

"I do think there are bad actors out there, and that causes the whole system to be tainted," Baffuto said. "Bad actors we need to identify and get out of the system. My fear is when you have problems, we take a chainsaw to the system and annihilate the whole system, rather than taking a scalpel. Where are folks going to go?"

When group homes run as they should, it can be life-changing for residents.

After suffering abuse at a previous group home, Michael McCarthy Jr., 28, blossomed when he moved to a home run by New Concepts for Living in Park Ridge.

"After only being there a week, he opened up. He wasn't going in a corner anymore, shaking like he was," said his father, Mike McCarthy. "The staff was all friendly, they welcomed Michael in with open arms, looked at all his charts and follow his plan to a T."

Black mold and bedbugs. A strong smell of urine. Overflowing toilets and trash. Feces smeared on walls and floors.

Unsanitary conditions at some group homes are often the first sign of trouble.

One parent said the Friends of Cyrus home where his son lived was "in total disarray. It looked like Beirut." Staff didn't vacuum his son's room -- so he did it himself. Toilets were always backing up.

"I was in there, you know, snaking toilets," he said. "It was terrible."

Parents said they find urine-soaked mattresses flipped rather than replaced, feces on floors and walls, and rooms reeking of air freshener in a failed attempt to hide odors.

It's unclear how widespread hygiene issues are. Since most inspections are announced, providers can prepare before state officials arrive. In the past decade, about 5% of licensing inspections were surprise visits.

Charmaine Cohen remembers scrubbing floorboards on her hands and knees the night before the state was going to inspect a group home where she worked, run by Beacon Specialized Living in Eatontown.

"I helped them pass inspection, because they were definitely going to fail," Cohen said. "The house was dirty."

State reports document a myriad of concerns, from dirty bedding and bathrooms to a stove so greasy it presented a fire hazard. There was a "heavy urine aroma" at an East Brunswick home run by APlus, along with ants on the kitchen counter and dining room chairs. A bedroom carpet was heavily stained and a black substance covered a shower floor.

At a Hamilton home run by Delta Community Supports, there was urine on a bathroom floor and a brown substance soiled the seat of an uncleaned toilet bowl; dirt and debris had accumulated on a carpet -- all repeat deficiencies from an inspection a year earlier.

Inspectors found a soiled adult diaper on a closet floor -- even though no resident in the home wore diapers.

Black mold and bedbugs forced residents of a Community Options group home to sleep elsewhere while the home was remodeled, according to a surprise visit report.

State inspectors ordered the immediate removal of a resident after finding conditions of "imminent risk and jeopardy" at a supervised apartment overseen by The Arc of Atlantic County in Hamilton Township.

A virtual tour detailed by the report showed that floors and countertops were covered with trash and feces, and so much garbage blocked the bathroom and bedroom that staff couldn't get in. Staff said bugs were flying around and the odor was "too much to withstand." The heating system was inoperable, and the staff hadn't checked on the resident for three weeks.

The resident had refused medication and doctor appointments for at least a year, staff said, and a planning team had met to discuss it.

"All staff that were involved in her care worked every day to try and encourage her to let them clean for her as well as administer her medications to no avail," The Arc of Atlantic County wrote in a plan of correction to the state.

Police took the resident to a local crisis center. She was moved to another provider agency, according to the plan.

Representatives from The Arc of Atlantic County, Friends of Cyrus, Beacon Specialized Living, APluscare and Community Options declined requests for interviews.

Delta President David Wyher said turnover at the staff and senior leadership levels contributed to the licensing concerns. "All our houses are back in good standing," he said.

Grave results

Jason Daggett had always been a big guy. His mother, Christine, said that even at around 300 pounds, the 26-year-old autistic man was healthy, active, able to move.

But after three years with Friends of Cyrus, Christine said, her son "doubled his weight. He is 600 pounds."

"They were not dealing with his diet," she said. "They didn't take his medical needs seriously."

Jason is now borderline diabetic and has hypertension and gastrointestinal issues. He has developed sleep apnea and needs to use a CPAP machine. His mobility has become so limited he can't shower without help. He needs hands-on assistance to stay clean -- part of his prescribed care plan -- yet Christine said "it doesn't happen."

