Parmly on the Lake: Oxygen Safety Gaps Found - MN
That gap, documented during a May 2026 complaint inspection, sat at the center of what federal surveyors found at the Chisago City facility. The harm level was recorded as minimal, affecting few residents. But the finding pointed to something more fundamental than a paperwork lapse: staff were being sent to care for residents on oxygen without a basic piece of information that determines whether those residents keep breathing.
The inspection records identify two nursing assistants by the labels NA-B and NA-C. Both had completed the facility's Nursing Assistant Facility Orientation Checklist. Both checklists included sections on oxygen use. Both were signed off as educated and completed.
Neither checklist told them how often to check the tanks.
Surveyors requested the facility's policy on oxygen use. None was provided.
What makes the finding harder to dismiss is the consistency. This was not one checklist with a gap, one nursing assistant who fell through the cracks. NA-B's checklist lacked the guidance. NA-C's checklist, dated separately, covered the same areas of oxygen use and lacked the same guidance. The orientation process itself had no answer to the question. The policy that might have answered it could not be produced.
Oxygen tanks in a care setting are not passive equipment. They deplete. A resident who needs supplemental oxygen and receives it through a tank that has quietly run empty is a resident who may not show obvious distress until the situation is already serious. The person responsible for checking that tank, in this case a nursing assistant working a floor at Parmly on the Lake, was never given a schedule, a frequency, a standard. They were handed a checklist that said they had been educated, and the education stopped short of the part that mattered most.
The checklist itself became the problem. It documented completion of training that was, on this specific point, incomplete. A supervisor reviewing those checklists would see two signatures confirming two nursing assistants had been oriented to oxygen use. The checklists would not reveal what they failed to cover.
That is how gaps like this persist. Not through obvious neglect, but through the appearance of thoroughness. The form exists. The signatures are there. The box is checked. And somewhere on the floor, a tank is in use, and the person responsible for monitoring it has never been told when to look.
The inspection was conducted in response to a complaint. The report does not describe a specific incident in which a resident was harmed by a tank running low or empty. The harm designation, minimal, reflects that. But the finding was not theoretical. Inspectors reviewed actual orientation documents for actual nursing assistants currently working with residents who use oxygen. The gap was live, not historical.
Surveyors noted the same deficiency across both checklists, which suggests this was not an isolated oversight on one employee's paperwork but a structural absence in the orientation program itself. If the checklist does not include monitoring frequency, no nursing assistant trained through that checklist would know it. The number of staff affected by that absence is not limited to NA-B and NA-C.
The facility was asked to produce a policy that would have addressed the question. Nothing came.
Parmly on the Lake sits on the edge of Chisago Lake, a small-city facility serving residents who, like residents at nursing homes everywhere, may depend on supplemental oxygen around the clock. The nursing assistants who care for them rely on their training to know what to do and when to do it. On the question of how often to check an oxygen tank in use, that training had no answer.
The checklists said otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parmly On the Lake LLC from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
Parmly on the Lake LLC in CHISAGO CITY, MN was cited for violations during a health inspection on May 26, 2026.
That gap, documented during a May 2026 complaint inspection, sat at the center of what federal surveyors found at the Chisago City facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.