Sitter and Barfoot Veterans Care Center

In the surveyor’s words

From the most serious findings on record at Sitter and Barfoot Veterans Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880May 2, 2021

  Based on observation, interview, record review, and review of policies and procedures, and of medical device and product user information, the facility failed to: A.) ensure the nursing staff cleaned and disinfected multi-use glucometers per the device manufacturer's instructions and per the Environmental Protection Agency (EPA)-registered (approved) disinfectant's instructions for use when performing fingerstick blood glucose (sugar) (FSBS) testing between residents. Specifically, five of five Licensed Practical Nurses, (LPN) 21, LPN22, LPN23, LPN25, and LPN26) on three of four units (Richmond, Bay Side, and Blue Ridge) failed to effectively clean and disinfect five of five glucometers used to perform FSBS testing for five of 30 sampled residents, (Resident (R) 4, R51, R82, R135, and… […]

• Immediate jeopardy, isolatedF578May 2, 2021

  3_F578-IJ Based on interview, record review, and review of the facility's policy, the facility failed to ensure a resident's advance directive was executed per the resident's wishes related to code status for one of 47 sampled residents (Resident (R) 24). R24 formulated an advance directive prior to being admitted to the facility; however, the resident's family member signed a Do Not Resuscitate (DNR) form without being educated about the form or it's implications. This failure had the potential to affect all residents of the facility who had, or who wished to formulate an advance directive. On [DATE] at 3:55 PM, the facility's Assistant Administrator was notified and issued an Immediate Jeopardy at F578, the right to formulate an Advance Directive. […]

• No harm, potential for more than minimal, patternF812Jun 5, 2025

  Based on observation, interview, and facility document and policy review, the facility failed to ensure expired food items were discarded, food items were labeled with the date opened, and an industrial fan in the kitchen was free of dust. This failure created the potential for foodborne illness for 167 residents who received food from the kitchen of 170 residents who resided in the facility. Findings included: A facility policy titled, Food Items to Discard, updated 06/04/2025, indicated, It is the policy of [facility name] Nutrition Services Department to ensure that all food and foodservice items are properly received, labeled, stored, rotated, and discarded in accordance with federal, state, and local food safety regulations. […]

• No harm, potential for more than minimal, patternF908Jun 5, 2025

  Based on observation, interview, and facility document review, the facility failed to ensure 4 of 4 washing machines were maintained in safe and proper working condition. Findings included: On 06/05/25 at 11:11 AM, Assistant Administrator B stated the facility did not have policies for maintenance of washing machines or submission of work orders to the maintenance department. An installation/operation/maintenance manual titled, Washer-Extractors, dated 12/2023, revealed a section titled Operator Daily Maintenance Checks that included instructions for the facility's model of washing machines. The manual specified, If the door lock and interlock are not functioning properly, disconnect power and call a qualified technician. 3. […]

• No harm, potential for more than minimal, patternF567May 2, 2021

  Based on resident and staff interviews, review of financial records pertaining to resident accounts, and review of the facility Resident Trust Fund Policy the facility failed ensure that one resident (Residents (R)57) of 47 sampled residents had access to his petty cash fund on weekends. This failure had the potential to impact all 112 residents for whom the facility manages personal fund accounts. Findings include: Interview with R57 on 04/27/21 at 2:56 PM revealed, when asked about access to his money in his patient account managed by the facility I can't get it on Sunday. They tell you to come back on Monday. […]