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In September 2016, Nestor Bunch lay in a hospital bed in the intensive care unit at Long Island Jewish Hospital. One machine kept him breathing; another fed him through a tube. With the color drained from his face and a sheet drawn to his throat, he looked dead.

His doctors suspected an assault. Bunch, 54, had been hit hard enough to break three ribs. Skeletal muscle tissue was jostled loose into his bloodstream, causing his brain to seize and kidneys to fail. For the people who knew Bunch best — his therapists, his social workers, his family — the scene was as unsurprising as it was painful.

Diagnosed with schizophrenia, Bunch had spent most of his life under some form of supervision, whether in a group home or psychiatric hospital. He was prone to hallucinations so vivid, he taught himself to distinguish the real from the imagined by reading the reactions of those around him, as if asking, “Did you see that?”

Up until a few years ago, Bunch lived in an adult home — a privately run group home that houses people with disabilities including mental illness. Many such homes had been plagued by scandals of abuse and neglect. But a landmark 2014 settlement won him a chance at what promised to be a better life.

A federal judge ordered that residents of nearly two dozen New York City adult homes be given the chance to transfer into subsidized apartments under a program called scattered site supported housing, where people with severe mental illness could cook in their own kitchens, administer their own medication and budget their own expenses with support from private case management agencies.

Historically, supported housing was meant as a finish line for those who had demonstrated, under decreasing levels of supervision, that they could live alone. But the court order ushered a wave of adult home residents directly into a system in which people like Bunch were expected, overnight, to be able to care for themselves.

Last week, ProPublica and the PBS series Frontline published an investigation, in collaboration with The New York Times, showing how the sudden shift has proven perilous, even deadly, for those who were not ready to live with minimal support.

For this story, ProPublica and Frontline obtained about 7,000 pages of records from nearly every hospital, psychiatrist, social service agency and housing program that intersected with the lives of Bunch and his roommates, with permission. We interviewed dozens of mental health experts, therapists, family members, caseworkers and others about the quality and effectiveness of their care.

The state moved hundreds of people into the program without tracking their outcomes until this year. Bunch’s story demonstrates the extraordinary fragility of some former adult-home residents and the limits of the support they receive.

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Bunch’s mother, a small Colombian woman with an outsized personality, fought for his right to live on his own.

Elda Villamil was devoted, but overwhelmed by her son’s early symptoms. He could break out into frightening outbursts. Records show he once punched a wall so hard that he broke his arm. He threw himself through a glass door and threatened her with a knife.

As Bunch bounced between psychiatric care and her home, she poured herself into the mission of the National Alliance on Mental Illness. She organized demonstrations, wrote to lawmakers, and even engaged in a yearslong correspondence with members of the Clinton administration, earning an invitation to both inaugurations, where she is seen in photos, beaming alongside Bill and Hillary.

Through her advocacy, she met a woman named Nora Weinerth, who would become a lifeline for Bunch.

Both women made helping people with mental illness find stable, independent housing, a top priority.

Their wish became real for Bunch for the first time in 2004. After years in and out of a psychiatric hospital, Bunch moved into a supported apartment with three other men. He stayed for five years, doing well for the first two. But, in time, he began to overwhelm his roommates, fighting and throwing out their belongings. He was hospitalized three times in a year.

The staff working with him there said in records that they were “unable to provide him with the supervision and monitoring he needs.”

And so, to the disappointment of his mother, he moved into the Queens Adult Care Center in 2009. Eight years earlier, when it was called Leben Home, the Times featured it in an investigation. Its residents had to be evacuated because the walls were crumbling. One woman died in a padlocked closet, from injuries sustained in a beating; another was raped by a janitor. At least a dozen residents had jumped off the roof.

Records from the adult home show Bunch ran into the occasional conflict there — he was once punched in the nose by another resident — but overall, he lived in a kind of malaise. He never got better, but never got worse. In therapy records from his time there, the phrase “no significant changes observed” appeared dozens of times.

