Inspection·March 31, 2025

K0351 SS = D Sprinkler System - Installation CFR(s): NFPA 101 Sprinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.

K0351 [No data entered] 06/06/2025 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 reverse for further 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 these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: MSW821 Facility ID: 35960985 If continuation sheet Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/09/2026 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106056 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED B. WING (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME STREET ADDRESS, CITY, STATE, ZIP CODE 4419 TRAM ROAD, PANAMA CITY, Florida, 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) (X5) COMPLETION DATE

K0351 SS = D Continued from page 1

K0351 In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1(1) This STANDARD is NOT MET as evidenced by: Based on observation and interview with the Maintenance Director, the facility failed to provide automatic fire sprinkler coverage in 5 of 5 mechanical rooms observed. Proper sprinkler coverage helps to ensure safety of all building occupants in an emergency situation. The findings include: During the Fire & Life Safety tour of the facility with the Director of Maintenance on 03/31/2025 from 11:00 am to 2:00 pm, it was found that the sprinkler heads in Mechanical Rooms 152, 153, 154, 155, and 168 were obstructed by Heating, Ventilation, and Air Conditioning (HVAC) system piping. The Director of Maintenance was present during the observation and confirmed the findings. Please refer to NFPA 101 (2012 Edition) sections 19.3.5.1 and 9.7; NFPA 13 (2010 Edition) section 8.1.1(1), as well as CMS memo S&C 13-55 LSC - requirement for nursing homes to be fully sprinklered.

K0353 SS = D Bldg. 01 Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing

K0353 [No data entered] 06/06/2025 Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: MSW821 Facility ID: 35960985 If continuation sheet Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/09/2026 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106056 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED B. WING (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME STREET ADDRESS, CITY, STATE, ZIP CODE 4419 TRAM ROAD, PANAMA CITY, Florida, 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) (X5) COMPLETION DATE

K0353 SS = D Bldg. 01 Continued from page 2 a) Date sprinkler system last checked b) Who provided system test c) Water system supply source Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This STANDARD is NOT MET as evidenced by: Based on observation and interview with the Maintenance Director, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25 for 4 of 4 sprinkler heads in the facility's laundry area. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed. The findings include: During the Fire & Life Safety tour of the facility with the Maintenance Director on 03/31/2025 between 11:00 am - 2:00 pm, it was observed that 4 of 4 sprinkler heads in laundry room were corroded and rust laden. The Director of Maintenance was present during the observation and confirmed the findings. According to NFPA 25 (2011 edition) section 5.2.1.1.1: "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage, and shall be installed in the correct orientation." and 5.2.1.1.2: "Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5) Loading, (6) Painting unless painted by the sprinkler manufacturer." FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: MSW821 Facility ID: 35960985 If continuation sheet Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/09/2026 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106056 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME STREET ADDRESS, CITY, STATE, ZIP CODE 4419 TRAM ROAD, PANAMA CITY, Florida, 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) (X5) COMPLETION DATE

E0000 Initial Comments

E0000 During the recertification survey conducted on 03/31/2025 at Clifford Chester Sims State Veterans Nursing Home, a nursing home in Panama City, FL, the Emergency Preparedness Program (EP) was reviewed. Clifford Chester Sims State Veterans Nursing Home is in compliance with the Emergency Preparedness rule per Code of Federal Regulations (CFR), 42, Part 483.73, Requirement for Long-Term Care Facilities. 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 reverse for further 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 these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: MSW821 Facility ID: 35960985 If continuation sheet Page 1 of 1 Florida Department of Health PRINTED: 04/09/2026 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 130471027 (X2) MULTIPLE CONSTRUCTION A. BUILDING 05 - MAIN LIC B. WING (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME 4419 TRAM ROAD, PANAMA CITY, Florida, 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) (X5) COMPLETION DATE

K0000 INITIAL COMMENTS K0000 An unannounced Fire & Life Safety re-licensure survey was conducted on 03/31/2025 at Clifford Chester Sims State Veterans Nursing Home, a nursing home in Panama City, Florida, in accordance with the standards of National Fire Protection Association (NFPA) 1 and 101 (2021) edition, and all applicable requirements of the Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C.) 61B-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 standards, collectively known as the Florida Fire Prevention Code, and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. There were deficiencies found at the time of the visit

