Sitter and Barfoot Veterans Care Center
1601 Broadrock Blvd, Richmond, VA 23224 · Richmond City County · 200 certified beds · avg 168 residents/day · certified since Jan 25, 2008
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · May 2, 2021 · F-0880
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jul 30, 2021 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 2, 2021 · F-0578
The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 30, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 12, 2018 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 24, 2018 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 12, 2018 · F-0804
The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Why it matters: Unappetizing or cold food leads residents to eat less, risking weight loss and malnutrition.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 24, 2018 (Deficient, Provider has date of correction)
All citations in the current public record (31)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 5, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 5, 2025 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 6, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| May 2, 2021 | ▲ K · Immediate jeopardy, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 2, 2021 | ▲ J · Immediate jeopardy, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 2, 2021 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. |
| May 2, 2021 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| May 2, 2021 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| May 2, 2021 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| May 2, 2021 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. |
| May 2, 2021 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| May 2, 2021 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 2, 2021 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 2, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 2, 2021 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Sep 12, 2018 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 12, 2018 | ▲ G · Actual harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Sep 12, 2018 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 12, 2018 | E · Potential for harm, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Sep 12, 2018 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Sep 12, 2018 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Sep 12, 2018 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Sep 12, 2018 | D · Potential for harm, one-off | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. |
| Sep 12, 2018 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Sep 12, 2018 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Sep 12, 2018 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 12, 2018 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 12, 2018 | B · Minimal risk, repeated | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (12 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2018 | 13 | 2 | G ▲ |
| 2021 | 12 | 2 | K ▲ |
| 2023 | 1 | 0 | D |
| 2025 | 5 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Virginia avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.75 | 3.67 | 3.95 | top 6% in Virginia; top 5% in the U.S. |
| Registered Nurse hours | 0.93 | 0.66 | 0.69 | top 13% in Virginia; top 19% in the U.S. |
| Weekend total nurse staffing | 4.76 | 3.21 | 3.50 | top 9% in Virginia; top 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.53 | 0.46 | 0.48 | top 20% in Virginia; top 29% in the U.S. |
| Total nursing staff turnover (%) | 24.4 | 48.1 | 45.8 | top 5% in Virginia; top 6% in the U.S. |
| RN turnover (%) | 25.8 | 48.2 | 42.9 | top 15% in Virginia; top 23% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.91, RN 0.79, weekend 4.07. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Government - State
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Commonwealth of Virginia | Organization | 5% or Greater Direct Ownership Interest | — | 09/26/2007 |
| Jennings, Robyn | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/25/2015 |
| Jennings, Robyn | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/25/2015 |
| Jennings, Robyn | Individual | ADP of the SNF | NOT APPLICABLE | 09/25/2015 |
| Mughal, Amjad | Individual | ADP of the SNF | NOT APPLICABLE | 01/20/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Forest Hill Health & Rehabilitation | 1.9 mi | Richmond, VA | ★☆☆☆☆ | 1/5 | |
| Beaufont Health and Rehabilitation Center | 3.1 mi | Richmond, VA | ★★☆☆☆ | 3/5 | |
| The Virginia Home | 3.3 mi | Richmond, VA | ★★★☆☆ | 2/5 | abuse |
| Southampton Rehabilitation and Healthcare Center | 4.5 mi | Richmond, VA | ★★☆☆☆ | 2/5 | |
| The Laurels of Bon Air | 5.1 mi | Bon Air, VA | ★★★☆☆ | 2/5 | |
| Vcu Health Children's Services at Brook Road | 5.4 mi | Richmond, VA | ★★★★★ | 5/5 | |
| Rosedale Health & Rehabilitation | 6.5 mi | Richmond, VA | ★☆☆☆☆ | 1/5 | |
| Glenburnie Rehab & Nursing Center | 6.8 mi | Richmond, VA | ★★☆☆☆ | 1/5 | |
| Westminster-Canterbury of Richmond | 7.2 mi | Richmond, VA | ★★★★★ | 4/5 | |
| Health Care Center Lucy Corr | 7.9 mi | Chesterfield, VA | ★★☆☆☆ | 2/5 | |
| The Laurels of Willow Creek | 8.3 mi | Midlothian, VA | ★★☆☆☆ | 2/5 | |
| Westport Rehabilitation and Nursing Center | 8.5 mi | Richmond, VA | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 495393.