Foley Center at Chestnut Ridge: Jeopardy Citation NC
BLOWING ROCK, NC - Federal inspectors have cited The Foley Center at Chestnut Ridge with immediate jeopardy violations after a resident died from respiratory failure while staff reportedly failed to notify medical providers of critical breathing problems and dangerously low oxygen levels.
Critical Response Failures Led to Resident Death
The most serious violation occurred when facility staff documented that a resident experienced severe breathing difficulties with oxygen saturation levels dropping to the high 70s and low 80s - well below the normal range of 92-100%. Despite these critical warning signs, nursing staff failed to contact medical providers or emergency services for nearly 10 hours.
According to the inspection report, a medication aide discovered the resident in distress at 7:00 AM, noting the dangerously low oxygen levels and observing that the resident was "struggling to breathe and asking for help." The Director of Nursing instructed staff to place the resident on supplemental oxygen but did not order a comprehensive medical assessment or provider notification.
The resident's family representative eventually removed her from the facility at 4:47 PM the same day, taking her directly to the emergency department. Hospital records revealed the resident was diagnosed with Influenza A, bacterial pneumonia, and acute hypoxemic respiratory failure. Despite aggressive treatment including intravenous fluids, steroids, and breathing treatments, the resident's condition deteriorated. She was later placed on comfort measures and died several days later.
Oxygen saturation levels in the 70s and 80s indicate severe respiratory compromise that can rapidly become life-threatening. When blood oxygen drops below 90%, cells throughout the body begin receiving insufficient oxygen to function properly. Levels in the 70s-80s range represent a medical emergency requiring immediate intervention, as vital organs including the brain and heart can suffer irreversible damage within minutes.
The failure to promptly notify medical providers violated both facility policies and basic medical protocols. Federal regulations require nursing homes to immediately contact physicians when residents experience acute changes in condition, particularly those involving respiratory distress or abnormal vital signs.
Medication Safety Violations Endanger Residents
Inspectors documented a 40% medication error rate during their review - eight times higher than the federal standard of 5%. The most concerning incident involved an agency nurse who prepared medications for one resident but nearly administered them to a different resident entirely.
Investigators observed the nurse hand medication cups to the wrong resident while calling her by another patient's name. The mix-up included apixaban, a powerful blood thinner that could have caused dangerous bleeding if administered to someone without an appropriate medical condition.
Blood thinning medications like apixaban carry significant risks when given incorrectly. These medications are prescribed specifically for conditions such as atrial fibrillation or blood clots. When given to patients who don't require anticoagulation, they can cause internal bleeding, including potentially fatal brain hemorrhages or gastrointestinal bleeding.
The incident highlighted systemic failures in the facility's medication verification processes. Standard nursing protocols require checking five "rights" before medication administration: right patient, right medication, right dose, right route, and right time. The nurse failed to verify the patient's identity before attempting to administer the medications.
Inadequate Pain Management Causes Resident Distress
A resident recovering from knee replacement surgery experienced severe, uncontrolled pain when her prescribed oxycodone order expired. Despite the resident's obvious distress - described as "screaming in pain, crying, and very upset" - nursing staff could not obtain replacement pain medication orders from the on-call provider.
The resident's pain was documented as 10 out of 10 on the standard pain scale, indicating the maximum level of reported discomfort. Staff administered only acetaminophen, a much weaker pain reliever inadequate for post-surgical pain management. The resident reportedly continued crying in pain throughout the night shift.
Inadequate post-surgical pain management can lead to serious medical complications beyond patient discomfort. Severe pain increases stress hormones, which can impair wound healing, suppress immune function, and increase blood pressure and heart rate. Proper pain control is essential for recovery and helps prevent the development of chronic pain conditions.
Pain management protocols should include contingency plans for medication renewals, particularly for residents recovering from major surgeries. The facility's inability to obtain appropriate pain medication orders suggests communication breakdowns between nursing staff and medical providers.
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: September 19, 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.
Despite these critical warning signs, nursing staff failed to contact medical providers or emergency services for nearly 10 hours.
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.