Then, in 2014, people working for nonprofit housing providers showed up with brochures advertising clean, spacious apartments, offered as part of the court settlement with advocates, who successfully argued that most people in adult homes did not have to live under such restriction. If he took the opportunity, Bunch would no longer have to share a room or eat in a cafeteria where meals were universally loathed. He could listen to music as loud as he wanted. He could, as he always yearned for, find a girlfriend.

His mother was nervous about his second chance in supported housing, but also grateful. To her, the dullness of the adult home was broken up only by danger, she told her friend Weinerth. But she also knew that the staff at the home at least made sure he took his medication and kept his government benefits in relative order.

On Sept. 15, 2014, Bunch sat for a evaluation. In it, he said that he could use “mental telepathy to heal people from a distance” and that he felt “blue, because of all the skinny children.” He also said he wanted to “detox” from his medication.

Two nurses listened. “Expresses ideas without difficulty,” they noted. “Understands others” with “clear comprehension.”

His evaluation did not mention his previous failure in supported housing. It said he had been hospitalized up to three times over his entire life, not routinely, for 30 years.

But he met the minimum standards for supported housing as set forth in the court order: He was seriously mentally ill and lived in an adult home. The judge had ordered assessors to determine whether residents could live alone, and to start with the assumption they could. Except in cases where evaluators determined that people could be a threat to themselves or others, residents were supposed to be allowed to leave.

Bunch was approved for supported housing on Nov. 6, 2014. In the months leading up to his move, he had two more psychiatric hospitalizations. The first time, he told psychiatrists he “felt like a bug about to get sprayed by Raid.”

His therapist tried to warn the Institute for Community Living, the housing contractor helping with the move, that Bunch did not seem ready. “He has already been approved,” an ICL clinical specialist said, according to therapy notes. “They can’t wait any longer.”

In response to questions, ICL officials said that they took multiple opinions into account, and that the person with the “least to gain or the least to lose was the independent assessor, who said he was ready to go.” Ultimately, his psychiatrist judged him ready, ICL officials said.

In a last effort to prepare him, his therapist tutored him on his medication schedule. “He agrees to comply and expresses understanding,” his therapist wrote. “But he also seems … focused on getting a job such as becoming a surgeon.”

Four days before he moved out, records show, Bunch said he stopped taking clozapine, a crucial prescription in his battery of antipsychotics.

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Bunch moved into a studio underneath the passing planes of John F. Kennedy International Airport. From the edge of his bed, he could touch nearly everything he owned — his milk crates crammed with classic rock records; a television; amps; a stereo and an old guitar.

Records reflect a basic goal: to “remain in the community without ER visits, hospitalizations and/or returning to the [adult home].”

Two organizations would work with him: ICL, handling his housing, and the nonprofit Federation of Organizations, coordinating his medical care and other services.

Shaquan Young, an ICL “peer care coordinator” with the frame of a linebacker, would teach Bunch the basics: How to get to therapy sessions and clean his apartment. How to get to the nearest grocery store, where he urged Bunch to opt for the occasional vegetable over his preference for Twinkies and Ding Dongs.

But Young could not get Bunch to master his medication regimen, even after demonstrating how to divide doses into pillbox slots. Bunch wound up taking his morning pills at night, or vice versa, or not at all.

Records show that a clerical error caused Bunch’s Social Security checks to be written in amounts smaller than he was entitled; they remained addressed to the adult home. Young got him an Electronic Benefit Transfer card and scraped together petty cash. It was never enough.

Bunch began to run out of food. When a social worker found only a bowl of sugar in his refrigerator, she took him grocery shopping, giving him $20 and a list of nearby emergency pantries. When he was out of food 11 days later, Young brought him a meal and Bunch devoured it.