"He gets rashes. He gets infections. He has all these creams. I show up and it's, 'Oh, he showered himself.' He smells when I show up."

Kamelia Kameli, founder and CEO of Friends of Cyrus, said the company does not comment on individual cases.

How Jason got to this extreme illustrates a key failing of the group home system: Basic care is not always provided, sometimes with grave results.

Alexandra Troncone, who has autism, was hospitalized with "severe protein-calorie malnutrition," weakness and a kidney infection last spring while under the care of Keystone Community Services -- she was down 26 pounds to 89 upon admission, hospital records show.

Despite knowing the 28-year-old had chronic caloric malnutrition, group home staff didn't monitor her weight weekly or have the loss addressed by a medical professional. They also failed to get her to an endocrinologist for more than two years, leaving a thyroid condition untreated, records show.

Her father, Anthony Troncone, said "they were constantly giving her nothing more than mac and cheese, and she grew tired of eating it."

"There were times when she was not eating vegetables, fruits and foods that would have allowed her to have regular bowel movements," he said.

Staff at the group home pointed the finger at Alexandra when they spoke with an investigator, calling her "picky" and claiming all she wanted to eat was mac and cheese and mashed potatoes.

But a nurse told a state investigator if that were the case, Alexandra would have maintained or gained weight. And her father said she enjoys other foods when he brings them, such as roasted sweet potatoes or spinach ravioli.

State officials found neglect by Keystone, yet nevertheless asked Anthony if they could return Alexandra to the home. When he refused, she languished in a rehab facility for four months.

"They demonstrated a marked inability to take care of her," Anthony said. "So why would I send her back there?"

Beacon Specialized Living, an affiliate of Keystone, cannot comment on individual cases, President Lisa Coscia wrote in a statement.

State inspectors have documented homes that lack food or fail to follow or train staff in residents' dietary needs; menus are inaccurate, reflecting a more diverse and healthier fare than the reality.

"This monthly food menu was a load of crap," said the father of another man with multiple disabilities. "They would never feed them the stuff that they had on the menu."

His son lost weight, and had skin and stomach issues -- including frequent bouts of vomiting -- while at a Children's Aid and Family Services group home. Staff didn't adhere to his non-dairy diet, feeding him cheese and Alfredo sauce.

"A lot of them didn't know what the dairy products were," his mother said.

He also had to have 10 teeth pulled because they rotted from a lack of dental care -- a frequent complaint.

"The staff is telling us that they're brushing his teeth, he's letting them in his mouth," said his mother. "We take him to the dentist, and the dentist is telling us that his teeth are black. Black. What is that from? It's from not brushing your teeth."

Shavonda Sumter, president and CEO of Children's Aid and Family Services and a state assemblywoman from North Jersey, said the provider cannot comment on individual cases but wrote that it is "committed to the highest standards of compassionate care, including adherence to specialized diets, timely medical and dental care."

Another mother whose son lives in a Benchmark Human Services home noticed rashes on her son's buttocks and open wounds on his back. Warts on his feet were left untreated for months, making it difficult for him to walk.

She has also documented abuse and neglect.

Benchmark delayed medical care for second-degree burns. Staff waited more than a day to explain to his mother the cause of bright red blotches on his stomach -- another resident had poured boiling water on him while he was alone in the bathtub as a worker took a smoke break.

And a video shows how a Benchmark worker reacted when her son ran away from his group home in January with no coat for nearly an hour: She chased him into a neighbor's yard, then straddled him, repeatedly struck him and shouted "let's go."

"In both the cases mentioned, abuse and/or neglect were substantiated, and the employees involved were terminated," said Courtney Heiser, chief culture officer at Benchmark. "We are deeply saddened and concerned when incidents happen within our programs, and when any individual we serve is harmed."

The state says to trust them

Jacquelyn Kaminski's family had concerns about Broadway as COVID visitation restrictions began to lift.

The 34-year-old is autistic and has cerebral palsy and a seizure disorder. She needs help navigating most parts of her day, including showering, dressing, taking medication, and going to the bathroom.

Her mother, Liz Filipovsky, started to notice that Jacquelyn's hair and clothes weren't clean. Jacquelyn began to get acne and developed a urinary tract infection. Her parents found feces on the floor -- hidden by a towel -- and mold in the bathroom. Staff let the smoke alarm beep for months.

