Toward the end of July, 2011, I began having back and abdominal pain that progressed from mild to extreme.  Four trips to the emergency room at McGuire Veterans Hospital provided no relief.  In desperation, and to avoid a wait time in the ER, on July 28th, I called an ambulance to pick me up at home.

Somewhere, during the trip to the ER, my mind went blank. I have no memory of being admitted to the hospital.  I have no memory of staying six nights.

My medical records show that seven days later, on August 3rd, I was transferred to Sitter and Barfoot Veterans Care Center.

Sitter and Barfoot is a veterans’ long-term care and rehab center. I had never heard of it.  I have no recollection of being included in the decision process. No family members participated in the decision to move me to a nursing home.

I’ve been told that I was discharged from McGuire on my own and arrived at Sitter and Barfoot by taxi. I have no memory of a cab ride. I completed the admitting paperwork but don’t remember doing so.

I have vague recollections of being in unfamiliar surroundings, being restrained in a bed at night with bolsters on both sides and with an attendant.  I have no idea why I was restrained other than being a possible flight risk. Staff members have told me that I was aggressive, delusional, and hallucinating.

In September, seven weeks later, I was scheduled for back surgery, returning to McGuire for a laminectomy at T-8 and T-9 vertebrae. I have no memory of the discharge from Sitter and Barfoot and being readmitted back to McGuire. The surgery was performed on September 22. I have been unable to stand or walk since.

My medical chart shows that on 10/26/2011, Kathryn L. Hall, a social work student wrote:  “When asked about his IDT [interdisciplinary team] meeting yesterday, the patient said that he understood he would not be able to return home, but hopefully will be able to return to Sitter & Barfoot.”

It remains unclear who was “hopeful.”

Ms. Hall was under the supervision of Thomas Olivieri, MSW.

I stayed at McGuire Hospital until December 9th, 2011, receiving various antibiotics, therapies, rehabilitation, and consults from a variety of medical disciplines.

Returning to Sitter and Barfoot was the only option offered, and I knew of no other comparable facility.  My previous experience at Sitter and Barfoot was unremarkable.

The social workers at McGuire glossed over the fact that I would have to switch from being treated under the Veterans Health Administration and change to Medicaid. I would lose all of my possessions; all retirement income less $40.00/mo personal needs allowance, and my best friend.

Even though the prognosis was grim, I remained optimistic about the future and refused to accept the fact that I would never walk again.

I did not comprehend the long-term consequences regarding the direction the social workers pushed me.  In retrospect, the options presented to me were end-of-life decisions—at the young age of 69.


I will spend the rest of my life in a nursing home where if feel constrained. I was coerced into a controlled environment and had to surrender my independence; placed in a closed social structure that was foreign to me. I found myself surrounded by persons, not of my choosing, many experiencing cognitive decline, some inconsiderate, and others too loud for my liking.

The few residents that I had formed a friendship, sadly, have died. I stopped trying to replace them.


Residents are encouraged to decorate their rooms for a personal, home-like feel.  Social activities offered are designed to entertain and provide a distraction for all age groups and abilities: Scattagories, Pictionary, Bingo, Trivia, Dominos, art classes, current events, music, etc.

Often residents remain alone with their thoughts, blankly watching TV or staring out at emptiness trying to recapture fading memories.

These conditions serve as a view into my future.  These conditions are what I will become. It is all too clear.  This is what I have to look forward to. It’s not a pretty picture. Those around me are in some stage of slow decline. It serves as a continual reminder of the futility of it all.


Through education and perseverance, I prepared myself to regain some autonomy that was initially denied.  I have been able to expand my boundaries and travel to downtown Richmond by city bus.

Although Richmond is a friendly city for those with disabilities, the bus schedule is less accommodating. Destinations of interest often require transfers and long waits. Weather is a major consideration, requiring advance preparation, often forcing a disappointing change in plans.

My independence is limited by my power wheelchair, city bus, and economic constraints. Still, I take pleasure in the occasional excursion downtown. My ability to come and go is hampered only by my physical affliction, financial hardship, and climate conditions.