Bunch’s stress intensified when he learned his mother had late-stage lung cancer. In December 2015, he entered his therapist’s office, disheveled. “He agrees to call 911 or [go] to a hospital should he have suicidal thoughts,” her notes said.

The next day, Bunch showed up at Elmhurst Hospital, twitching, showing doctors how he had clawed at his wrists. He said he’d tried to gouge his eyes out with a pen.

“He admits to feeling hopeless,” a psychiatrist wrote, “and is worried about his rent arrears and having enough money to eat and maintain his new life.”

Young still held optimism for Bunch’s survival in supported housing. “We were just thinking, ‘Okay, maybe he’s just lonely.’”

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Bunch moved into a cramped apartment above a jerk chicken restaurant in Jamaica, Queens, to live with Bernard Walker.

Walker, 54, had schizoaffective disorder and had been reliant on others for much of his life. “They thought he could be out on his own,” said his 83-year-old mother, Rosetta Walker. “I said, I don’t think so.”

“Mr. Walker chose to move into the community after the fact several treatment providers suggested otherwise,” an ICL worker wrote in his records, calling him “brave.”

According to Young and others, the idea in pairing Walker with Bunch was that Walker was more functional. Records show he once held down a job as a sanitation worker. “If you have a roommate that’s higher functioning,” Young said, “you would probably follow that person’s lead.”

ICL leadership contested that notion. Its CEO said it tried to “match people’s skills and abilities, rather than to take care of somebody else.”

On Jan. 22, 2016, an ICL worker came to check on Walker; the forecast called for a blizzard, and she wanted to make sure he had food. Walker was not there, but Bunch let her in. She checked the refrigerator, then left.

Two days later, Bunch found his roommate dead.

Walker was face down in the unheated foyer of their building, naked. Much of the city was covered in 2 feet of snow.

Neighbors recall seeing Walker days before he died, in his underwear, “practicing his karate” in the snow. Carmen Pacheco said he often banged on her door, begging for money and cigarettes. “I told him: ‘Excuse me. Why don’t you go inside, put on some clothes? You’re going to get sick.’” Records indicate he showed up to a day treatment program wearing sandals in the middle of January.

The medical examiner concluded Walker died of cardiac arrest. Photos of empty pillboxes suggest he had been keeping up with his prescriptions.

Working with ProPublica and Frontline, Walker’s mother and brother Michael, a retired New York City police officer, tried to obtain the results of a state investigation into the death. But officials said these documents are shielded by state law.

“It almost feels like they are trying to cover something up,” Michael Walker said.

Two days after Bunch found his roommate dead, his mother died.

It fell to Young to deliver the news. Bunch showed little emotion, sitting glumly and talking about wanting a girlfriend. “Sometimes, I feel like there’s something missing in my life,” he said, according to records, “a wife, kids … a family.”

In the weeks that followed, Young saw him unravel anew. Bunch came to the door one day, bedraggled, murmuring to himself, according to records. He looked like he had lost weight and could not say when he last ate. His pillboxes were full. Young felt he had no choice but to get Bunch to commit himself to a psychiatric hospital.

Four days after he was discharged, Young found him in even worse shape, slurring his words, shivering, gulping tap water from an unwashed can of Chef Boyardee.

During a two-month hospital stay this time, his therapist, hospital psychiatrists and workers with two care agencies met. “It is agreed that he is not appropriate” for supported housing, his therapy notes show.

Bunch said he felt more comfortable moving back into an adult home, even if it was just temporary, “because he could always get his medications on time and he had lots of people around. He stated that he does not like to be alone.”

Three days before he was discharged, he repeated his desire to either stay at the hospital or go back to the adult home. He also said that Hitler was alive and ruling Russia, and that it was only a matter of time before he attacked the United States.

Records are unclear about who made the final call. But Bunch was discharged to another apartment.

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Bunch moved in with Eddie Lopez, who insisted in an interview that he was not mentally ill.