"The state basically said we have to trust them," Ryan Filipovsky, her stepfather, said when they first complained about Broadway. "They're doing everything they're supposed to do."

Liz discovered Jacquelyn alone one day under a scalding shower, and repeatedly found Jacquelyn's clothes and bed soaked in urine. Liz also noticed bite marks and bruises on Jacquelyn, some inflicted by housemates.

At times Jacquelyn was so thirsty when her parents visited that she wouldn't stop drinking. They suspected that workers were limiting her liquids -- they overheard staff say they wouldn't give the other residents more to drink because they would wet themselves.

What's more, Jacquelyn's weight had dropped about 30 pounds during the lockdown; at a low, she weighed 88.

"I took her clothes off to shower her and I cried," Liz said. "You saw her hip bones. You saw her ribs. You saw everything."

Her family said she has a healthy appetite, yet the staff told them she didn't like to eat.

Her family began to visit at mealtimes. One night, Ryan saw staff serve her an uncut chicken breast with bones. When she didn't eat it, the worker whisked it away, declaring "she must not be hungry."

Jacquelyn -- who is nonverbal -- does not know how to cut meat.

Michael McCarthy Jr.'s weight dropped from 220 to 149 while he was living in the same home as Jacquelyn. The 6-foot-3-inch man's dramatic weight loss was just one symptom of a multi-faceted breakdown in care that saw Michael, who has autism, regress and lose the little bit of speech he once had.

The 28-year-old was forced to wear incontinence underwear when he began wetting himself because he wasn't taken to the bathroom enough. He developed urinary tract infections so severe his father saw blood dripping from him. Michael has one kidney -- making him prone to such infections -- and needed to drink a lot of water. But his father said staff didn't bother.

His family, meanwhile, said they received no explanation for the scrapes and bruises that appeared on Michael -- or his broken foot. One employee was fired after chasing Michael around the house and hitting him on the head with a frying pan, his father said.

Broadway expands, residents suffer

The state Department of Human Services had been aware that residents were suffering under Broadway's care as early as 2019. Yet it allowed the company to expand.

Video footage at Broadway's East Brunswick day program that year showed a worker slam a young woman with autism into a wall, punch her in the face, put her in a headlock and knock her across the room, according to court audio and filings describing the footage.

Another worker kicked a man with cerebral palsy who had slid onto the floor, and a coworker grabbed him and threw him back into his wheelchair.

Two other workers were present and did nothing.

Five caregivers - and initially the company - were indicted by a Middlesex County grand jury on charges of neglect, endangerment and assault.

Zhanna Basina, the CEO of Broadway at the time, signed a non-prosecution agreement with the Prosecutor's Office in April 2020, agreeing to pay a $100,000 fine up front, enhance training, make policy changes, and pay for three years of monitoring.

Only Broadway's day program was held to these conditions, even though court records show both victims also suffered from poor care in Broadway's group homes.

The man shed 30 pounds during his year living at Broadway, dropping to 90 pounds.

When the woman with autism moved to Broadway, "she was a happy young lady with sparkles in her eyes," her mother said at the caregivers' sentencing. "She left the group home like a caged animal fighting for her life."

In the years after the assaults, the state allowed Broadway to add at least five more homes -- nearly doubling its portfolio.

The state did not explain to NorthJersey.com why Broadway was allowed to grow, but it maintained there is a "stringent" multi-step process for licensing.

Basina did not return a certified letter request for comment. Other former members of Broadway management did not return calls and emails.

RHA Health Services, which bought Broadway in 2023, wrote in a statement, "We are committed to providing high quality services in safe and healthy environments for the people we serve."

Rarely used tools

Adelman, the Human Services commissioner, says the state needs "more enforcement tools," claiming to the Legislature that her department lacks authority to "hold providers accountable" for "systemic failures."

But even now, it has a range of powers to hold the state's 132 group home providers accountable -- yet rarely uses them.

The Department of Human Services can deny, revoke or suspend licenses, reduce the number of people who can live in a house, or halt new admissions to homes and programs -- all actions that affect a company's bottom line.

In the last decade, it has halted admissions across all homes for just four providers and refused to renew licenses at six program sites across four companies, documents show.