I have a private room. I have my laptop. I have my music, and I am left alone to pursue the only thing of interest—writing.

I hope, as I move forward, my thoughts and opinions will reach those that share the same interests.





1601 Broad Rock Boulevard # 103
Richmond, Virginia 23224

March 15, 2015

The Honorable Terry McAuliffe
Governor of Virginia
1111 East Broad Street,
Richmond, VA 23219

Dear Governor McAuliffe:

If trust and transparency are to be the cornerstones of your administration, you need look no further than Sitter and Barfoot Veterans Care Center (SBVCC).

SBVCC has refused to conduct business in an atmosphere of trust, transparency, and professionalism; instead, choosing to operate under a blanket of deception and secrecy.

One has to question the motivation behind such policies and practices—what are they trying to cover-up and hide? Why the refusal to be accountable and transparent?

Residents of a nursing home are not considered credible; they have no voice—it is only through the voice of the responsible party that they can be heard.

I am the responsible party. I conduct my own business and personal affairs: banking, taxes, social security, Medicaid eligibility, college courses, etc. It is absolutely necessary to communicate electronically to reduce confusion, misunderstanding, and to remove vagueness.

Memories can be refreshed with written communication—verbal communications cannot. Verbal communications leave the door open for uncertainty and conflict. Verbal communication allows for doubt, deceit, and deniability. Written emails open lines of communication that permit accountability, clear understanding, and verification.

Sitter and Barfoot is a high profile agency within your administration. Its practices are not only unacceptable, but an embarrassment to your administration’s efforts to regain trust and transparency in state government.

It is mandatory that the communication practices and policies of Sitter and Barfoot be reviewed, and corrective actions are made.

Robert Carr




February 9, 2015

Congressman Robert C. “Bobby” Scott
1201 Longworth House Office Bldg.
Washington, D.C. 20515

Dear Congressman Scott:

Ms. Ranicki, the Administrator at Sitter and Barfoot Veterans Care Center, validated all of my assertions. It begs to question why such policies and practices existed.

Unfortunately, my sphere of influence does not extend far. Many of the veterans at Sitter and Barfoot experience the same indignities but are unwilling, unable, or too fearful to raise a voice. It would be naive to think otherwise. It is for those veterans that I also raise my voice. Hopefully, others will hear my truth and implement much-needed reform.

Despite the oppression exerted by Sitter and Barfoot, I have persevered, and by attacking the tyranny of the administration and Sitter and Barfoot, I have been able to improve my end of life experience. I continue to pursue my dreams, to fulfill a life packed with purpose and meaning—despite Sitter and Barfoot and my disability.

I will not be silenced. I will continue to make others aware of the indignities I’ve suffered; a veteran that served to protect the very rights I’ve been denied.

It is shameful that the noblest of institutions has failed me in so many ways. An aware, concerned, responsive, and dedicated administration would never allow such practices under their purview. Ageing veterans deserve leadership that manages with integrity, transparency, and by example.

The prevailing culture at Sitter and Barfoot is one of control. Not only control over the veteran resident, but control over the counterfeit image projected to the public.

I too, invite you or your representative to visit me at Sitter and Barfoot. It is a beautiful facility. Sadly, it is the epitome of the axiom, “Beauty is only skin deep.” Come visit and we can review several years of enlightening health department inspections.

Thank you.



Robert Carr




Reality has hit home and the alternatives are complicated. Options are limited and uncertain. Time may be of the essence. Motivation for such a move may be the inability or the unwillingness to provide the necessary care. Both justifications come with guilt.

Placing someone you love in a nursing home, into the custody and care of an unknown—to be cared for 24/7 by persons never seen—demands trust and understanding.


How will you approach the decision? With confidence or confusion? With anxiety or relief? With generosity or selfishness? Haste or with deliberation? As a challenge or an annoyance?

Emotions drain you. You’re surrendering total care and control of a loved one to the unknown, untried, and unproven. You want to—you have to—make the right decision for the loved one and yourself.

Nursing homes know you’re in a vulnerable position. They emphasize the positives and ignore the negatives. They want you to make hasty decisions based on first impressions, and imprecise, flexible language.

