By Jake Pearson, illustrations by Dominic Bodden, special to ProPublica

This story was originally published by ProPublica.

Unchanged diapers. Fees collected for care never given. New York Guardianship Services is often tasked with caring for the “unbefriended,” but records show more than a dozen cases where it failed to meet the needs of the most vulnerable.

Across New York City, hundreds of vulnerable people have been entrusted to New York Guardianship Services, one of roughly a dozen companies the courts rely on to care for “the unbefriended,” those without family or friends to help them.

The state’s guardianship law is supposed to prevent these guardians from abusing, neglecting and defrauding those under their care. But, as ProPublica reported last week, the measure is failing to safeguard those who need protection the most.

Our reporting told the story of Judith Zbiegniewicz, who suffers from depression and anxiety and spent a decade under the care of NYGS. The company placed her in a dilapidated Queens apartment where she lived among rats and bedbugs, sometimes with no heat or electricity. She complained to the company regularly but said it did little to fix the problems. Instead, NYGS repeatedly told court-appointed examiners that her housing was adequate — a claim these authorities never challenged.

ProPublica has now identified more than a dozen cases like Zbiegniewicz’s in which NYGS — and the court officials charged with oversight of the cases — failed to meet the needs of those entrusted to its care.

The stories provide a stark portrait of New York’s overtaxed guardianship system, which experts say is straining to care for more than 28,600 people statewide — 60% of whom live in New York City. Across the five boroughs, there are only 157 examiners to monitor how guardians care for wards. And just over a dozen judges review their work. Such thin ranks can render oversight almost meaningless, with annual assessments often taking years to complete.

NYGS executives Sam and David Blau declined to be interviewed for this story and didn’t answer written questions about the cases identified by ProPublica or the company’s broader business practices. Sam Blau, the company’s chief financial officer, said in a statement that as a fiduciary he was barred from answering questions “about any specific client.” However, he noted, “we are accountable to the Court and our annual accounts and reports are scrutinized by Court appointed examiners and any issues would be addressed.”

In his statement, Blau called ProPublica’s reporting “misguided, without full and proper context, filled with omissions and less than accurate information.” But when asked to specify his concerns, he did not respond.

These stories of NYGS’s wards represent the range of harms that can befall New Yorkers whose needs are great and bank accounts are small.

Renea Richardson became a ward of NYGS in March 2018, two years after suffering two strokes and undergoing surgery to relieve swelling in her brain. The health crisis left the former Port Authority of New York and New Jersey worker with brain damage and trouble walking.

But her time in rehabilitation facilities didn’t help her recover, and her goddaughter, Erin Samples, said NYGS wasn’t responding to her many calls. So by the fall of 2021, Samples took her concerns directly to the judge overseeing the guardianship. She was particularly concerned about the conditions in the Brooklyn nursing home where NYGS had placed Richardson.

Richardson was “not receiving regular diaper changing, not being properly dressed when I have visited her and not receiving physical therapy services,” Samples wrote. “Simply put, many people including Ms. Richardson’s guardian has dropped the ball when it comes to her care.”

The judge discharged NYGS four months later, replacing it with Integral Guardianship Services — a nonprofit guardian firm where Blau had also worked. Richardson and her family, however, were unaware that the group had its own problems. During Blau’s tenure, the state attorney general had investigated Integral, ultimately accusing it in 2015 of improperly loaning its executives hundreds of thousands of dollars while wards sat unnecessarily in nursing homes. Blau was not named in the probe, and Integral executives repaid the loans and pledged widespread reforms.

But Samples said the group was just as unresponsive as NYGS when she complained about Richardson’s care, according to emails she provided to ProPublica.

Samples now plans to become Richardson’s guardian herself.

“I never thought I’d be like this,” Richardson said in an interview last summer from her hospital bed in the Bedford Stuyvesant nursing home. Asked what she does all day, she said: “I lay in this bed and get fat and watch TV.”

Integral shut down last spring, and the courts reassigned its wards to other guardians. In a statement, John Ousley, Integral’s former CEO, acknowledged the delays in Richardson’s case, saying that more than half of the firm’s cases were pro bono and that due to limited resources and crushing needs, his staff had to “prioritize the most urgent requests in a given moment.” While he recognized Richardson and Samples’ frustrations, he said, he hoped they understood that “we were doing the best we could under very difficult circumstances.”

Another NYGS ward, Sigifredo Morante, appears to have slipped through the cracks entirely.

The former accountant and his wife, whose memories were fading, were appointed a guardian in the spring of 2017. The couple was living in a Queens nursing home, though they wanted to return to their native Colombia, where they had family and property. As it turned out, they had given a nephew, Francisco Arango, power of attorney, and he’d petitioned the court to send them back to their home country that fall. A Queens judge allowed the dual citizens to return under Arango’s care.

In an October 2017 hearing, the judge ordered NYGS to relinquish the guardianship altogether after the couple relocated and to reimburse Arango for fees associated with the move, which was completed before the end of that year. That never happened.

For reasons that are unclear, NYGS instead stayed on as Morante’s guardian — at least on paper — and took $450 in compensation from his Social Security check each month. In annual reports, the guardianship disclosed that Morante had moved to Colombia but provided no explanation for its fees. Reviews of those reports, court records show, were delayed in part because of NYGS’ own delinquency in responding to the examiner. Pandemic-era courthouse closures further prolonged his examination. By the time the examiner had enough information to flag the apparent no-show guardianship, Morante had been dead for more than two years.

Arango had no idea the company had continued to take compensation even after Morante died in March 2021, just shy of his 83rd birthday. He has since hired an attorney in Colombia, but it’s unclear whether Arango will be able to claw back the thousands of dollars NYGS took while Morante lived — and died — overseas.

After Arango’s lawyer notified NYGS of Morante’s death last summer, David Blau, the chief operating officer of NYGS, told him that the company could “conclude this matter I think fairly simple” once Arango provided a death certificate, an email shows. Arango has since done so, but Blau hasn’t responded to his lawyer’s subsequent inquiries, according to emails Arango’s lawyer provided to ProPublica.

Arango said law enforcement should investigate how NYGS was able to maintain the guardianship and take a cut of Morante’s government benefits, even as Arango spent thousands of his own dollars caring for him. “In my opinion they did what they could to take money” from vulnerable elderly people, he said of NYGS.

Even in cases where the company did know about dire conditions, it was slow to act, former employees said.

That was the case for William Bell, who was in his mid-80s and being looked after by his stepdaughter when the city sought a guardianship for him in 2017 to help stop an eviction from his apartment. Widowed and fiercely independent, he refused for years to move into a nursing home, even as his health deteriorated and his needs exceeded what his stepdaughter could provide.

In February 2019, a Brooklyn judge granted NYGS’s motion to permanently move Bell into a rehabilitation center, where he was eventually diagnosed with dementia.

Last June, Bell, then 90, was rushed to NewYork-Presbyterian Brooklyn Methodist Hospital, where hospital records show he presented with “agonal breathing” — gasps or moans that a person near death utters. Doctors told the guardianship that they could not save him and advised ending life support, according to a person familiar with Bell’s case who spoke on condition of anonymity to discuss his medical records.

But it took NYGS nearly a month to request a formal ethics assessment from the hospital to facilitate that process, that person said. The report, completed just after the July Fourth holiday, unambiguously argued that Bell’s care should be withdrawn since he’d lost “mental status” and couldn’t be weaned from a ventilator. “The prognosis is extremely grave without any hope of recovery,” it read.

Bell died the following day, on July 7, before any action could be taken.