E 000 Initial Comments
E 000
During the recertification survey conducted on
01/29/2024 at Clifford Chester Sims State
Veterans Nursing Home, a nursing home in
Panama City, FL, the Emergency Preparedness
Program was reviewed.
Clifford Chester Sims State Veterans Nursing
Home complies with the Emergency
Preparedness rule per Code of Federal
Regulations (CFR) 42, Part 483.73, Requirement
for Long-Term Care Facilities.
K 000 INITIAL COMMENTS
K 000
An unannounced Fire & Life Safety recertification
survey was conducted 01/29/2024 at Clifford
Chester Sims State Veterans Nursing Home, a
nursing home in Panama City, Florida.
The facility is in compliance with Code of Federal
Regulations (CFR) 42, Part 483.90, Requirement
for Long Term Care Facilities: Physical
Environment and National Fire Protection
Association (NFPA) 101 (2012 edition) and NFPA
99 (2012) requirements for nursing homes.
Initial Plan Review:2003
Existing
NFPA 220 Construction Type: II (222)
Number of beds: 120
Census: 88
There were no deficiencies found at the time of
the visit
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date of survey these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02/99) Previous Versions Obsolete
Event ID: PBHO21
Facility ID: 35960985
If continuation sheet Page 1 of 1
PRINTED: 04/05/2024
FORM APPROVED
Agency for Health Care Administration
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER: 35960985
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: 01, 05
B. WING __
(X3) DATE SURVEY
COMPLETED 01/29/2024
NAME OF PROVIDER OR SUPPLIER
CLIFFORD CHESTER SIMS STATE VETERANS NURSI
STREET ADDRESS, CITY, STATE, ZIP CODE
4419 TRAM ROAD
PANAMA CITY, FL 32404
(X4) ID
PREFIX
TAG SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION) ID
PREFIX
TAG PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY) (X6)
COMPLETE
DATE
K 000 INITIAL COMMENTS K 000
An unannounced Fire & Life Safety re-licensure
survey was conducted on 01/29/2024 at Clifford
Chester Sims State Veterans Nursing Home, a
nursing home in Panama City, Florida, in
accordance with National Fire Protection
Association (NFPA) 1 and 101 (2021 edition) and
applicable requirements of Florida State Fire
Marshal's Rules and Regulations, Florida
Administrative Code (F.A.C) 69A-3, F.A.C.
69A-53, F.A.C. 59A-4, and Florida Statutes (F.S.)
400 Part II, and F.S. 633.0215, adopting National
Fire Protection Association (NFPA) 1 and 101
(2021 edition), collectively known as the Florida
Fire Prevention Code, and all NFPA referenced
standards and requirements adopted per NFPA
101, Chapter 2.
There were no deficiencies found at the time of
the visit
AHCA Form 3020-0001
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
STATE FORM
6809
PBHQ21
If continuation sheet 1 of 1
