Inside a weathered green group home in southern New Jersey, Yosary grew weaker and weaker. She felt tired all the time, and when she got out of bed in the morning, she sometimes became so dizzy she needed to lie back down. Bruises started appearing all over her body. She craved ice, chewing cups of it whenever she could.

For months, the slender 15-year-old, who’d fled Honduras with her 2-year-old son, had been reporting her symptoms to the shelter’s staff. But they dismissed her pleas for help, she said: She was dizzy because she’d just stood up too fast. Her bruises? She probably bumped into something and didn’t remember. Chewing ice was a bad habit she needed to break.

By the time someone finally took her to one of the shelter’s pediatricians last summer, Yosary was in such bad shape she had to be hooked up to an IV at a local hospital. The pediatrician, Elana Levites-Agababa, recognized the telltale signs of severe anemia, which, untreated, could have resulted in heart failure and damage to other organs. The staff should have known — the teen’s history of anemia was documented in the shelter’s records.

“I was devastated by the care she got,” Levites-Agababa said. “Her hospitalization could likely have been prevented if she had been brought in when she first started raising concerns that she needed to see a doctor.”

For Levites-Agababa, a pediatrician for CAMcare, it was another alarming lapse. For months, she’d been noticing a lax attitude about the medical needs of children at the federally funded immigrant youth shelters run by the Center for Family Services, a nonprofit based in Camden, New Jersey. So, she decided to review the charts of the 90 CFS patients the community health center had seen.

Children, including infants, were showing up as many as 10 weeks late for their booster vaccines, increasing their risk of contracting infectious diseases, she said. There were an unusual number of no-shows and cancellations, even though nearly all the health center’s clinics are within a half-hour of the shelters. And the shelters routinely failed to schedule the prescribed follow-up appointments after emergency room visits, psychiatric admissions and hospitalizations.

She reported her findings to CAMcare, which had been hired by CFS to provide medical care for its immigrant youth, many of whom crossed the U.S.-Mexico border, seeking asylum. But as months passed and the situation didn’t improve, Levites-Agababa escalated her concerns, filing complaints earlier this year with the federal Office of Refugee Resettlement and authorities in New Jersey, which separately regulate the shelters.

While she awaited a response, Levites-Agababa said the medical office received a troubling new request: CFS wanted doctors’ approval to physically restrain kids in its care.

“They feel no obligation to provide appropriate care to the kids or follow any recommendations by a medical provider,” said Levites-Agababa, who has worked at CAMcare since 2015. “And that’s demonstrated over and over again to the point where it interferes with our ability to practice medicine.”

CFS denied wrongdoing but declined to answer specific questions.

“The program’s main objective is the safety and wellbeing of all of the children under our care,” Eileen Henderson, the chief operating officer, said in an email. “CFS continues to work with the Office of Refugee Resettlement and our medical providers to ensure that the children receive proper medical treatment in accordance with our directives from ORR.”

The care of immigrant children in U.S. custody has faced intense scrutiny over the past year as thousands of sexual abuse allegations and reports of personal enrichment by some nonprofit operators have raised questions about the federal government’s ability to monitor its network of about 100 shelters.

Now, a surge of families and unaccompanied children at the border is testing the system as never before. The U.S. Department of Health and Human Services was already scrambling to find new places to house immigrant kids after policies by the administration of President Donald Trump resulted in more children being housed for longer periods. Trump’s recent ousting of his top immigration officials is expected to herald even harsher policies — and possibly a ramped-up effort to separate children from their families.

There were 13,500 children in shelters as of the end of February, more than five times as many as there were two years ago. On Wednesday, Trump requested congressional funding to nearly double the number of beds.

The medical care for these new arrivals became a focus in December, when two ill children died in Customs and Border Protection custody near the border. But unlike those children, Yosary, who asked that only her first name be used, developed her symptoms long after crossing the border. She and the other children Levites-Agababa saw were in a place that was supposed to be safe, staffed by youth care workers trained to recognize medical symptoms and overseen by federal and state agencies responsible for health and social services.