Lopez said he injured his leg in a knife fight when he was 15, and it got worse in prison, during a sentence he said he served for selling drugs. He was living in a homeless shelter when he learned that the Queens adult home had beds available for the physically challenged. He lived there for six years, until the opportunity arose to live in an apartment.

In a way, Lopez is a model for supported housing. He recycles cans and bottles, fixes bikes and appliances, and performs odd jobs for his neighbors. But the downside to his success, according to records and interviews, is that he has become a de facto home health aide for severely mentally ill roommates.

“Us that are functional are being used,” he said, referring to the three roommates he has had to care for in as many years. “If it wasn’t for me being here, who knows what’d happen?”

When Bunch showed up at a schoolyard, leering at children, neighbors asked Lopez to take him away. “He thought he was a kid,” Lopez said. “I had to explain to him, ‘No, you don’t do that.’”

When Lopez came home to a blaring fire alarm, empty pots burning on the stove, he realized he had to start cooking for Bunch.

Records show the apartment had plumbing problems. Lopez said the toilet wouldn’t flush, so he found a solution: a bucket, filled with water, to pour down the bowl. Bunch couldn’t figure it out, and the apartment soon “smelled like defecation,” Lopez said.

On Young’s visits, Bunch came to the door shirtless, screaming expletives. He told his therapist he did not “like his medication because it looked like rocks.”

The arrangement went on for five weeks. Lopez grew “very frustrated,” according to Young’s notes, telling him, “I don’t want to be someone’s home attendant.”

Young said he and his superiors worried Lopez would complain to the state. ICL disputes this, saying he was moved only because of the plumbing issue. Regardless of motivation, Bunch wound up in another apartment, with yet another roommate.

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This time, he moved into a brick duplex on the border of Jamaica and Cambria Heights, Queens, with a 67-year-old Guyanese immigrant named Jagnanan Ramnanan.

For 17 years, Ramnanan, who had a diagnosis of paranoid schizophrenia, had lived in the Queens adult home, where his peers elected him to run the residential council. He was gregarious and often donned a fedora, tie and jacket.

But records show he was also an alcoholic and a repeat presence at Elmhurst Hospital. Sometimes, he came in for head injuries sustained while drunk; other times, because his caretakers feared alcohol poisoning. A girlfriend at the home once alleged he punched her in the face, his adult home records show.

Reached by ProPublica and Frontline, his estranged wife said she filed multiple orders of protection against him. She said he once damaged cartilage in her nose and face. “He can hurt you,” she said. “And then, he can take care of you.”

By the time he and Bunch moved in together, Ramnanan had been kicked out of an apartment where he’d spent just a few days. His landlord “worried he may burn down the house,” according to ICL records. She had found him drunk, the apartment thick with cigarette smoke, the fire alarm screeching.

That fall of 2016, Bunch came under the care of a new Federation worker, his fourth in 18 months. Between the time that she started and his last worker quit, a full month had gone by. Records show she called him repeatedly on Sept. 6, but he wasn’t picking up. She arrived at his apartment that day to find keys hanging from the door. She rang the bell, then yelled through an open window.

Finally, Ramnanan told her he had found Bunch on the floor in the middle of the night, having a seizure, and called an ambulance. She went into Bunch’s room and saw his mattress had been knocked off the box spring. Ramnanan could not explain why.

Doctors in the intensive care unit at Long Island Jewish Hospital suspected Bunch had been beaten. The muscle damage was so severe, one doctor thought he could have suffered for days before he received medical attention.

To Weinerth, he looked like a “cadaver.” She had sworn to his mother, on her deathbed, that she would watch out for Bunch. Now, with doctors telling her he had been attacked, “I felt a certain bitter relief that she wasn’t alive anymore to witness it,” Weinerth said.

Records show a doctor told the caseworker he wanted to speak with Bunch’s roommate. But in hundreds of pages of documents, there is no record showing anyone questioned Ramnanan. Bunch’s therapy notes reference an “incident report” made to “the state,” but records from his three primary providers do not include evidence of follow-up.

