Violations lead to revoked license for retirement home
By Steve Weddle
Unpaid taxes.
A urine-stained couch.
Empty fuel tanks.
Feces-covered toilets.
Medical orders ignored.
An 86-year-old resident, wearing only a diaper and nightshirt, found facedown in a muddy field behind the building at 2:30 a.m.
These are just some of the problems the Virginia Department of Social Services reported finding at Warsaw Village Retirement Center.
As a result of two-years’ worth of investigations, social services plans to revoke the operating license of the facility.
A 13-page “letter of revocation” sent to Dr. Nazir Chaudhary, who owns the facility through Dogwood Realty, details more than a dozen “serious” violations in which, according to the department, the facility failed to property care for its residents.
The investigations exposed a wide range of problems, from financial irresponsibility to physical endangerment, according to social services.
One of the most recent charges stems from the October death of a resident.
According to police reports, at 4:30 p.m. on October 27, a resident who had a physician’s order requiring that she be served only pureed food died when she choked to death staff fed her a bowl of peach slices.
The resident, referred to in reports as “Resident #6,” began choking at dinner. Staff then “administered abdominal thrusts and a small piece of peach came up. The resident was then taken to her room where she began choking again,” according to the report obtained by the Northern Neck News.
After a staff member called 911 and two others attempted CPR, emergency medical technicians arrived but were unable to revive the resident. She was pronounced dead at 5:02 p.m.
According to the “Standards and Regulations for Licensed Adult Care Residences,” the licensing manual for social services, the next of kin and “any responsible social agency” must be notified “at least within 24 hours” of any serious illness or emergency situation.
The Department of Social Services was not informed of the resident’s death until contacted by the Northern Neck News six days later.
“The facility failed to notify the licensing office of Resident #6’s death. The licensing office learned of the death from a news reporter who had called the licensing administrator on November 2 inquiring about the death,” according to reports obtained by the Northern Neck News.
Staff at the retirement center told investigators that the resident was given peach slices because “she said she didn’t like the way pureed food looked and tasted.”
Lack of proper diet was also a concern as the investigation further revealed that the resident “had not been given any other food besides peaches for dinner.”
Other violations listed in the letter concern residents who have not been receiving proper medication.
Inspections on July 20 and September 21 show that medication orders were not being followed for at least 10 of the 84 residents at the time. Inspectors for social services found that on September 15, 18, 20, and 21, a resident did not receive prescribed medication or received it inconsistently.
A review of the medical records for four other patients found similar violations.
A July 20 inspection showed that five residents “were receiving psychotropic medications without a diagnosis or treatment plan.”
The Department of Social Services found that, while some medical plans were not being followed, other prescriptive plans did not exist at all.
The “Standards and Regulations” manual requires the facility to “develop and implement an individualized service plan [ISP] to meet the resident’s service needs.”
Though one resident had a documented history of violent outbursts, Warsaw Village Retirement Center had no plans to address the resident’s needs, social services noted.
According to reports, Resident #8 “became physically aggressive at least once a month.” A note written by a nurse in June indicated that the resident “became angry and attempted to physically assault staff.”
The ISP made “no mention of aggressive behavior,” according to a social services July review of the documents.
The resident also grabbed staff members and displayed aggressive behavior on October 4 and October 7, according to a nurse’s notes and social services records reviewed by the Northern Neck News.
On September 12, “the resident turned over a table and threw water on the floor after being given something to drink,” the revocation letter states.
In addition to lacking treatment plans, Warsaw Village Retirement Center also lacked the ability to provide care for some of its residents. A January 25 interview that social services conducted with a staff member outlined that at least two residents “lacked the ability to assist in any way with taking care of their own personal needs.” According to the facility’s records, “both residents were totally dependent in all Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL),” social services found.
After the January 25 interview, social services recommended to the center’s administrator that both of the residents “be screened for nursing home placement,” as Warsaw Village Retirement Center was unable to provide the necessary care.
Four months later, in April, an inspection by social services found that the screenings had not taken place. During another inspection, in July, social services determined that the screenings still had not taken place.
In September, the residents were transferred to a nursing home.
In addition to failing to provide proper medical treatment for residents, the retirement center failed to provide effective supervision, social services found.
