ElderGrade

Inspection citations at Sitter And Barfoot Veterans Care Center

31 citations on record, 4 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 5 0
2023 1 0
2021 12 2
2018 13 2
D June 5, 2025 Tag F0695 Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D June 5, 2025 Tag F0605 Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

No actual harm, potential for more than minimal harm

D June 5, 2025 Tag F0558 Corrected Jul 2025

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E June 5, 2025 Tag F0908 Corrected Jul 2025

Environmental Deficiencies

Keep all essential equipment working safely.

No actual harm, potential for more than minimal harm

E June 5, 2025 Tag F0812 Corrected Jul 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D September 6, 2023 Tag F0686 Complaint investigation Corrected Oct 2023

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D May 2, 2021 Tag F0791 Corrected Jul 2021

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

No actual harm, potential for more than minimal harm

D May 2, 2021 Tag F0689 Corrected Jul 2021

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D May 2, 2021 Tag F0677 Corrected Jul 2021

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D May 2, 2021 Tag F0641 Corrected Jul 2021

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D May 2, 2021 Tag F0609 Corrected Jul 2021

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D May 2, 2021 Tag F0602 Corrected Jul 2021

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

No actual harm, potential for more than minimal harm

D May 2, 2021 Tag F0550 Corrected Jul 2021

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E May 2, 2021 Tag F0883 Corrected Jul 2021

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

No actual harm, potential for more than minimal harm

E May 2, 2021 Tag F0607 Corrected Jul 2021

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

No actual harm, potential for more than minimal harm

E May 2, 2021 Tag F0567 Corrected Jul 2021

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

No actual harm, potential for more than minimal harm

J May 2, 2021 Tag F0578 Corrected Jul 2021

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Immediate jeopardy to resident health or safety

K May 2, 2021 Tag F0880 Corrected Jul 2021

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Immediate jeopardy to resident health or safety

B September 12, 2018 Tag F0577 Corrected Oct 2018

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

No actual harm, minimal potential

D September 12, 2018 Tag F0761 Corrected Oct 2018

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D September 12, 2018 Tag F0755 Corrected Oct 2018

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D September 12, 2018 Tag F0690 Corrected Oct 2018

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D September 12, 2018 Tag F0582 Corrected Oct 2018

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

No actual harm, potential for more than minimal harm

D September 12, 2018 Tag F0573 Corrected Oct 2018

Resident Rights Deficiencies

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

No actual harm, potential for more than minimal harm

D September 12, 2018 Tag F0558 Corrected Oct 2018

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

D September 12, 2018 Tag F0554 Corrected Oct 2018

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

D September 12, 2018 Tag F0550 Corrected Oct 2018

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E September 12, 2018 Tag F0645 Corrected Oct 2018

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

F September 12, 2018 Tag F0812 Corrected Oct 2018

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

G September 12, 2018 Tag F0804 Corrected Oct 2018

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Actual harm to a resident

G September 12, 2018 Tag F0689 Corrected Oct 2018

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.