The department can also appoint an independent monitor.

Bellwether Behavioral Health, after years of reported failings, is the only company the department assigned a monitor to oversee, documents show. It is also the only provider where New Jersey revoked all its licenses.

By the time the state started imposing serious punishments such as halting admissions in 2018, four other states had already severed ties to Bellwether, and it had garnered significant media attention. At least two New Jersey residents had unexpectedly died in Bellwether's care, and the state found higher rates of abuse and neglect in the company's homes.

New Jersey more recently tried to assign a monitor to PennReach, but was rebuffed by the company -- the board president wrote to the state last year that a monitor would be a "repetitive audit with no value added."

CEO Krystal Odell said in an interview that PennReach had met all its goals and couldn't afford an independent monitor. As a "compromise," PennReach hired a private consultant for 10 hours a month.

"He's helping us making sure that we're all being as productive as possible, coming up with any other management ideas," Odell said.

The state can also set up a "Quality Management Team," or QMT -- a panel of state officials that meets periodically to review and fix what's going wrong at a company.

"We don't hesitate to start a quality management team where there's evidence that there should be one," Adelman said.

Only six companies have actually faced such oversight: Community Options, Bellwether, REM-NJ, Delta Community Supports, PennReach and Friends of Cyrus.

Friends of Cyrus is the only company currently under a QMT.

Exactly what triggers a QMT and how it operates is unclear.

A Department of Human Services spokesperson said there are no formal procedures. "Each QMT's approach is based on unique circumstances of the provider," said spokesperson Tom Hester.

Eleven group home companies have earned the lowest "one star" score on the department's report card -- a rating system based on the conditions of homes, abuse and neglect allegations, and how quickly companies report issues to the state.

New Jersey assigned a QMT to just two of these companies.

Hester said QMTs remain "focused on a limited number of providers due to the intense effort and focus it demands."

Adelman said that when assigning a QMT, the state considers family complaints, as well as issues uncovered during twice-a-year surprise visits to every home, as required since 2018 under the Stephen Komninos' Law. The law is named after a 22-year-old who was left alone by his Bancroft caretaker and died after choking on a bagel. These are different from the usually-announced licensing visits each year.

When issues in homes "directly endanger the health, safety or wellbeing" of residents, inspectors can dole out shorter "provisional" licenses. That means they come back within three to six months -- instead of a year -- to make sure issues are corrected.

The state issued 42 of these shorter licenses a year on average between 2018 and 2024, according to documents obtained through public records requests.

When NorthJersey.com asked Adelman why the state rarely uses its enforcement tools, she said, "Are you under the impression that there are systemic, egregious issues happening in provider agencies where we should have intervened and didn't? Where does the assumption come from that what we're doing is not enough?"

'My son, honestly, has no quality of life'

Group home providers get paid based on each resident's annual budget for personal care.

The state uses a tier system to determine the amount: the higher the tier, the greater the services needed, and the larger the budget and the amount paid to the group home provider from Medicaid funds.

The average cost per person is $221,000 in the Community Care Program, the funding stream that covers group home care, as well as less expensive supports for thousands of other people with disabilities, according to state budget estimates.

Additionally, most of each resident's Supplemental Security Income is used to cover rent and other household costs such as food and utilities.

Many parents question why their loved ones' basic needs are not being met, given the large sums going to the group homes.

Take the 25-year-old autistic man with an annual budget over $500,000.

He was placed in a group home run by Friends of Cyrus. The home abuts a creek that swells when it rains; the backyard is only partially fenced in. State records say people with "elopement behaviors" shouldn't be placed there.

Yet he runs away. Frequently. He often strips naked and appears in nearby yards -- and once inside a neighbor's car. He was captured on video at a nearby house -- a worker pulled him by the arm to the ground before he wrenched himself away and continued to run.

Another time police were called by a neighbor when the man was naked, yelling and screaming outside the group home for more than 10 minutes and appeared to be locked out. The staff explained there was "a malfunction with the rear door."

The man has even fled well beyond the street the group home is on.

His care plan says one staff member should be assigned to him at all times and he should always be in view, including with a baby camera monitor.

A former Friends of Cyrus director who oversaw multiple homes said the company is "exploiting the individuals' money."

