Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parmly On The Lake Llc during CMS and state inspections, most recent first.
A resident with COPD, OSA, atrial fibrillation, and heart failure had conflicting oxygen orders in the chart, with hospital discharge paperwork showing 2 L/min at bedtime while facility records reflected 6 L continuous oxygen without a signed physician order. After a room change, the oxygen concentrator was left in the old room, and the resident’s portable tank ran empty overnight because staff did not have a consistent process for checking tank levels. The resident was found unresponsive on the toilet with no oxygen available.
A resident with dementia and behavioral disturbances was subjected to physical and mental abuse by staff, who failed to use appropriate de-escalation techniques and instead engaged in antagonistic and physically inappropriate actions, including swearing, taunting, and forceful restraint. The incident was substantiated through witness statements and documentation, leading to the termination of the involved staff.
The facility failed to timely implement wound care orders for two residents, leading to a severe infection and recommended amputation for one resident. Orders were delayed due to inconsistent transcription practices, with staff waiting days to process them. The facility's policy required timely transcription, which was not followed.
A long-term care facility failed to follow proper infection control practices for residents on precautions. Staff did not wear required PPE or perform hand hygiene correctly, and linens were stored uncovered in hallways. These oversights were acknowledged by staff, highlighting lapses in adherence to infection prevention protocols.
A resident with a history of falls and cognitive alterations was found to have a pillow placed under the fitted sheet of their concave mattress, intended to prevent them from rolling out of bed. This action was not ordered or documented as a restraint, and staff interviews revealed uncertainty about the resident's ability to remove the pillow due to weakness. The DON confirmed that this was not an appropriate intervention for falls, and the facility's restraint policy was not provided.
A resident with a history of fractures and on narcotic pain medication experienced constipation, but the facility failed to initiate a bowel regimen. Despite the resident's requests and the facility's protocol for bowel management, there was no evidence of bowel medications being offered or administered. Staff interviews revealed inconsistencies in monitoring and addressing constipation, leading to the resident's ongoing discomfort.
The facility failed to implement pressure ulcer interventions for two residents, leading to deficiencies in their care. One resident, with severely impaired cognition, was observed without necessary heel protectors and with heels not properly floated off the bed. Another resident, with severe cognitive impairment and an unstageable pressure injury, was left in a wheelchair for extended periods without repositioning. The facility's policy on skin assessment and wound management was not followed, resulting in inadequate care.
A resident with intact cognition and independent mobility was observed smoking on facility grounds, contrary to the non-smoking policy. The resident's smoking evaluation lacked staff observation documentation, and the resident did not sign out as required. Observations showed the resident smoked in the parking lot and disposed of cigarette butts in a trash can, posing a potential fire hazard. Staff interviews revealed unclear responsibilities for smoking assessments.
A facility failed to implement a provider's response to a pharmacist's medication review for a resident with medication irregularities. The resident, who was cognitively intact and had multiple diagnoses, requested a stool softener due to discomfort. The pharmacist recommended a bowel regimen and discontinuation of loperamide. The provider ordered senna and discontinuation of loperamide, but these orders were not transcribed into the medical record. Interviews revealed a lack of clarity in handling pharmacy recommendations, leading to the deficiency.
Oxygen Orders Not Clarified and Equipment Not Transferred During Room Change
Penalty
Summary
The facility failed to ensure oxygen orders were clarified and documented in the medical record for a resident with multiple respiratory and cardiac conditions, including COPD, OSA, atrial fibrillation, and acute-on-chronic heart failure. The hospital discharge paperwork identified oxygen at 2 L/min at bedtime for heart failure, but the care center’s Oxygen & Equipment Order Form documented 6 L/min continuous oxygen and need for an oxygen concentrator and portable gas tanks. The resident’s MAR/TAR also reflected oxygen 6 L via nasal cannula continuously, yet the record lacked a signed physician order supporting 6 L/min until after the resident’s death. Staff interviews confirmed the discrepancy was not identified or clarified before the resident died. The resident was moved to a different room, and the oxygen concentrator was not transferred to the new room. Staff later found the concentrator in the old room after the resident had expired. During the night shift, the resident was using a portable oxygen tank, but the tank ran out of oxygen while he was in the bathroom. Nursing assistant and nurse interviews showed there was no consistent process for checking the portable tank’s remaining oxygen during the shift, and staff stated they had not been told how often to check it. The orientation materials reviewed also lacked direction on how often to check portable tanks while in use. On the morning the resident died, staff found him seated on the toilet and unresponsive, with no heartbeat. Documentation and interviews showed the portable tank was empty, the concentrator was not in the room, and the tubing was disconnected from oxygen. Staff described that room changes were handled collaboratively, but there was no checklist or documentation to verify that oxygen equipment had been moved. The record also showed conflicting information about the resident’s oxygen needs, with staff relying on a verbal report of 6 L/min despite the hospital discharge order stating 2 L/min at bedtime.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
A resident with moderate cognitive impairment, a history of dementia, Parkinson's disease, and behavioral disturbances experienced an incident involving physical and mental abuse by staff. The resident, who was hard of hearing and used both a walker and wheelchair, exhibited agitation, aggression, and confusion, including swinging objects at staff. During the incident, staff failed to de-escalate the situation and instead engaged in unprofessional conduct, including swearing at the resident, taunting, and physically restraining the resident inappropriately. One staff member threw a blanket over the resident's head and forcefully grabbed objects from the resident, while another staff member used a pressure point technique and verbally threatened the resident with statements such as "you're going to jail" and derogatory language. Multiple staff statements and witness interviews confirmed that the staff involved did not follow appropriate de-escalation techniques and instead antagonized the resident, escalating the situation further. The resident was left feeling abused, as evidenced by statements made during and after the incident, and was observed to be in significant distress. Documentation and interviews indicated that the staff's actions were not in accordance with the resident's care plan, which included specific interventions for managing behavioral symptoms and ensuring the resident's safety and dignity. The incident resulted in the substantiation of abuse against the involved staff members, who were subsequently suspended and terminated. The resident was evaluated by emergency medical services and transferred to the hospital for further assessment. The deficiency was identified through observation, interviews, and document review, which revealed that the facility failed to protect the resident from mental and physical abuse by staff, as required by regulatory standards.