It’s quite possibly the last destination before the funeral home for a loved one, and their techniques are very similar. Nursing homes are intent on making a positive first impression. They are selling the unknown to the uninformed.

Many questions go through your mind when making the decision. How will my loved one be treated? What type of care will they receive? What is the quality of the medical staff? What is the availability of trained personnel to meet particular needs? Is emergency care available (defibrillators) on site or do they use outside first responders (911)? How safe will my loved one be?

Your choice of a nursing home is a quality of life and death decision for a loved one.

Appearing too firm can lead to an awkward relationship with the nursing home. A relationship filled with the fear of reprisals, payback, and guilt. Fear of the unknown settles over you.

What happens in nursing homes, far too often, stays in nursing homes.

Nursing homes have the upper hand, and they know it. Complaints are trivialized, ignored, forgotten, or buried under bureaucratic mountains of paperwork and delays. Residents are viewed as bewildered, confused, or having hallucinations….Conditions brought on by dementia or medications.

The Virginia Department of Health, the investigating body, tells you it takes twelve to fifteen months to investigate a complaint, depending on the severity. Some residents in nursing homes would be fortunate to have twelve to fifteen months remaining.

The demand for quality nursing homes far outweighs the supply and continues to grow while quality management and accountability go unchanged or worsens.

Nursing homes do everything to control the resident. It is, after all, their responsibility to provide care, comfort, and safety to those under their protection. They have little flexibility in accommodating individual preferences regarding the personal activities of those under their purview. Personal dignity and respect yield to satisfying the needs of the majority and what is necessary for the nursing home to meet its financial and administrative goals.


Know their business! Do your research. Ask detailed questions, and know the answers beforehand. Nursing homes have strict federal guidelines that must be followed. The Centers for Medicare/Medicaid Services (CMS) manual is online:


Know it! Take your time, be thorough, and take notes! Search using keywords identifying areas of concern geared to your individual needs.

Nursing homes don’t follow the guidelines. Nursing homes take shortcuts, speak in generalities, and make vague, yet plausible excuses for deficiencies.

Health inspections: Federal law requires that the most recent annual health department survey be available for public examination. Request the health department surveys for the previous two years. That’s the only way to determine if the nursing home has a history of deficiencies. If they shy away, ask why! Question their refusal.

Don’t go by the sanitized survey results found online. The surveys online don’t specify deficiencies and omit much of the critical details. You’re making decisions for your loved one, and you have the right to make an informed choice.

Resident Assessment: CMS Manual §483.20(k) Comprehensive Care Plan. The Minimum Data Set (MDS) is a comprehensive resident assessment required by federal law under strict guidelines. This evaluation is lengthy (30 to 40 pages in some cases) and must be reviewed with the interdisciplinary team from the nursing home. The nursing home may have its self-interests, may not be informed, or final instructions may be unclear. Do your homework and be prepared. Once again, it’s important to take notes. Don’t yield to pressure from the nursing home and don’t gloss over the importance of this meeting. The responsible party must be given the opportunity to review this assessment in detail prior to the meeting to prepare questions and to correct errors. A simple entry error of “DNR” (do not resuscitate) in place of “FULL” will have consequences.

The MDS reviews all aspects of the resident’s care and treatment including mental acuity or a cognition evaluation. This document may have legal importance if future decisions are challenged by family members regarding end of life wishes, advance care planning or advanced directives. Caution is advised; preparation and participation are mandatory for an interdisciplinary care plan meeting. Allow enough time and remember this is the final care plan for the one you love.

Security of personal items: Nursing homes advise residents to keep a limited amount of cash (no more than $10.00) in their rooms. But they make no guarantees and do very little to stem the threat of theft. I have been robbed four times by employees to a total of $141.00. According to their guiding principle, I should have been robbed a fraction over 14 times.

Photograph valuable items where they are placed in the room: i.e., electronics, memorabilia, and other irreplaceable personal items. Download pictures to a remote computer. Lock up everything else.

