Foley Center: Resident Dies After Oxygen Crisis - NC
The resident's family finally removed them from The Foley Center at Chestnut Ridge at 4:47 pm and drove straight to the emergency department. There, doctors diagnosed Influenza A, inflamed airways, elevated infection markers, and acute respiratory failure. The resident died five days later.
Federal inspectors found the facility failed to complete proper assessments during the medical emergency and failed to respond effectively when the resident's condition deteriorated rapidly in July 2024. The violation carried an immediate jeopardy designation, meaning inspectors determined residents faced imminent risk of serious harm or death.
The crisis began when Resident #278's family requested a chest x-ray after Nurse #1 observed the resident had developed a cough, congestion, and decreased appetite. A nurse practitioner examined the resident the following day and prescribed oral medication to break up mucus every 12 hours, plus nebulizer breathing treatments four times daily for seven days.
But the resident's condition worsened overnight.
At 7:00 am, Medication Aide #1 received a warning from the departing night nurse that Resident #278 "was not doing well." The medication aide immediately checked the resident's oxygen saturation levels and discovered they had dropped into the high 70s and low 80s. Normal oxygen saturation ranges from 92 to 100 percent.
The medication aide alerted the Director of Nursing, who instructed her to place the resident on supplemental oxygen and continue monitoring. No other interventions were ordered. No physician was contacted.
Throughout the day, Medication Aide #1 repeatedly reported breathing issues and concerns about the resident struggling to breathe. The Director of Nursing received multiple updates about the resident's deteriorating condition. Yet no one called for emergency medical evaluation or transport to a hospital.
The resident remained in distress for nearly ten hours.
At 4:47 pm, the resident's family representative arrived and removed them from the facility. The family drove directly to the emergency department, where medical staff immediately began aggressive treatment.
Hospital doctors administered intravenous fluids, steroids to reduce airway inflammation, and breathing treatments. Blood work revealed an elevated white blood cell count indicating active infection. The resident was admitted for continued care.
The emergency department diagnosis was comprehensive: Influenza A with influenzal bronchitis, which causes severe inflammation of the airways and breathing passages. The resident's respiratory system was failing.
Despite hospital intervention, the resident's condition continued declining. Medical staff diagnosed acute hypoxemic respiratory failure, a life-threatening condition where the lungs cannot provide adequate oxygen to vital organs. The resident was transitioned to comfort measures and received inpatient hospice services.
The resident died five days after the family's emergency hospital transport.
The death certificate listed the immediate cause of death as acute hypoxemic respiratory failure, with contributing factors of Influenza A and bacterial pneumonia. The respiratory failure that killed the resident was the same condition that nursing home staff had observed and monitored for ten hours without seeking emergency medical intervention.
Federal inspectors interviewed multiple facility staff members, including the social worker, nurse practitioner, and medical director. They also spoke with the resident's family representative who had requested the initial chest x-ray and ultimately transported the resident to the hospital.
The inspection revealed a systematic failure in emergency response protocols. When presented with a resident showing obvious signs of respiratory distress, with oxygen saturation levels far below safe parameters, facility staff chose to monitor rather than act.
Oxygen saturation in the 70s represents severe hypoxemia, a medical emergency requiring immediate intervention. At these levels, vital organs including the brain and heart are deprived of adequate oxygen. Without prompt treatment, organ failure and death can occur rapidly.
The facility's response consisted entirely of placing the resident on supplemental oxygen and continuing observation. No assessment was conducted to determine the underlying cause of the respiratory crisis. No physician evaluation was requested despite the resident's rapidly declining condition.
The medication aide's repeated reports of breathing struggles throughout the day documented a pattern of deterioration that should have triggered emergency protocols. Instead, the Director of Nursing maintained a monitoring approach while the resident's condition worsened.
The family's intervention likely prevented an even more rapid decline. By the time they transported the resident to the emergency department, medical professionals found multiple serious conditions requiring immediate treatment: viral infection, bacterial pneumonia, airway inflammation, and developing respiratory failure.
Hospital staff provided the aggressive medical intervention that the nursing home had failed to initiate. Intravenous medications, steroids, and breathing treatments addressed the immediate crisis, but the delay in treatment had allowed the resident's condition to progress beyond recovery.
The acute hypoxemic respiratory failure that ultimately caused death was preventable with earlier medical intervention. Prompt recognition of respiratory distress, immediate physician consultation, and emergency transport could have provided treatment before the resident's lungs failed completely.
Federal inspectors designated this violation as immediate jeopardy, their most serious finding. This classification indicates that facility practices created an immediate threat to resident health and safety, requiring immediate correction to prevent additional harm or death.
The inspection reviewed three residents for change in condition protocols. Inspectors found deficient practices in the care of one resident, but that single case resulted in a preventable death.
The resident's family had advocated for medical attention from the beginning, requesting a chest x-ray when they first observed symptoms. Their persistent concern and ultimate decision to remove their family member from the facility prevented what could have been an even more rapid death in the nursing home.
The Foley Center at Chestnut Ridge failed its most basic obligation: recognizing and responding to a medical emergency. A resident gasped for breath for ten hours while staff watched oxygen levels that should have triggered immediate hospital transport. The family's intervention came too late to save their loved one's life, but it documented exactly how long the facility had ignored a dying resident's struggle to breathe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Foley Center At Chestnut Ridge from 2024-07-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
The Foley Center at Chestnut Ridge in Blowing Rock, NC was cited for violations during a health inspection on July 3, 2024.
The resident's family finally removed them from The Foley Center at Chestnut Ridge at 4:47 pm and drove straight to the emergency department.
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.