The nursing home failed to ensure a working call system was available in each resident’s bathroom and bathing area. Cited November 2021 — limited pattern, potential for harm.
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F-Tag 919 — 42 CFR §483.90 — S/S: E
Nursing home report
CLYDE E LASSEN STATE VETERANS NURSING HOME
SAINT AUGUSTINE, FL · Medicare-certified · 120 beds
In good standing
Government-runChain member
5 of 5 overall
Clyde E Lassen State Veterans Nursing Home in Saint Augustine has an overall 5-star rating, with 5 stars for health inspections and 4 stars for staffing, and reported nurse staffing above the federal benchmark (5.31 vs 4.1 hours per resident per day). Its quality measures rating is 2 stars, with no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
5.3103 hrs/resident/day
Quality measures
Last inspection: August 22, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 5.3103.
Staffing detail
- Registered nurses
- 0.74
- Licensed practical nurses
- 1.26
- Nurse aides
- 3.31
- Weekend nursing
- 4.69
Hours per resident per day.
Total staff turnover: 64%
Registered nurse turnover: 55%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
21.4%14.3%Improving
Residents with a fall causing major injury
2.9%3.6%Worsening
Residents with pressure ulcers (bedsores)
6.1%1.2%Improving
Residents with a urinary tract infection
1.9%4.5%Worsening
Residents who lost too much weight
11%3.5%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
16.9%12.3%Improving
Residents whose ability to walk got worse
34.7%14.5%Improving
Long-stay residents on antianxiety or sleep medication
41%33.7%Improving
Short-stay residents newly given an antipsychotic
—6.5%—
Residents with a long-term catheter
0.8%0%Improving
Residents with new or worsening incontinence
19.9%27.7%Worsening
Residents with depressive symptoms
2.2%1%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—90.9%—
Long-stay residents given the pneumonia vaccine
79.8%91.9%Improving
Short-stay residents given the seasonal flu vaccine
—81.5%—
Short-stay residents given the pneumonia vaccine
59.3%70.8%Improving
What the inspectors found
The home failed to provide safe and appropriate breathing care when a resident needed it. Cited August 2025 — isolated incident, potential for harm.
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F-Tag 695 — 42 CFR §483.25(i) — S/S: D
The home failed to support and respect residents’ choices and self-determination. Cited November 2021 — isolated incident, potential for harm.
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F-Tag 561 — 42 CFR §483.10 — S/S: D
The home failed to ensure residents kept their ability to do everyday activities unless there was a medical reason. Cited November 2021 — isolated incident, potential for harm.
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F-Tag 676 — 42 CFR §483.24 — S/S: D
The home failed to make sure feeding tubes were used only when medically needed and that residents with feeding tubes received proper care. Cited November 2021 — isolated incident, potential for harm.
View the original federal record
F-Tag 693 — 42 CFR §483.25 — S/S: D
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
Operator & ownership
- Ownership
- Government - State
- Chain
- Part of FLORIDA DEPARTMENT OF VETERANS' AFFAIRS · 8 homes · 3.6 stars avg
- Occupancy
- 115 residents on an average day (96% of 120 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 15 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.