ORR declined a request to interview its medical staff. The agency said that after investigating Levites-Agababa’s complaint, it temporarily suspended CFS from receiving new kids until problems were addressed. But it didn’t say when the suspension happened, how long it lasted or what CFS did to fix the problems.

ORR also wouldn’t say how many complaints about medical care it has received but said that “physicians and nurses who have medical-related concerns often reach out” to staff to discuss and resolve them.

The lapses documented by Levites-Agababa raise critical questions about the patchwork of state regulations that ORR relies on to monitor the shelters, which range from tiny group homes to 2,000-bed facilities and are often tucked in small towns and remote locations. On Tuesday, a 16-year-old boy died shortly after arriving at an ORR shelter in Texas.

Levites-Agababa’s concerns were recently substantiated by New Jersey regulators, who found numerous failures in CFS’ care of immigrant children. But despite the violations, the state agency lacks the ability to fine the shelter operator or remove kids from its care.

Levites-Agababa said she fears she could be fired for speaking out but agreed to go public in hopes of drawing attention to the care of children in the shelters.

CAMcare did not return calls for comment.

With access to children’s health records strictly limited, it’s hard to tell if the problems Levites-Agababa reported are isolated or emblematic of more widespread issues. A review last year of the Yolo County Juvenile Detention Facility in California found similar problems with immigrant teens’ access to medical care, including a failure “to follow up on serious injuries” and long waits for urgent medical needs.

Concerns over such lapses have prompted the HHS inspector general to conduct a nationwide review of the medical and mental health care provided in the youth shelters.

The American Academy of Pediatrics has expressed serious concern about the mental health consequences of detaining children, noting that even short periods can cause psychological trauma and carry lifelong consequences. The AAP doesn’t consider shelters a form of detention and its policy statement doesn’t address the impact of long-term stays in ORR shelters. The shelters were designed as community-based alternatives to detention but are now holding children for longer amounts of time.

Levites-Agababa said her experience has led her to believe that pediatricians should take a firmer stand. She compared it to when doctors started refusing to participate in lethal injections, deciding that their role in relieving suffering was outweighed by the harm of aiding execution. Levites-Agababa said she similarly believes that providing medical care to immigrant kids does not outweigh the traumatic effects of being held in a shelter.

“They are using us as a medical rubber stamp to keep these kids detained,” she said. “And by us participating in this without objection, we’re allowing for the detention of thousands and thousands of kids to continue.”

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Who monitors the care of immigrant children in shelters — and how vigilantly they do it — depends a lot on where the children end up.

All shelters must follow ORR rules, but the agency leans heavily on the states to license the facilities and ensure the children’s safety. And that has resulted in a haphazard set of standards.

In Texas, the shelters are considered residential child care centers and must follow stringent regulations set by child welfare officials. In Arizona, the shelters are deemed behavioral health facilities, with a more limited set of rules that hinder state inspections.

In New Jersey, child welfare officials, who normally oversee facilities with children, are prevented by statute from inspecting the immigrant youth shelters because they’re not funded by the state, said Tammori Petty, spokeswoman for the New Jersey Department of Community Affairs.

Instead, the ORR facilities are licensed as emergency homeless shelters and inspected by the department’s Bureau of Rooming and Boarding House Standards. The rules permit children to live in the shelters as long as they’re part of a family. In the case of immigrant children, Petty said, the department decided that ORR qualifies because it provides custodial care to the children.

The bureaucratic restriction makes for an interesting juxtaposition. CFS’ immigrant youth shelters — which can’t be overseen by child welfare — are known as the Juntos program, the Spanish word for “together.” In contrast, the center’s crisis program for American teens, simply called the Together shelter, is regulated by the state’s child welfare agency.

“I’m concerned about the lack of state oversight, that these shelters are not being licensed by any state agency that looks into child care,” said Farrin Anello, senior staff attorney with the American Civil Liberties Union of New Jersey.

Under a federal court settlement, the shelters are required to provide routine medical care and emergency services, including a medical exam, immunizations and screening for infectious diseases within 48 hours of admission.