While Bunch was in the hospital, Ramnanan was found in his apartment by a worker for his old adult home who had been searching for a missing friend of his, known to drink with him. They were both drunk; Ramnanan was unconscious. A pot of food was burning on the stove.

Ramnanan was taken to the hospital but died eight days later of complications related to liver failure.

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“My roommate died, my mom died and he died,” Bunch told me, referring to Ramnanan. “That’s a hell of a lot to go through.”

Bunch sat across from me one brisk night last year in a Brooklyn pizzeria. When we met, he spoke in loops so inscrutable, I asked to see identification to be sure it was him.

He could not remember his social workers or the names of roommates. He thought he had lived at the Queens adult home for months, not years. He was as likely to answer a question about what he had for breakfast with a fantasy of becoming an orthopedist as he was to say something like “Froot Loops.”

That is not to say he could not recall vivid memories: Finding one roommate “frozen” in an “embryo position” and “totally naked.” “The Hindu man” who drank a lot and watched films about cowboys and Indians.

He later said that he doubts Ramnanan could hurt him but remembers an argument about cleaning, and that Ramnanan was “dancing” on top of him just before he awoke in the hospital. (Ramnanan’s family also doubts he was capable of the attack, because he was so physically weak at that point.)

From documents, we pieced together that, during months in rehabilitation, several social workers and case managers once again voiced concerns about Bunch’s ability to live independently, but he was returned to his dead roommate’s apartment anyway.

“There were beer bottles, cigarettes. The floor was dirty,” Bunch said.

ICL determined he should stay somewhere else while the apartment was cleaned. He finally wound up at the kind of facility his therapists and social workers had long been discussing: Level II housing, with 24-hour staff, medication management, three meals a day and therapeutic services. These kinds of beds were limited, and Bunch first had to fail out of the care he had.

The stay was supposed to be temporary, but just eight days in, he was found by police, wandering the streets on a freezing night in January 2017, hypothermic, dehydrated and delusional. A hospital psychiatric nurse gave him an evaluation that summed up what so many had said for so long:

“Nestor Bunch requires constant behavioral supervision and medication management, which he cannot perform for himself. … He cannot perform any activities of daily living without support, which would not be available in a less restrictive setting.”

In August, we presented all we had learned about Bunch to David Woodlock, the chief executive officer for ICL, which had been the most consistent presence throughout Bunch’s time in supported housing.

Woodlock acknowledged that Bunch had taken a number of “enormous whacks,” but said that ICL went “above and beyond” its “contractual obligations” with Bunch when it came to things like helping with his Medicaid benefits. He explained that, technically, ICL was responsible for little more than housing him.

He said that Bunch’s treatment was primarily under the domain of his “Health Home,” the Medicaid program that organizes his plan of care. That agency, Northwell Health, said it left it to its subcontractor, Federation of Organizations, to report any incidents and handle care coordination. With Bunch’s consent, Federation supplied 381 pages of his case management notes. It would not share documents related to the care of Walker or Ramnanan unless the families could prove they had been previously authorized to make health care decisions for the two men.

Later, ProPublica and Frontline sent Federation a 10-page letter with more than 60 questions about the cases of Bunch and his roommates, and the organization’s involvement in the settlement.

In a five-page response, the organization would not answer questions about specific cases, saying it was limited because of health privacy laws, but it noted that the two deaths were “not caused in any way by the provision of services provided.” Federation said people are only moved into supported housing by their own choice, and only after they have been assessed and deemed ready.

Joseph Buzzell, an attorney representing the organization, said Federation reviewed its records and determined that it had not “violated any of its duties to provide service.” He said that “incident reports were filed and submitted to necessary entities,” but that such reports were not in the documents provided because state law required them to be housed separately.