Medications: Med mistakes are a persistent problem in nursing homes. Be sure to ask about the med error percentage. The federal guideline is less than 5%. Know the answer before asking the question (15%). Ask why it’s so high and what’s being done to lower this number.

It’s preferred that the resident be able to count! The residents should, from time to time, count the medications dispensed to them. If there is a discrepancy, call the nurse supervisor and report it. Follow up to make sure it’s noted on the resident’s medical chart. The responsible party or the resident have the right and obligation to report med errors to the attending physician and the Office of Licensure and Certification at the Department of Health.

Get a list of all medication to be administered, know what each is for and the side effects.

Personnel: An inspection of employee licenses, background checks, and police records are part of the annual survey done by the health department. Don’t take the word of the nursing home. Nursing homes don’t follow the minimum standards regarding hiring practices. Licenses for healthcare workers in Virginia are online at:


A search can be done with just the first and last name. It shows violations listed with the licensing agency, but only if offenses are reported.


There are many lists available online to use as a guide for choosing a nursing home. Use them; they are helpful.


However, not to be overlooked is the reality that this is an end of life decision. Checklists are sterile and impersonal. Don’t ignore the personal aspects that shape the end of life experience for a loved one.

The decisions you make have a profound effect on the memories that your loved one takes on the final journey. Do your part. It’s through your involvement, knowledge, and understanding that you will find the peace and comfort you want.

Listen to your loved one—believe in your loved one—and be a strong advocate. Do your research, take your time, and make it a comfortable, peaceful passage for the one you love.




Am I a statistic or a “harmless error” of the Veterans Administration Health Care System?

The diagnosis was that I needed a triple bypass and an evaluation of my heart valve.

My heart surgery was put on the fast track and scheduled for late March, 2011. The result was a “successful” quadruple bypass and a bovine aortic valve replacement.

Beginning in mid-July of 2011, I started experiencing lower back pain on the left side. It became increasing more severe. I finally decided to go to the emergency room at McGuire Veterans Hospital located here in Richmond, Virginia. The ER doctor examined me, and her suspicion was an intestinal issue. I was treated and released.


I was diagnosed six weeks later with an abscess between T-8 and T-9 vertebrae caused by the MRSA (Methicillin-resistant Staphylococcus aureus) bacteria that colonized in my spine. The abscess was putting pressure on the spinal nerves and needed to be removed. McGuire Veterans Medical Center performed a laminectomy on my spine, and I have not walked since the surgery.

Below is an excerpt from my progress notes dated 09/21/2011 on page 630:

Epidural abscess & Back pain: The source is probably the bovine valve which was replaced on March [30th, 2011] since there is no other obvious cause of abscess in this otherwise healthy gentleman. No history of pneumonias or admissions for sepsis. No hx of IV drug use.

The progress note points the smoking gun back towards the “bovine valve” that was implanted at McGuire Veterans Medical Center five months earlier.


The Veterans Administration placed me in a veterans’ nursing home as a paraplegic, cast aside like waste, destined to die a slow and heartbreaking death—alone.





There is no mechanism in place for the Department of Veteran Services to perform operational oversight of Sitter and Barfoot Veterans Care Center, according to the Care Center’s administrator.

Sitter and Barfoot is a long-term care facility that provides rehabilitation services and medical care and comfort to as many as 160 veterans. It has two units, each with sixty private rooms. In addition, there is a specialized Alzheimer’s/dementia wing with forty rooms.


I requested a copy of an inspection done by the Department of Veteran Services. Instead, I was shown the review done by the Department of Veterans Affairs, the federal agency. When questioned, the administrator stated that the Virginia Department of Veteran Services does not inspect the operation of Sitter Barfoot. Further, the administrator said that Sitter and Barfoot is checked twice a year by two separate agencies: one federal and one state.

The two annual inspections, done by the Virginia Department of Health and the Department of Veterans Affairs, are done to evaluate the operation and care given to the most deserving of our aging population.

The Department of Health and Department of Veterans Affairs inspections cover the operation of the Care Center and typically last three to four days. Each department operates independently and comes at different times of the year.