"If the state is paying for this extra tier, they're supposed to have the service, and that's what causes most of the incidents in these homes, because they're not giving sufficient staffing," he said.

The resident's mother says he does little more than sit in the house.

"My son is constantly naked every time I go there. He's naked every time I see a video chat with him. My son, honestly, has no quality of life. He sits in a urine-soaked chair 90% of his day," she said. The group home got rid of the chair last month.

His mother said he has not in four years seen a neurologist, a cardiologist or a primary doctor in person. She contends virtual appointments are not sufficient for his health issues, which include diabetes, necrotizing pancreatitis and a seizure disorder.

He's seen an endocrinologist just once in that time, in the last month. And he's been to the dentist twice: she took him once because he was having difficulty eating, and one visit recently arranged by the agency found his teeth so bad he needed fillings and extractions.

His service plan says he is "non-compliant and physically combative when he has to attend medical appointments." His mother says that before his current group home his family could get him to the doctor and even out to eat.

He also struggles with schizophrenia and bipolar disorder and an array of challenging behaviors: He can be physically aggressive toward others, hit himself, destroy his clothes and property, and smear feces.

Yet a behavior specialist was not provided for him until late last year.

His mother said at one time the group home was addressing his behaviors by repeatedly calling 911 and taking him to the hospital, where he was calmed with drugs.

"I kept saying, this can't be like the behavioral plan. Every time that this kid is having behaviors, you can't just call 911 and send him to the hospital."

His mother said she has repeatedly contacted state officials about his care, to no avail. And she has written to the group home provider, saying it is "taking money from the state to care for my son with the agreement that his needs are met. This is clearly not the case."

She despairs for what will happen to her son, who she said has also suffered unexplained injuries at the group home, including a black eye, bruising and cuts to his face. Staff, she says, are placed with him without training to understand his behaviors.

All her attempts to move him have failed; the only agency interested in taking him couldn't meet his needs.

"He's stuck in the system," his mother said. "He's in the wrong place. Everyone at the state level knows that, but there aren't any other options."

'Substantial failure'

It took the state years to crack down on Friends of Cyrus.

Documents show that concerns date back at least to 2018, when the state cited a "substantial failure to demonstrate compliance with the standards."

In 2019, the state briefly banned Friends of Cyrus from accepting new residents -- a punishment that lasted one month. Later that year the state noted a "level of disorganization and failure to demonstrate an understanding" not only of state standards, but of its own policies.

Though it found problems every year since, New Jersey continued to approve licenses for new Friends of Cyrus group homes -- and the company tripled in size.

All the while, the needs of residents weren't being met, and the state wrote that it was "concerned" about "dangerous conditions." Parents bombarded the state with complaints, and reports of abuse and neglect had swelled.

The state halted new admissions to Friends of Cyrus group homes again in 2023, and this time put in place a Quality Management Team -- the highest level of state oversight.

Kameli, the founder and CEO, declined to be interviewed by NorthJersey.com.

The state routinely delays putting companies with problems under heightened supervision.

For years, the state allowed PennReach to expand, even as it noted "patterns of substantial non-compliance," failures to follow physicians' orders and a lack of medical follow-up.

It took until 2022 to put in a QMT, in part for taking individuals whose needs it was unable to meet, and another two years for the state to bar PennReach from taking any new residents.

But when the agency said that would pose a financial hardship, the state relented, allowing "emergency exceptions."

Odell, the CEO, said nursing homes didn't give PennReach a full picture of the needs of a few residents it had accepted. PennReach has since improved its admissions process, she said.

In December the state ended PennReach's QMT and lifted the suspension of admissions, writing PennReach had "satisfactorily addressed" issues. But it warned the agency to proceed slowly with expanding.

"We went through that time period, which was very difficult, but it was very productive in the end, and we feel that we're really proud of where we are," Odell said. "They tutored us, they helped us."

The state did not explain to NorthJersey.com why Friends of Cyrus and PennReach were allowed to grow, but maintained there is a "stringent," multi-step process for licensing.

Investigating themselves, undermining trust

Most incidents are investigated -- or merely documented -- by the group home providers themselves.

The bulk of allegations -- "lowest-level" claims that residents ran away, were unexpectedly hospitalized or had their rights violated -- end with an incident report. The state closes 60% of cases this way.