After months of questions from ProPublica and Frontline, Bunch’s case surfaced at a hearing on the implementation of the settlement last week. Clarence Sundram, the independent court monitor installed to oversee the transition, cited this case to show the kinds of episodes agencies will now have to report to the state, which will investigate and analyze them for corrective actions. Up until recently, there was no such incident tracking system for things like unsafe and unsanitary living conditions and repeat crisis episodes, including two or more psychiatric hospitalizations within a year. U.S. District Judge Nicholas Garaufis ordered a report on the tracking system’s effectiveness in response to the investigation by ProPublica and Frontline published last week.

In a statement, Office of Mental Health officials said that though the vast majority of former adult-home residents are doing well in supported housing, they recognize “there are very few cases in which class members were ultimately unable to thrive in an independent setting, were negatively impacted by their transition, or have decompensated since moving to the community. For these class members, the State is focused on continuing to improve its systems of care and ensuring there are no gaps in service so that issues and concerns may be addressed in real time for the maximum benefit of all class members.”

Officials said they have put an additional $10 million into staffing and training and stepped up payments to housing providers for new residents.

The Department of Health denied a Freedom of Information Law request for any records related to Bunch’s injury, citing privacy restrictions. The Office of Mental Health also denied such a request. Officials said the records are shielded by state law.

As for Woodlock, he referred to Bunch’s final injury as a “medical crisis,” which ICL had no obligation to report to the state. “If you assume it’s an assault, there’s a certain pathway. If you assume it’s a medical crisis, it’s kind of another pathway,” he said.

Beyond reviewing Bunch’s rehabilitation records, he said ICL did not investigate. “I don’t know that any of us have a conclusion, a firm conclusion, about what did or didn’t happen.”

Ultimately, Woodlock said Bunch’s housing came down to the decisions of one person above all others: Bunch himself. He referred to the concept as the “dignity of risk,” allowing people with mental illness to choose where they live except under extraordinary circumstances, even if they might fail.

“Could many of the sad things that happened to Nestor have happened if he was in a 24-hour supervised setting?” Woodlock asked. “Yeah, I think they could have.”

We learned that in the days prior to the interview, Woodlock and other ICL executives had taken Bunch to lunch. ICL officials say they did so as a courtesy, to gain his perspective and better inform the interview. It was around that time that his life had begun to dramatically change.

By then, he had moved into another ICL apartment in the Lefferts Gardens section of Brooklyn. He has a new roommate now, 41-year-old Jeanne Satchell, whom he calls a “sweetheart.” He also has an aide for several hours per day. From nearly his first day in supported housing, his providers knew he needed one, but a holdup with his Medicaid benefits left him without one for years.

Alma Bravo, a 27-year-old mother of two, buys his groceries, does his laundry and takes him around town. He has been to Ripley’s Believe It or Not in Times Square and the New York Aquarium on Coney Island.

But the support he is getting is not meant to be permanent.

He is now in what is called a Treatment Apartment Program. On average, the program costs about $48,000 a year, split between state and federal funds. This is almost double the average price tag of what he was getting before, in supported housing. Only eight former adult-home residents out of the 764 who have transitioned as of mid-November are in a treatment apartment, according to state officials.

But, like any Level II program, treatment apartments are meant to be transitional, and residents are eventually supposed to move back into a more independent situation with fewer services.

For now, it is clear how much Bunch relies on Bravo. When she was out sick for just two days in early October, she returned to find Bunch struggling. He was hallucinating, laughing to himself and clapping to music no one could hear. He had not eaten. The refrigerator was empty, except for frozen meat. He had run out of money and complained of an excruciating toothache.

Bravo said she was skeptical he could live by himself again. “Who’s going to cook for him?” she asked. “Who’s going to remind him of his appointments?”

She looked up an urgent care dental clinic, and together, they set out.

Tom Jennings, Kate McCormick, and Nicole Reinert contributed reporting. Frontline and ProPublica are working together on an upcoming documentary.

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