ORR’s guidelines further require shelter workers to observe children for signs of illness and to respond to nonemergency requests for medical attention within 24 to 48 hours. The shelters must notify ORR within four hours of an emergency room visit, review hospital discharge plans and follow doctors’ treatment recommendations.

But while ORR has the power to remove kids from shelters and cut off funding, it’s also desperate for beds, and any major reduction in capacity could create a crisis. Those conflicting priorities are why child advocates say state oversight is important.

The care delivered by the shelters has become more critical as their role has evolved. Originally, the shelters were viewed as short-term way stations where children would stay while the government located and vetted relatives who could care for them while their asylum cases were reviewed. But under the Trump administration, the average stay grew to three months last fall.

The New Jersey shelters have largely existed in obscurity even as last summer’s family separation crisis cast a spotlight on the government’s network of facilities, which have received $5 billion since rising numbers of unaccompanied minors started arriving in 2014.

CFS, which has provided social services in Camden and southern New Jersey for nearly 100 years, opened its first shelter for unaccompanied minors in 2017. It has since received nearly $11 million in federal funds. One group home behind a church in Burlington houses 20 kids ages 13 and 17. Another in Woodbury is designated for up to 10 teen mothers who cross the border with their children. The program was recently approved to open a third shelter near Atlantic City later this year.

A review of inspection records shows that before Levites-Agababa’s complaint, the Bureau of Rooming and Boarding House Standards had cited the shelters for relatively minor violations: a loose toilet, a shower fixture that needed repair, a reminder to conduct monthly fire drills. Once last fall, it cited CFS for operating its Burlington shelter with an expired licensed and fire certificate. But the Department of Community Affairs later said the bureau simply hadn’t mailed the new license in time for the inspection.

New Jersey’s regulations for emergency homeless shelters contain little in regard to child welfare. The shelters must provide three meals a day, refer residents to medical care, report child abuse to the Department of Children and Families and have an undefined “sufficient number of competent staff” on-site to supervise the premises.

Police reports obtained by ProPublica show a few incidents that would typically draw additional scrutiny from regulators. In November, a 16-year-old boy ran away from the Burlington shelter. And last April, police responded to a report that a male staff member had made inappropriate comments and touched a girl while conducting an assessment in a closed office.

In other states, similar incidents have resulted in citations for failure to maintain supervision and proper boundaries around children. But the New Jersey inspection reports don’t mention any of these incidents.

Nor did the inspections address any medical issues. Department of Community Affairs officials insist they never received Levites-Agababa’s complaint. But after a referral of medical neglect by the Department of Children and Families, where Levites-Agababa had also complained, and several calls from ProPublica, an inspector visited the shelter in late March and found a number of violations.

CFS had failed to ensure that staff were properly trained to monitor changes in residents’ behavior, the inspector concluded. It had failed to ensure that staff understood how to handle emergencies. It had failed to arrange medical care after a resident developed a condition that required attention. It had failed to investigate and maintain records of incidents involving child endangerment. And it had failed to report child abuse and mistreatment to the state’s child welfare agency.

The “facility must exercise care in handling and documenting emergencies, including referring residents for medical care or other emergency services and maintaining records of any special medical needs or conditions, the prescribed regimen to be followed and the name and phone numbers of medical doctors to contact” in an emergency, the report said.

The Department of Community Affairs later said CFS had in fact submitted the child abuse report, attributing it to a paperwork mix-up at the bureau.

Still, while the bureau has OK’d CFS’ plan to fix the violations, it doesn’t have many other options. The only enforcement tool the bureau has at its disposal is to revoke the shelters’ licenses, which it has no plans to do.

The consequence of that? Instead of being regulated as homeless shelters, the facilities would be regulated as hotels according to New Jersey law. Under the state’s hotel statute, there are no rules regarding the care of children.

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After arriving at Cooper University Hospital in Camden, Yosary received the first of what would be several iron infusions. Lying in the hospital bed, separated from her toddler and far from other family members who’d fled with her from Honduras, Yosary thought of her mother, who died of cancer when Yosary was very young.