The Department of Health evaluates the overall care delivered to those 160 veterans: quality of care, medical records, privacy, personnel practices; rehabilitation, food preparation, staffing, resident complaints, medications and more. Towards the end of the inspection process, a meeting is scheduled. The administrator and the director of nursing convene with the survey team to review the deficiencies found and draw up a corrective action plan.

Sitter and Barfoot received the highest grade possible in the 2014 survey.

After an interview with a health department surveyor, the health department failed to address four of my concerns:

• Medication errors
• Short staffing
• Ignoring communications
• Lack of dignity and respect

The health department showed little interest in my issues. Complaints from nursing home residents are considered unreliable and often ignored.

It begs to question the effectiveness of such an assessment and the trustworthiness of the Department of Health.

The Department of Health acknowledges a 12 to 15 month wait time to investigate complaints. I now have to wait again to get resolution. Residents in a nursing home would be fortunate to have that many months left.

The cleanliness of Sitter and Barfoot affects those doing the survey and accounts for the disparity between fiction and reality. Cleanliness covers many evils. Overall appearance diverts attention and unduly influences the outcome of the inspection.

The Health Department and Sitter and Barfoot are both state agencies. I question the reliability of one state agency evaluating the performance of another. Corruption, complacency, and a lack of transparency obscure objectivity in government self-appraisals. It is unlikely that a state agency tarnishes another agency’s operation; particularly one with such high and honorable intentions as caring for aging veterans.

The Department of Veterans Services needs more accountability in the delivery of care to deserving veterans.

Accountability does not stop with the administrator. The administrator has self-interests and financial demands to protect, as well as job security for the employees that have shown allegiance. The administrator and staff can hardly be expected to be objective. Government agencies have demonstrated that they do whatever is necessary to protect their province.

The Department of Veterans Services needs to be held accountable and responsive to the needs of all veterans it serves. It is mandatory that the Department of Veterans Services be pro-active and aggressive in ferreting out problems. Not just a self-serving propaganda arm for the Commonwealth.

Accountability at the top will cure the ills of Sitter and Barfoot and the Department of Veterans Services—and accountability with consequences must filter down to all levels.





Nursing homes mislead the end user by promoting “private rooms.” Misleading because, in fact, that only means the room has a door on it. There is no privacy unless those that have access respect the sanctity of privacy.

I have been a resident of Sitter and Barfoot Veterans Care Center for three years and most of that time “privacy” has been a condition that has had to be regularly requested and often denied. Only after three years do I have a modicum of real privacy.


Constant guidance and reinforcement have resulted in acceptance of my desire for privacy. If someone wishes access to my “home,” they knock and ask for permission before entering; it is an essential of courtesy, dignity, and respect. Still, I still have a few that just knock and open the door; much to my displeasure.

Not asking for permission has resulted in friction between me and factions of employees. Some staff members think that I am here for their convenience. The reality is that they are here for my benefit, and they are to adhere to my expectations of privacy.

I have had doctors, staff, and registered nurses just enter my room whether the door be opened or closed. They have been met with displeasure.

Employees of nursing homes should be treated no differently than the contractor you hired to cut your grass, clean your pool, fix your plumbing or the cable guy. You would not expect someone you hired to come to your home and interrupt your dinner nor would you expect them just to walk into your house without knocking. The nursing home staff works for the resident and is hired to perform a service. It is no different. It is a matter of respect.

Unlike life outside a nursing home, once inside you have to demand respect. Nursing homes have the mistaken view that the resident is there for their benefit, not the other way around. Nursing homes control meals, medication, and comfort. Privacy is the last remnant removed from the control of the resident.

Nursing homes will attempt total control of the resident in any fashion they can. However, privacy is not their domain. Privacy is one area that the resident has control, and it should be made clear to the nursing home from the beginning.

Private rooms are not private if everyone one has unfettered and uncontested access.





One only has to look around the room to be struck with the absence of feeling or emotion.

The forgotten souls staring into the emptiness of space. Staring blankly in the direction of the dark TV screen.

Some with chins on their chest — asleep. Others just sleeping slumped in their wheelchairs.

