K0000 INITIAL COMMENTS K0000 12/10/2025
Bldg. 01 A revisit to the recertification survey was conducted
by desk review on December 10, 2025.
The previously cited deficiencies were found to have
been corrected as of October 5, 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: 1D1509-L2 Facility ID: 35961021 If continuation sheet Page 1 of 1
DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 03/25/2026
CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONS (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106088 (X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING (X3) DATE SURVEY COMPLETED
12/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
CLYDE E LASSEN STATE VETERANS NURSING HOME 4650 STATE RD 16, SAINT AUGUSTINE, Florida, 32092
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION
TAG TAG DATE
E0000 Initial Comments E0000 12/10/2025
A revisit to the recertification survey was conducted
by desk review on December 10, 2025.
The facility's Emergency Preparedness Program was in
compliance at the time of the recertification survey.
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: 1D1509-L2 Facility ID: 35961021 If continuation sheet Page 1 of 1