“I was really scared,” she recalled. “I was thinking, I don’t want to die.”

Yosary had come to the United States last March to seek asylum. In Honduras, she said, she had been raped when she was 12 and became pregnant with her son. After the family reported the attack, she said, they began receiving a series of threats. The lines between the local gang and the police and military in her city seemed increasingly blurry.

As the child got older, Yosary said, her attacker started lingering near her house, and she feared her son would be kidnapped.

So Yosary decided to flee with several members of her family, carrying her toddler by foot, by truck and finally by inflatable raft across the Rio Grande. After finding Border Patrol agents, she was taken to a processing station, where she was separated from the rest of her family and sent with her son to CFS’ mother-and-children’s home in New Jersey.

The first few months she felt fine, she said. But by late spring, she started feeling dizzy and sleepy all the time, and she noticed the bruises popping up on her legs and arms.

“I told them several times,” she said. “But they wouldn’t take me seriously.”

Yosary began to feel trapped inside the shelter. There were only three other girls with their babies there, she said. And they were rarely allowed out of the home even to get fresh air. Her only connections to the outside world were two brief calls a week with family members in the same precarious immigration situation.

Finally, there was a meeting at the home that included outside staff members. Yosary told one of them about the bruises.

But even in the doctor’s office and hospital, Yosary said, CFS staff wouldn’t let her talk to the doctor alone. “There was always somebody with me,” she said.

Levites-Agababa said this was a recurring problem with patients in the program, and she worried that it might make kids afraid to be forthcoming about their care in the shelter.

“When I insisted that chaperones leave the exam room so I could talk to the kid alone, they refused to leave and insisted it was policy,” she said.

After a few days, Yosary was discharged from the hospital with instructions to get another IV treatment. But CFS failed to inform CAMcare about the treatment, according to Levites-Agababa’s complaint.

The failure to schedule follow-up visits and heed doctors’ recommendations to see specialists or get lab tests or radiological studies became routine, said Levites-Agababa, who confronted CFS staff over the lapses.

At first, she said, shelter staff told her that ORR wouldn’t approve them, but she later learned that CFS hadn’t even submitted some of the orders.

A nurse at CAMcare, who asked not be identified, echoed Levites-Agababa’s concerns. “There were many appointments I had that got declined or they no-showed,” the nurse said. Another CAMcare doctor said that she was aware of the issues but didn’t have enough information to speak about them.

In some cases, Levites-Agababa said, the mothers of the babies actually had vaccination records from their home countries, but shelter staff failed to bring the paperwork to the initial medical exam.

“The poor teenage mom has painstakingly traveled through numerous countries and protected [the vaccination record] to bring it with the kid,” she said, “and they don’t even bring it to the visit?”

Yosary, who has since settled in Alabama with her older sister, said she couldn’t forget her five months in the shelter and wanted to speak up to help other girls there.

“I hope they don’t have to go through what I went through,” she said, her curly-headed toddler resting against her, “because being locked in that place, it was horrible.”

Even now, she said, she is reminded of the lack of concern about her well-being. According to ORR’s rules, upon release, shelters are supposed to give unaccompanied minors a copy of their medical records.

Yosary’s sister, who didn’t want her name used to protect the family, took out a thick manila envelope containing the records for Yosary and her son. While some pages are printed clearly, page after page are illegible.

“They told me these are the papers from the school, from the hospital, from everything,” Yosary said. But the printer had apparently run out of ink. “You couldn’t even read it,” she said. “One of the papers even looked blank.”

Back in New Jersey, Levites-Agababa said she worries about “what’s happening systemically throughout the United States in all these countless other homes” and whether other doctors will be emboldened to complain. “I just don’t know who else could raise this concern to the public or to ORR.”

Yosary and her sister said they’re glad Levites-Agababa decided to speak up.

“Nobody from the shelter is going to report anything,” said Yosary’s sister, who also stayed in a federal youth shelter when she arrived.

“I wouldn’t have done it because I’m an immigrant here,” Yosary said.

“And,” her sister added, “she doesn’t know the rules or the laws.”