Delayed Implementation of Wound Care Orders
Penalty
Summary
The facility failed to implement treatment orders in a timely manner for two residents, R1 and R2, who were receiving wound care from an outside provider. For R1, the orders for wound care to his great and second toe lacerations were not transcribed and implemented until three to five days after they were written. This delay in care resulted in R1 developing a wound infection, which led to a recommendation for an above-the-knee amputation due to the severity of the infection and decreased perfusion of his foot. R1 had a history of peripheral vascular disease, which complicated his condition. The facility's process for transcribing and implementing orders was inconsistent, as evidenced by the health unit coordinator's practice of waiting until Monday to transcribe orders from the previous Friday's wound rounds. This delay was not in line with the expectations of the facility's Nurse Practitioner, who stated that orders should be processed within 24 hours. The registered nurse manager and other staff members were aware of the new wound and order changes but did not take immediate action to update the orders themselves, relying instead on the health unit coordinator's delayed transcription process. R2, who was cognitively intact, also experienced a delay in the implementation of wound care orders. The orders for her moisture-associated skin damage were not started until three days after they were written. Although R2 did not express complaints about the frequency of her wound care, the facility's policy required timely transcription and implementation of treatment orders, which was not adhered to in these cases.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed for several residents. For one resident with enteric precautions due to a C-diff infection, a nursing assistant entered the room without wearing the required gown and gloves and used hand sanitizer instead of washing hands with soap and water upon exiting, as required by the precautions. This oversight occurred because the nursing assistant prioritized assisting the resident quickly and forgot the proper protocol. Another resident on enhanced barrier precautions (EBP) due to a wound was transferred and had personal care provided by staff who did not wear gowns, as required. The staff members admitted to forgetting the protocol, partly due to the absence of an isolation cart outside the resident's room. Similarly, a third resident on EBP due to a gastronomy tube had personal care provided by a nursing assistant who failed to perform hand hygiene between glove changes, citing the absence of hand sanitizer in the room. Additionally, the facility did not ensure linens were stored properly, as uncovered blankets were observed in the hallway near rooms of residents on precautions. Staff confirmed that linens should be covered to maintain cleanliness, but this practice was not followed. The infection preventionist and other staff acknowledged the importance of adhering to these protocols to minimize infection risks, but the facility's policies lacked specific guidance on linen storage.
Inappropriate Use of Pillow as Restraint for Resident
Penalty
Summary
The facility failed to ensure that methods to restrain residents were not used, as evidenced by the use of a pillow placed under the fitted sheet of a concave mattress for a resident identified as R74. R74 was cognitively intact upon admission but later had alterations in cognition due to brain cancer, along with a history of falls and weakness. The care plan for R74 included interventions such as supervision, assistance with movement, and the use of a concave mattress, fall mat, and low bed. However, there were no orders for restraints in R74's provider and nursing orders. Despite this, staff members were observed placing a pillow under the fitted sheet of R74's bed, which was intended to prevent the resident from rolling out of bed. Multiple observations and interviews revealed that nursing assistants and a licensed practical nurse were aware of the pillow's placement under the fitted sheet, which was not an approved intervention for fall prevention. The nursing assistant stated that the pillow was used to prevent R74 from rolling out of bed, and it was uncertain if R74 could remove the pillow due to weakness. The Director of Nursing confirmed that placing pillows under fitted sheets was not an appropriate intervention for falls, and the facility's policy on restraint use was not provided. The facility's failure to adhere to proper restraint policies and procedures resulted in the inappropriate use of a pillow as a restraint for R74.