About a third of cases -- allegations such as abuse or neglect that leads to a minor injury -- are investigated by group home companies. A state office reviews the paperwork and may ask follow-up questions.

Between 2018 and 2024, group homes substantiated more than a quarter of the 7,400 allegations of abuse, and 60% of the 8,500 allegations of neglect, according to data obtained by NorthJersey.com.

Adelman said it is common across human services programs for providers to investigate themselves.

"One, because of capacity, but also because for minor incidences there is a value in agencies doing the work to understand what issue may have led to an incident," Adelman said.

Valerie Sellers, head of the New Jersey Association of Community Providers, says she doesn't see it as a conflict because there is state oversight.

Advocates disagree.

"Allowing provider agencies to investigate themselves is just bad policy," said Aronsohn, the state ombudsman. "At the most basic level, it undermines trust in the provider agency and in the system of care as a whole. The process is suspect. The final report is suspect. And no finding of 'unsubstantiated' will ever be believed. Without trust, the system will eventually fail."

Chona Del Mundo had reason not to trust the system.

When her son Jordan stole a bike and rode to a deli a mile away from his Monroe group home, Friends of Cyrus told his mother they didn't need to report it to the state.

The 24-year-old with autism requires a one-to-one aide, and he has a history of running away.

A company executive told her that a staff member had Jordan in view the entire time. But Chona got a very different story from a deli employee and the police report.

Jordan was alone when he entered the store, sweaty and exhausted. The deli worker realized Jordan had a disability and didn't want him to leave and get lost, so the worker called the police. Jordan was at the deli without staff for about 45 minutes, the deli worker told Chona.

"Friends of Cyrus told me because there was no loss of supervision, it is not reportable" to the state, Chona said. "They think that we're stupid. You add things up and then you'll see the whole picture."

Even when group homes do investigate, the reports are confidential.

Families shared with NorthJersey.com the information they do receive: letters that include little information other than a case number and the conclusion.

Most of those letters don't describe the allegation they are referring to, or when the incident happened. And providers don't explain how they reached their conclusions.

Group home workers who spoke with NorthJersey.com also expressed skepticism about their companies' internal investigations.

"Quality assurance works for the company -- it's never going to say anything wrong about the company," said Cohen, the former manager at Beacon Specialized Living, where she worked for close to a year.

One parent advocate group wants all abuse and neglect cases to be primarily handled by the Office of the Attorney General or an independent agency.

The Arc of New Jersey also supports a third-party handling "the more egregious" cases, said Executive Director Tom Baffuto.

"Chapters of the Arc I think do a good job on the investigations, but if this is what families are concerned about, I wholeheartedly support bringing in a third party," Baffuto said.

'Trivialized and pushed aside'

Only the most serious allegations of abuse, neglect and exploitation are assigned to one of New Jersey's 45 state investigators.

The Office of Investigations handled 284 group home cases in 2024 -- about 2% of all incidents reported.

In 2024, the Office of Investigations substantiated 25% of abuse allegations it was assigned, and 58% of neglect claims, according to data obtained by NorthJersey.com.

But even if a case makes it to this level, families say they rarely see anyone held accountable.

Take, for instance, the investigation into Tameea Selby's extreme injuries: a fractured rib, collapsed lung and punctured and infected hand.

Now 43 and living with her brother Kevin, Tameea will flinch violently if someone raises a hand near her. Kevin still isn't sure what happened at Tameea's group home in Galloway run by Delta Community Supports. But he refused to let her remain there after he discovered extensive bruising along her shoulder and side.

"I was raising her arm, and it was like red, black, blue, green spots all around her ribs," Kevin recalled. "She was crying and had trouble breathing. That's when we took her to the hospital.

"The doctor comes outside and says 'Tameea Selby has been abused. This is, like, stomp marks.' Like someone was stomping her ribs. I was like, 'Oh, my God.'"

The state did not substantiate abuse. Investigators could not identify who hurt Tameea.

David Wyher, who became president of Delta Community Supports in 2022, said after reviewing case notes that it looked like Tameea could have been hurt at her day program -- something Tameea's family finds unlikely.

"We know that it couldn't have been at day program," said Leslie Selby, Tameea's sister-in-law. "She still goes there now. She loves it. They take very good care of her."