K0351 SS = D Sprinkler System - Installation K0351 [No data entered] 06/06/2025 Sprinkler System - Installation 2015 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) Office of Primary Care and Health Systems Management LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM Event ID: MSW821 Facility ID: 35960985 If continuation sheet Page 1 of 4 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 130471027 (X2) MULTIPLE CONSTRUCTION A. BUILDING 05 - MAIN LIC B. WING (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME STREET ADDRESS, CITY, STATE, ZIP CODE 4419 TRAM ROAD, PANAMA CITY, Florida, 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) (X5) COMPLETION DATE

K0351 SS = D Continued from page 1 K0351 2015 NEW Buildings are to be protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state and local regulations prohibit sprinklers. Listed quick-response or listed residential sprinklers are used throughout smoke compartments with patient sleeping rooms. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed six square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 18.3.5.1, 18.3.5.4, 18.3.5.5, 18.3.5.6, 9.7, 9.7.1.1(1), 18.3.5.10 This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on observation and interview with the Maintenance Director, the facility failed to provide automatic fire sprinkler coverage in 5 of 5 mechanical rooms observed. Proper sprinkler coverage helps to ensure safety of all building occupants in an emergency situation. The findings include: During the Fire & Life Safety tour of the facility with the Director of Maintenance on 03/31/2025 from 11:00 am to 2:00 pm, it was found that the sprinkler heads in Mechanical Rooms 152, 153, 154, 155, and 168 were obstructed by Heating, Ventilation, and Air Conditioning (HVAC) system piping. The Director of Maintenance was present during the observation and confirmed the findings. Please refer to NFPA 101 (2021 Edition) sections 19.3.5.1 and 9.7; NFPA 13 (2010 Edition) section 8.1.1(1), as well as CMS memo S&C 13-55 LSC - STATE FORM Event ID: MSW821 Facility ID: 35960985 If continuation sheet Page 2 of 4 Florida Department of Health PRINTED: 04/09/2026 FORM APPROVED (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 130471027 (X2) MULTIPLE CONSTRUCTION A. BUILDING 05 - MAIN LIC B. WING (X3) DATE SURVEY COMPLETED 03/31/2025 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS NAME OF PROVIDER OR SUPPLIER CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME STREET ADDRESS, CITY, STATE, ZIP CODE 4419 TRAM ROAD, PANAMA CITY, Florida, 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) (X5) COMPLETION DATE

K0351 SS = D Continued from page 2 requirement for Nursing homes to be fully sprinklered. K0351 ​

K0353 SS = D Bldg. 05 Sprinkler System - Maintenance and Testing K0353 [No data entered] 06/06/2025 ​ Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. ​ ​ ​ a) Date sprinkler system last checked ​ ​ ​ b) Who provided system test ​ ​ ​ c) Water system supply source ​ ​ ​ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. ​ ​ ​ 9.7.5, 9.7.7, 9.7.8, and NFPA 25 ​ ​ ​ This LICENSURE REQUIREMENT is NOT MET as evidenced by: ​ ​ ​ Based on observation and interview with the Maintenance Director, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25 for 4 of 4 sprinkler heads in the facility's laundry area. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed. ​ ​ ​ The findings include: ​ ​ ​ During the Fire & Life Safety tour of the facility with the Maintenance Director on 03/31/2025 between 11:00 am - 2:00 pm, it was observed that 4 of 4 sprinkler heads in laundry room were corroded and rust laden. ​ ​ ​ The Director of Maintenance was present during the observation and confirmed the findings. ​ ​ ​ ​ ​ ​ STATE FORM Event ID: MSW821 Facility ID: 35960985 If continuation sheet Page 3 of 4 Florida Department of Health PRINTED: 04/09/2026 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 130471027 (X2) MULTIPLE CONSTRUCTION A. BUILDING 05 - MAIN LIC B. WING (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME 4419 TRAM ROAD, PANAMA CITY, Florida, 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) (X5) COMPLETION DATE

K0353 SS = D Bldg. 05 Continued from page 3 K0353 According to NFPA 25 (2011 edition) section 5.2.1.1.1; "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage. And shall be installed in the correct orientation." and 5.2.1.1.2; "Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5) Loading, (6) Painting unless painted by the sprinkler manufacturer."Based on observation and interview with the Maintenance Director, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed. Class III STATE FORM Event ID: MSW821 Facility ID: 35960985 If continuation sheet Page 4 of 4