Failure to Initiate Bowel Regimen for Resident
Penalty
Summary
The facility failed to initiate a bowel regimen for a resident (R18) who was reviewed for constipation. R18 was cognitively intact and had diagnoses including a right arm fracture, depression, and diabetes. Despite being continent of bowel and bladder, R18 experienced frequent pain and had requested a stool softener due to hard stools and discomfort. The resident was on scheduled narcotic pain medications, which can cause constipation, yet there was no individualized treatment plan or evidence of bowel medications being offered or administered. The facility's bowel management protocol was not followed, as R18 experienced multiple periods of four days without a bowel movement, and the medical record lacked evidence of any bowel regimen being initiated. Interviews with staff revealed gaps in the facility's process for monitoring and addressing constipation. A nursing assistant mentioned that alerts were supposed to notify nurses if a resident had not had a bowel movement for several days, but was unaware of R18's condition. A licensed practical nurse (LPN) noted that the night team was responsible for creating a bowel movement list, which the day shift would use to administer medications, but this process was not consistently followed, especially by agency staff. The Director of Nursing confirmed that standing orders for bowel medications were not implemented as required, and there was no documentation of R18 refusing medications. The facility's policy for constipation management was not effectively executed, leading to the resident's ongoing discomfort and lack of appropriate care.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement pressure ulcer interventions for two residents, leading to deficiencies in their care. Resident R25, who had severely impaired cognition and was at risk for pressure injuries, was observed without the necessary heel protectors and with her heels not properly floated off the bed. Despite having a care plan that included the use of blue foam heel protectors and floating heels, these interventions were not consistently applied. Observations revealed that R25's heels were often in direct contact with the bed, and there was a lack of documentation regarding any refusal of care by the resident. Resident R68, who had severe cognitive impairment and an unstageable pressure injury on the coccyx, was observed sitting in a wheelchair for extended periods without being repositioned as required. The care plan specified that R68 should not remain in a wheelchair for more than 2 hours and should be repositioned every 2-3 hours. However, during a continuous observation period, R68 was left in the wheelchair for nearly 3 hours without being offered repositioning or a chance to lie down. Staff interviews confirmed that the resident was not repositioned according to the care plan, and there was no documentation of any refusal of care. The facility's policy on skin assessment and wound management outlined the need for regular skin inspections and adherence to care plans to prevent pressure ulcers. However, the observations and interviews indicated a failure to follow these guidelines, resulting in inadequate care for residents R25 and R68. The lack of documentation regarding refusals of care further highlighted the facility's failure to adhere to its own policies and procedures.
Deficiency in Smoking Policy Enforcement and Resident Supervision
Penalty
Summary
The report identifies a deficiency related to the supervision and management of a resident, R69, who is a smoker in a non-smoking facility. R69, who has intact cognition and is independent in activities of daily living, was observed smoking on facility grounds, which is against the facility's smoking policy. The resident's smoking evaluation lacked documentation of staff observation while smoking, and R69 admitted to keeping smoking materials in his walker during the day, contrary to the policy that requires these materials to be stored with nursing staff. Additionally, R69 did not sign out when leaving the facility to smoke, as required by the leave of absence policy. Observations and interviews revealed that R69 smoked in the facility's parking lot and disposed of cigarette butts in a trash can, which posed a potential fire hazard. The Director of Nursing (DON) confirmed that R69 was not in the designated smoking area and had not signed out. The facility's smoking policy prohibits smoking on the premises, including parking lots and sidewalks. Interviews with staff indicated a lack of clarity regarding responsibility for completing smoking assessments, and it was noted that assessments should include direct observation of the resident smoking to ensure safety.
Failure to Implement Provider's Medication Orders
Penalty
Summary
The facility failed to ensure that the provider's response to a monthly medication review was followed for a resident with identified medication irregularities. The resident, who was cognitively intact and had diagnoses including a right arm fracture, depression, and diabetes, was experiencing frequent pain and had requested a stool softener due to hard stools and discomfort. The consultant pharmacist recommended initiating a bowel regimen and discontinuing loperamide if it was no longer needed. The provider responded by ordering senna to prevent constipation and discontinuing loperamide. However, the facility did not implement these orders, as they were not transcribed into the resident's medical record. Interviews with facility staff revealed a lack of clarity and follow-through in the process of handling pharmacy recommendations. The LPN stated that pharmacy recommendations were placed in a folder for the provider to review, but was unsure of the subsequent steps. The DON confirmed that the provider had responded to the pharmacist's recommendations, but the orders were not transcribed as expected. The facility's policy directed that recommendations should be acted upon and documented by the staff or prescriber, but this was not done in this case, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chisago City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadows On Fairview | 6.1 mi | ★★★★★ | 1 | 0 |
| Birchwood Health Care Center | 6.9 mi | ★★★★★ | 4 | 1 |
| Christian Community Home Of Osceola, Inc | 9.6 mi | ★★★★★ | 4 | 0 |
| Ecumen North Branch | 11.7 mi | ★★★★★ | 0 | 0 |
| Dove Healthcare - St Croix Falls | 12.7 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.