The Citadel at Kingsbridge sits on a quiet block in the Bronx between the river and a string of charming old houses. Its lobby is bright and clean, with a glittering new chandelier, courtesy of recent renovations. But according to former employees and patient families, that façade masks a pattern of neglect that has resulted in misery, hospitalizations and at least one resident wandering off. It’s a pattern that inspection reports and first-hand accounts indicate could extend to at least one of Citadel’s sister sites – and that started after both were taken over by the for-profit company, Citadel Care Centers
Yet these homes aren’t flying under the radar. In fact, Citadel at Kingsbridge was recently singled out for a $30 million grant from New York state for renovations, approved by political figures who received campaign donations from Citadel’s owners.
Diana Dou says she noticed a difference as soon as Citadel took over the nursing home where her uncle, 85, had been living for nearly two years. She says the change in ownership was accompanied by a new name, The Plaza, along with cuts to staff and a decline in care.
“He lost 10 pounds in three months,” she said. “They also didn’t give him any water at mealtime or at any other time, and he got dehydrated and his kidneys stopped working.”
Dou says she tried to remove her uncle from The Plaza, but that staff called the police and Adult Protective Services to prevent her from doing so. He finally left when he was hospitalized for kidney failure from extreme dehydration. Doctors also told Dou he was suffering from malnutrition and rhabdomyolysis, a condition in which lack of movement causes muscles to deteriorate, and release toxic compounds into the blood.
Media and government survey inspection reports reveal different, but equally serious, dangers at The Plaza’s sister site, Citadel at Kingsbridge. The most famous occurred in June 2016, when a 76-year-old patient named Doris Dunbar, who suffers from dementia, wandered off unnoticed. Surveillance footage later showed that she walked out through the front door.
Though the incident received major media coverage, nothing at the nursing home changed, according to Samantha Otero, who worked there briefly as a certified nursing assistant in the summer of 2017.
“Patients leave out of the facility all the time,” she said, adding that she frequently heard staff joking about resident escapes. In fact, she says, she often saw staff parking patients in the lobby hours before they were scheduled to be picked up for appointments, leaving them with little supervision.
A recent visit to the facility confirmed Otero’s claims. Patients in wheelchairs sat waiting in a chaotic lobby, as well as outside the front door. The receptionist manning the front desk seemed unaware of visitors, and was unable to produce the facility’s most recent inspection survey, which federal law requires be made available for public inspection.
The most recent surveys, which are available online, document numerous other violations, including a lack of cleanliness, mishandled medication regimens and unsafe bed rails, which can lead to falls and strangulation.
Otero, who stayed at Citadel for only a month, says she was troubled by the callous attitude of the staff toward the residents.
“It made me feel so sad; everybody is just like, they don’t care,” Otero said. “It’s like eat your food, don’t eat your food, nobody cares.”
Most frightening to her was the way staff would ignore residents’ misery and requests – and sometimes even the alarm bells in their rooms.
“It’s just so scary,” she said. “I just feel like maybe some of those people passed away due to the neglect, and you honestly would never know.”
According to court records, this pattern of neglect is nothing new. Under its previous name, Kingsbridge Heights Care Center, the facility was the object of multiple lawsuits from former residents and their families.
One 2014 lawsuit details the story of Tula Lassalle, who stayed at the facility in November 2011 while recuperating from a minor surgery. After multiple requests for help going to the bathroom were ignored, Lassalle attempted to get up on her own. She fell and fractured her hip, requiring two surgeries.
Other complaints detail untreated bedsores, deadly falls and failure to address medical conditions resulting in death.
Though these lawsuits occurred before Kingsbridge changed hands, many of the specific complaints are repeated in Citadel’s survey inspections, in which it receives a one-star rating. The Plaza, on the other hand, has a five-star rating, despite a note that the facility hasn’t submitted its staffing data. Data from the Association of Health Care Journalists gives both facilities a one-star rating for staffing.
Citadel Kingsbridge’s rating doesn’t seem to have hurt it. In May 2016, the state of New York set aside $30 million in its budget for the nursing home, to be distributed over the following 30 years. Bronx state Sen. Jeff Klein said the grant will save the state money, because it’ll be used to pay for renovations rather than a new facility.
NYC Housing and Development records show a small renovation that was launched in early 2017. Currently, the lobby features a giant, opulent chandelier and a marble countertop for the reception desk.
Klein came under fire when it was discovered that Citadel’s owners had donated thousands of dollars to local politicians, $22,000 of which went to directly to his campaign coffers.
These donations weren’t the only ones Klein has received from nursing homes. Over the past three years, he has brought in at least $116,000 from the industry.
The Plaza, Citadel at Kingsbridge and Citadel Care Centers did not respond to requests for comment.