The state did substantiate neglect: One Delta employee had seen Tameea crawl into a van and move slowly; another worker was aware that Tameea had bruising on her abdomen. Neither employee sought medical help for her.

"The direct support staff worker should have called 911, instead of contacting their manager regarding the bruise and maybe potentially watered down what it was," Wyher told NorthJersey.com.

Delta told the state it would retrain its staff, revise policies and procedures and check on residents more often.

Delta settled in court, and paid money to a special needs trust for Tameea, according to court records. It was used to convert space in the Selbys' house so Tameea could live with them and not in a group home.

"When I voiced my concerns about the other vulnerable and non-verbal women in the home, I was only then told that a staff member had been terminated but that no further information could be told to me," Leslie Selby wrote to former Human Services Commissioner Carole Johnson in 2020. "We truly feel that this case has been trivialized and pushed aside."

Group homes are required to develop a "plan of correction" after a substantiated allegation or when concerns are noted in an investigation. But the state denied public records requests for these documents, so it's unclear how detailed they must be.

The state also denied NorthJersey.com's requests for investigative reports, even with privacy redactions.

Reporters were able to obtain copies through other means. Many were filled with errors, confusing timelines -- and, in one case, a complete reversal of the conclusion after parents asked to see the state's work.

Reversed conclusion

Jacquelyn Kaminski's seizures had been under control for some time. When she started seizing again, her doctor wrote a prescription to check her blood levels.

Nearly two months passed, and the staff at Broadway Group Home -- where she had lost weight and wasn't kept clean -- still had not taken her to get tested.

"Jacqui needs her blood work done asap to make sure her med levels aren't outta whack," her mother, Liz Filipovsky, wrote to a Broadway director. "These seizures can harm her if not controlled or stopped."

A few days later, Jacquelyn had nearly 30 seizures within five hours. Her parents rushed her to the hospital at her neurologist's urging.

Jacquelyn's bloodwork showed she was not given her anti-seizure medication, phenobarbital, her neurologist later wrote to the state. Her normal baseline is 29-30, and the hospital test showed her level was at 22.3.

Any level below 29 is "concerning for seizures," her neurologist wrote.

State investigators are supposed to have registered nursing licenses with four years of experience on the job, according to the job description.

Most of the 45 members of the team do not have nursing licenses, according to a NorthJersey.com analysis of licensing records.

However, if an investigator doesn't have a nursing license, a bachelor's degree with three years of experience in a health or human services setting can suffice. A master's in public health can reduce the required experience to two years.

The state investigator on Jacquelyn's case has no apparent medical credentials.

The investigator had the neurologist's letter, along with Jacquelyn's lab work and doctor's notes. He also had pictures Jacquelyn's parents took of her pill packs with seizure medications still inside for days that had passed.

To substantiate a claim, state investigators must decide there is a 51% chance that an allegation occurred. The state concluded that it didn't have enough evidence to say Jacquelyn was neglected. Broadway did not take any remedial action. Criminal charges were not filed.

The Filipovskys were shocked.

"How do you argue with the man with the degree?" Ryan said, referring to Jacquelyn's neurologist. "We have the documentation, we have the proof."

They continued to catch medication errors even after Jacquelyn came home from the hospital.

It wasn't until Liz asked for a copy of the investigative report that the case got another look and the conclusion was changed -- long after Jacquelyn had moved out of Broadway.

This time, more than a year after their initial report, the state substantiated that neglect occurred. Jacquelyn didn't receive a number of her medications and wasn't taken for bloodwork in a timely manner, the report found.

In a follow-up letter, a state official wrote, "The situation that happened to Jacqui and your family was terrible, avoidable and I am very sorry it occurred."

Broadway retrained staff on how to administer medication, the state told the family. Liz and Ryan were unsatisfied.

Liz is happy with her daughter's current care at New Concepts for Living, but worries about the housemates Jacquelyn left behind.

"How does our daughter end up in the hospital with proof of lack of meds not be enough proof to take these people and literally close them down?" Liz said.

"Because not only is that our child, there's four other clients in that house that are also being neglected and abused. There's something wrong here, but I didn't know how to fight it. I didn't know how to fight it."