In March of last year, a male resident, referred to as “Resident #4,” was found standing in a field outside the facility at 9 p.m. Nine days later, the same resident was found at 1:30 a.m. in a field behind the facility. A week after that incident, the resident twice wandered away from the building. That summer, staff once again found the resident in a field near the center. Months later, just before midnight, staff at the retirement center discovered Resident #4 missing again. According to records, they were unable to locate the resident. Staff called local police, who used a K-9 unit to search for the resident, who was found three-and-a-half hours after he had been reported missing.
At 2:30 a.m., the resident was found “lying facedown in the mud, wearing only a diaper and a nightshirt,” a report indicates.
A review conducted after the incident determined that the resident was a “wanderer.”
“Staff at the facility failed to report the incident [to social services] until after the resident was discharged from the facility,” the letter of revocation says.
In addition to lack of effective supervision and necessary care, Warsaw Village Retirement Center has also been financially irresponsible, according to social services.
In March of this year, Tina King, then the facility’s administrator, told the licensing inspector that she and her assistant had not been reimbursed for pizzas they had purchased when the facility’s fuel oil ran out and they were unable to prepare lunch for residents. King told the inspector that the fuel oil company refused to refill the tank until previous invoices had been paid.
Less than a month earlier, Warsaw Town Manager John Slusser told Dr. Chaudhary, the facility’s owner, that the town was owed nearly $2,000 in overdue taxes.
In November, the licensing inspector spoke with a representative from Northern Neck Electric Cooperative who informed her of an overdue bill in the amount of $1,485.
During the same visit, according to the letter of revocation, the inspector discovered that BFI Waste Management refused to pick up the facility’s garbage until a past-due bill was settled. The inspector further noted a “huge amount of garbage lying outside the dumpster.”
According to the inspection records, “Staff reported that this is not an unusual event, as phone and cable services had also been disconnected in the past.”
The Department of Social Services itself is still owed $1,500 in unpaid civil penalties levied against the retirement center.
A public notice declaring social services’ intent to revoke the facility’s operating license should appear at the entrance to the building, which remains open for business. No notice is currently posted.
Asked whether he intended to post the notice, Chaudhary said, “I would like you to leave now.”
According to social services, Chaudhary has the right to appeal the agency’s decision by requesting an informal conference. Chaudhary, who refused further comment, has 15 days from the receipt of the November 28 letter to request a conference.
The Warsaw retirement home, which is licensed for 96 residents and averages 33, is only the latest of Chaudhary’s facilities that fails to meet state standards.
In April, the Department of Social Services denied Chaudhary’s attempt to renew his operating license for Patriot Retirement Center in Williamsburg.
According to an April 6 letter the department sent to him, Chaudhary has “failed to prevent and resolve systemic and recurring violations at Patriot Retirement Center.” Those violations, according to the agency, have “placed the health and safety of residents in serious to extreme risk for harm. Investigations into that facility revealed that some diabetic residents did not receive breakfast until as late as 11 a.m., despite requiring timely meals.
Social services also reported finding one resident in the dining room alone, facedown in a plate of food. While at the facility, they also found another resident at Patriot screaming in pain and another who had gotten herself stuck while trying to get into bed.
According to the reports, staff at the facility either did not respond at all to the residents in need or “walked right past them.”
After the denial of license, Chaudhary reportedly sold the facility to Micand Two, Inc., which has renamed it Micand Retirement Center.
Another Chaudhary-owned facility, Commonwealth Assisted Living Center in Frederisckburg, had its license revoked last spring, due to numerous, and now familiar, violations of health and safety.
While Chaudhary was appealing that revocation, he sold the facility to A.W.K. Durrani, which has renamed the facility Onyx Assisted Living.
Chaudhary is under no legal obligation to sell the Warsaw retirement home, however.
According to social services, during the informal hearing he has yet to request, Chaudhary could dispute the agency’s findings. He could also take a pro-active approach by submitting a plan for corrective action and financial responsibility, a step he has not taken at his other troubled facilities.
While Chaudhary determines a response to the letter of revocation, Warsaw Village Retirement Center remains open for its residents.
