Health inspection·February 1, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few logs, which revealed no grievances related to Resident #26. A review of progress notes showed no documentation for missing personal property. On 01/31/2024 at approximately 10:34 AM, an interview was conducted with the Social Worker, where she indicated that Resident #26 did report these items missing to her, but that Resident #26 couldn't tell her if the items had been labeled or not. The Social Worker indicated that she did not complete a grievance log but does have a log for lost items that she keeps up with on her computer. She stated that she has debated on whether to file a grievance for missing items or not but decided to just keep a log on her computer instead. When asked to review the log for lost items, the Social Worker indicated she was not able to locate it right now. She stated she spoke with the son of Resident #26 about the missing items and advised him to notify staff when new items come in so that they can be labeled with the resident's name. On 01/31/2024 at approximately 11:00 AM, the policy titled Resident Grievances (dated 08/24/2009 and last revised date of 10/18/2017) revealed the Social Worker acts as the Grievance Officer. Under Procedures on section 2 of the policy number 3, the policy states, All alleged abuse, mistreatment, neglect, injuries of unknown source, and/or misappropriation of property by anyone furnishing services on behalf of the provider will be reported to the Administrator immediately, and will be referred to the Risk Manager, and/or designee, for investigation and reporting of abuse, neglect and misappropriation of property, as per federal and state law. On 01/31/24 at approximately 11:20 AM, an interview was conducted with the Administrator and the Social Worker. The Administrator indicated that the Delta side of the building has a book for grievance logs and presented the book with grievances for missing items. When asked if Resident #26's grievance would be in this book, she indicated that it would not. She indicated that Alpha side has it's own system of keeping up with missing items and Resident #26 is on the Alpha side. When asked how missing items are followed up, results documented, and/or resident notified of results, the Social Worker indicated that she would go look for her log on her computer and return with it. On 01/31/24 at approximately 11:55 AM, the Social Worker returned with a notebook of printed papers inside that included the name of Resident #26 with missing items noted. There was no follow up, investigation, or tracking record noted on the form. The Social Worker indicated that she mostly keeps up with the missing items and status of the search for them in her head. On 01/31/24 at approximately 01:44 PM, an interview was conducted with the Administrator. When asked what the expectation of the facility is when residents report missing personal property, the Administrator indicated that, when residents first bring it up to them and if it's something small such as a missing shoe, eyeglasses, or a remote, then they should look for it and wait to see if the items can be located. If they can find the personal property, then the issue is resolved and nothing else is done, but if it becomes a pattern then she would expect it to go on grievance form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106056 If continuation sheet Page 2 of 3 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifford Chester Sims State Veterans Nursing Home 4419 Tram Road Panama City, FL 32404 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations and interviews, the facility failed to maintain a safe environment for staff in the laundry room. Residents Affected - Few The findings include: On 2/1/24 at approximately 12:40 PM, a tour was conducted of the laundry's dirty linen room, which revealed standing water on the floor in front and behind the three industrial washing machines that the facility uses to launder the resident's linens and personal clothing. (Photographic evidence obtained) On 2/1/24 at approximately 12:57 PM, an interview was conducted with the Supervisor of Laundry and Housekeeping concerning the leaking washing machines. The Laundry Supervisor indicated that the washing machines have been leaking for about 2 months now and that she has been reporting the issue to maintanence. The supervisor went on to state that a plumber did come out to look at the washing machines on 1/29/24, but they are still leaking. The Laundry Supervisor stated that they have been notifing the Administrator as well. She stated she tries to keep it mopped up as much as possible and have been putting blankets down to keep the water out of the walk area. On 2/1/24 at approximately 1:00 PM, an interview was conducted with Staff B, a maintenance worker, concerning the leaking washing machines. Maintenance Worker B stated that he had informed his supervisor a couple of weeks ago, and the issue had been looked at by an outside repairman a few days prior, but they could not find a leak. Maintenance Worker B stated that his helper checked the drains and found and removed a knife which helped some. He stated he was going to take a look at the machines again today to see if he could find the leak. On 2/1/24 at approximately 1:30 PM, an interview was conducted with the Administrator, who indicated that they have been working on the issue to try and get it fixed. The Administrator stated that another outside repairman was supposed to look at the machines again soon. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106056 If continuation sheet Page 3 of 3