Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sitter And Barfoot Veterans Care Center during CMS and state inspections, most recent first.
Surveyors found expired and unlabeled food items in the kitchen's freezers and refrigerator, as well as a dusty industrial fan in the dish room. Despite staff training and established protocols for food safety and sanitation, these deficiencies were observed during routine checks, affecting food service for a large number of residents.
All four washing machines were not maintained in safe working order, with staff using washcloths to keep doors closed and blankets to absorb ongoing leaks. The machines continued to be used despite door and seal issues, and there were no current work orders or maintenance policies in place. Key staff, including the DON and maintenance technician, were unaware of the extent of the problem, while the Assistant Administrator acknowledged ongoing leakage and unresolved repairs.
A resident with multiple medical conditions and no cognitive impairment was observed over several days with a nonfunctional clock in their room. Despite staff acknowledging the importance of an accurate clock for orientation and daily routines, the issue was not addressed during the survey period.
Facility staff failed to ensure two residents were free from unnecessary psychotropic medications and chemical restraints. One resident received PRN Lorazepam for anxiety over an extended period without proper documentation of indication or duration, while another was administered Seroquel for dementia and PTSD without documented symptoms of psychosis or appropriate rationale, and despite the medication not being FDA-approved for those conditions.
A resident with multiple chronic conditions and moderate cognitive impairment was observed on several occasions to have their CPAP machine, tubing, and mask left uncovered and open to air on the bedside table when not in use, contrary to facility policy requiring storage in a plastic bag. Staff did not follow established infection control procedures for respiratory equipment.
Expired and Unlabeled Food, Unclean Equipment in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety practices in the kitchen, as evidenced by the presence of expired food items, lack of labeling on opened food packages, and unclean equipment. Observations revealed that several food items in the freezers and walk-in refrigerator, including sliced frozen salami, poppy seed coffee cake, thickened orange juice, thickened dairy beverage, and cottage cheese, were either not labeled with the date and time they were opened or were stored past their expiration dates. Additionally, a large industrial fan in the dish room was found to have a visible layer of dust on its outer cage. Interviews with staff indicated that multiple individuals were responsible for monitoring food storage and cleanliness, with expectations set for daily, weekly, and monthly checks according to facility policy and ServSafe guidelines. Despite these protocols and staff training, the deficiencies were observed during the survey, affecting the kitchen that served 167 residents. The facility's own policy required regular inspections and audits to ensure compliance with food safety standards, but these were not effectively implemented, leading to the identified lapses.
Failure to Maintain Washing Machines in Safe Working Condition
Penalty
Summary
The facility failed to maintain all four washing machines in safe and proper working condition, as evidenced by direct observation, staff interviews, and review of facility documentation. Laundry staff were observed using washcloths wedged in the doors of washing machines #2 and #3 to keep them closed, as the doors would otherwise open slightly and leak water. Blankets were placed on the floor in front of all four machines to absorb ongoing leaks, and several of these blankets were confirmed to be damp or wet at the time of inspection. The installation and maintenance manual for the machines specified that they should not be operated if the door does not remain securely locked during the cycle, and that a qualified technician should be called if the door lock and interlock are not functioning properly. Interviews revealed that the laundry worker had been using the washcloth method for about a year, and the Director of Environmental Services confirmed the practice and the presence of leaks, but stated there were no current work orders for repairs. The maintenance technician was unaware of the leaks and stated that repairs were attempted when doors became loose, but no current work orders existed. The Assistant Administrator acknowledged knowledge of the leaks and loose door handles, stating the machines were out of warranty and that previous contractor repairs had not resolved the issues. The DON was not aware of the leaks and stated her expectation was for immediate notification and repair. There were no facility policies for maintenance of the washing machines or for submitting work orders to maintenance.
Failure to Maintain Functional Clock for Resident
Penalty
Summary
Facility staff failed to ensure the reasonable accommodation of a resident's needs and preferences by not maintaining a functional clock in the resident's room. Over the course of several days, surveyors observed that the clock consistently displayed the incorrect time (6:30) during multiple visits, despite the resident being present and able to participate in interviews and daily activities. The resident, who had no cognitive impairment and required assistance with all activities of daily living, was observed in various states such as resting, watching television, and talking on the phone, with the nonfunctional clock remaining unaddressed. Staff interviews confirmed the importance of an accurate clock for residents to prevent disorientation and to help them prepare for activities, meals, appointments, or visits. Despite these acknowledgments, the issue persisted and was not corrected during the survey period. The administrator was informed of the findings, but no additional information or corrective action was provided at that time.
Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraints
Penalty
Summary
Facility staff failed to prevent the use of unnecessary psychotropic medications and did not ensure residents were free from chemical restraints. For one resident with moderate cognitive impairment and multiple diagnoses, including dementia and Parkinson's disease, staff administered PRN Lorazepam for anxiety over an extended period without proper documentation of the indication for use or a specified duration of therapy. The medication was given repeatedly for several months, and there was no provider documentation justifying the continued use beyond 14 days, as required. In another case, staff administered the antipsychotic Seroquel to a resident with a history of dementia, PTSD, and other medical conditions. The clinical record showed the medication was prescribed for dementia and PTSD, but the psychiatric assessment did not document symptoms of psychosis or behaviors that would warrant antipsychotic use. Additionally, Seroquel is not FDA-approved for the treatment of dementia or PTSD. The facility was unable to provide adequate documentation supporting the rationale for the prescription.
Failure to Properly Store CPAP Equipment According to Infection Control Policy
Penalty
Summary
Facility staff failed to provide respiratory care according to professional standards of practice for a resident who required CPAP therapy. Multiple observations over three consecutive days revealed that the CPAP machine, including its tubing and mask, was left uncovered and open to air on the resident's bedside table when not in use. This was in direct contradiction to the facility's own policy, which required that CPAP and BiPAP masks be stored within a plastic bag when not in use, with the bag changed weekly or as needed. The resident involved had a complex medical history, including aphasia following cerebral infarction, chronic kidney disease stage two, type two diabetes, Barrett's esophagus, nontraumatic subarachnoid hemorrhage, a history of cerebral infarction, and coronary atherosclerosis due to lipid plaque. The resident was assessed as having moderate cognitive impairment and required assistance with all activities of daily living, using a wheelchair for mobility. Despite physician orders for nightly CPAP use, staff did not follow infection control protocols for storing the equipment, as documented in the facility's policy.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Hill Health & Rehabilitation | 1.9 mi | ★★★★★ | 0 | 0 |
| Beaufont Health And Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
| The Virginia Home | 3.3 mi | ★★★★★ | 0 | 0 |
| Southampton Rehabilitation And Healthcare Center | 4.5 mi | ★★★★★ | 4 | 1 |
| The Laurels Of Bon Air | 5.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.