Parmly on the Lake LLC

In the surveyor’s words

From the most serious findings on record at Parmly on the Lake LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Sep 8, 2023

  Based on interview and document review, the facility failed to comprehensively assess and monitor for signs of injury after a fall, resulting in delayed diagnosis and treatment for injuries for 1 of 3 residents (R1) reviewed for delay in treatment. This resulted in an immediate jeopardy (IJ) for R1 who required emergent care and hospitalization as a result of their injuries. The immediate jeopardy began on [DATE], when R1was not assessed for any injuries after a witnessed fall, that resulted in displaced rib fractures, chest wall hematoma (blood collection outside of large vessels) and hemothorax (blood accumulation between the chest wall and lungs). The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 2:45 p.m. […]

• Immediate jeopardy, isolatedF760Feb 17, 2022

  Based on interview and document review, the facility failed to ensure an International Normalized Ratio (INR a standard lab test used when taking blood-thinning medications) was obtained per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This caused a delay in care and treatment and resulted in an immediate jeopardy (IJ) for R54. In addition, the facility failed to administer an antibiotic medication for 12 days, prior to being identified by the physician, for 1 of 15 (R35) residents, on antibiotic therapy. The IJ began on 2/10/22, when nursing staff failed to obtain an INR and did not administer [MEDICATION(S)] for four days to R54. R54 had history of pulmonary embolism(PE -blood clots in the lung) and was at increased risk of serious harm and/or death. […]

• No harm, potential for more than minimal, widespreadF725Aug 27, 2026

  Based on observation, interview and document review, the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares were completed timely or as ordered. This affected activities of daily living (ADLs) for 4 of 5 residents (R52, R66, R50, R2), positioning for meals for 1 of 1 resident (R9), toileting program schedules and check and changes for 3 of 5 residents (R66, R8, R9), timely pain medication delivery timely for 1 of 3 resident (R62), dialysis care for 1 of 1 resident (R11). This also affected timely meal service for 9 of 9 residents (R56, R30, R44, R26, R2, R8, R72, R10, R73). […]

• No harm, potential for more than minimal, widespreadF761Aug 27, 2026

  Based on observation, interview, and record review the facility failed to ensure refrigerated medications categized as controlled substance were properly stored with a two-lock system in 3 of 4 medication rooms reviewed for safe medication storage. In addition, the facility failed to ensure stock supply lab specimen collection supplies were not outdated. Findings include: On [DATE] at 1:35 p.m., a review of the Lakeside TCU medication room was completed with registered nurse RN-A. RN-A used a key to gain access to the medication room. The medication room fridge was not locked. There was an unlocked black box on the shelf inside the fridge. There was a bottle of Ativan inside the box. RN-A was not able to find a key that would lock the box. […]

• No harm, potential for more than minimal, widespreadF809Aug 27, 2026

  Based on interview and document review, the facility failed to ensure residents were offered a substantial snack when there were more than 14 hours between the dinner and breakfast meals. This had the potential to affect all residents who resided in the facility.Findings include:During an observation on 8/25/26 at 11:47 a.m., a sign posted on the main dining room indicated mealtimes for dinner were 5:30 p.m., and breakfast at 8 a.m. (which is 14.5 hours between meals).During an interview on 8/26/26 at 1:22 p.m., R36 stated they did not come around with snacks in the evening, but we can ask and they will bring them to us.During an interview on 8/26/26 at 1:39 p.m., R18 stated they didn't come around with snacks in the evening, he got really hungry around midnight.During interview on 8/26/26… […]