There is no dialog between those thrown into this arena. Some don’t know where they are or why they are there.

Boredom is the activity of the day….Every day.

Those that appear to be alert look as if they are searching motionless; staring into the future that is now behind them.

Some cross their arms on the table and put their heads down to sleep.

Emptiness fills the room.

Bodies and minds drained of all feeling but pain.

These are the souls that are considered “fall risks” and require constant observation.

The escape is the same for those that are lower risks. They sit expressionless in their wheelchairs in the hallways and stare into the emptiness of their mind.

Is it light?

Is it dark?

Is it good or is it bad?

What do they think?

Do they think?

Are they looking toward the future?

Are they looking forward to the past?

To the observer it looks like a gathering of gloom.

Despair and loneliness seep from the listless and sleeping bodies.

An aide reads the newspaper aloud. Only one listens. To the rest, they are unaware.

One lying reclined on a chair; face covered with a towel to block out reality.

There is an absence of color that pours from the room.

They are all wrapped in invisible black shrouds waiting to die.

This is my future… This is what I have to look forward to.





In April of 2013, I experienced repeated abuses in the restricted parking at the McGuire VA Hospital. The handicapped crosswalks were blocked with automobiles illegally occupying those designated areas. I went to the police office and lodged a formal complaint. In this instance, the officer that responded to my complaint refused to ticket the offending vehicle.

I wrote a letter to the interim director, David Budinger. His response, in writing, was that because of the shortage of parking spaces the Veterans Police had adopted a system of “compliance enforcement.” That term was never explained to me, but clearly it meant no enforcement at all.

The conditions continued until April of 2014. I wrote a second letter to the new Director of the hospital, John Brandecker:

April 7, 2014

John Brandecker,
Director, Hunter Holmes McGuire VAMC
1201 Broad Rock Boulevard
Richmond, Va. 23249

Mr. Brandecker:

You are just one more failure in an unresponsive Department of Veterans Affairs.

You, as director, should be ashamed to have under your leadership, a law enforcement department that discriminates against a disabled veteran and fails to enforce traffic laws.

I have dedicated my time, professionalism, and intellect to serve the veterans and family members at McGuire Veterans Medical Center. Under your leadership, I have been unnecessarily inconvenienced and discriminated against by the Department of Veterans Affairs Police Department. The parking problem exists because of poor management and planning. That does not exempt you from the mandated laws and the requirements associated with enforcement. The Department of Veterans affairs chose to discriminate against the disabled as the avenue of least resistance. You have allowed this discriminatory practice to establish itself, and it has become the norm. To subject those that devote their energies and resources to assist veterans and family members to such abuse and ridicule is contemptible.


Robert E. Carr
cc: Mrs. Michelle Obama
Honorable Tim Kaine
Office of the Inspector General

This letter apparently hit a nerve.

My heated verbal encounter with the Police Chief and his pathetic defense of the “compliance enforcement” doctrine did not resonate well with the Director. He immediately changed the policy and placed orange cones in the wheelchair crosswalks.

The following is the net result.


Even police chiefs can be stupid!

I thank the Director, John Brandecker, for standing firm and in support of veterans that are wheelchair bound.



Hundreds of Medical professionals have been entering and exiting Ebola stricken areas for months. Only recently has the question of “quarantine” been raised.


The case in Spain is an example of a knee-jerk reaction at the expense of civil liberties, which resulted with the loss of a dog, Excalibur.
Unfortunately, Excalibur’s demise was the result of overreaction and not supported by scientific fact. This is further supported by Nurse Nina Pham’s dog Bentley.

We would be naïve to think that all medical personnel with direct contact with Ebola stricken patients have been subjected to 21 day quarantine.

Those that think nurse Hickox should be placed in quarantine have bought into the fear mongering and paranoia presented by hyped up and uninformed mainstream media. There is no conclusive scientific evidence to support her being quarantined.

This is another example of government overreach, and criminal intimidation. Are we to deny the civil liberties to all those that treat the flu?

I applaud Kaci Hickox’s sacrifice and courage.