St Mary of the Woods: Oxygen Crisis Sends Patient to ER - OH
Resident #58 came to St Mary of the Woods on April 1 with acute respiratory failure, Parkinson's disease, and heart failure. The 36-bed facility knew the resident needed continuous oxygen through a nasal tube at two to three liters per minute and required maximum help with basic care because shortness of breath made even minimal movement difficult.
Three days later, the resident's condition deteriorated. Oxygen levels dropped to 87-89 percent — well below the normal range — and the resident became restless and short of breath. The nurse switched from the nasal tube to a simple mask but kept the oxygen flowing at just three liters per minute while waiting for an ambulance.
When paramedics arrived, they found the resident's oxygen saturation at 89 percent with the flow rate somehow reduced to only one liter per minute. They immediately cranked it up to eight liters per minute. The resident became more responsive, and oxygen levels climbed to 93 percent.
The resident was hospitalized with respiratory failure.
Federal inspectors discovered that none of the facility's licensed practical nurses understood basic oxygen delivery requirements. LPN #406 could only recite flow rates for nasal tubes — one to five liters per minute — but couldn't explain what rate a simple mask requires or when to use one.
LPN #387 had never used a simple mask on any resident and only worked with nasal tubes. LPN #351 also had "knowledge deficits related to the use of a simple mask," according to the inspection report.
The facility stocks a wide array of respiratory equipment. Inspectors found nasal cannulas, high-flow nasal cannulas, simple masks, aerosol treatment masks, and non-rebreather masks in the supply room.
But nobody had trained the nursing staff how to use them properly.
The facility contracts with Respiratory Partners for equipment and oxygen concentrators. Respiratory Therapist #516 helps set up complex equipment like CPAP and BIPAP machines for residents with sleep disorders, and he trains staff on tracheostomy care and suctioning. But he works off-site and had never educated the nurses about oxygen flow rates for different delivery systems.
The Director of Nursing confirmed that she had not provided education to staff about flow rates for the various oxygen systems available at the facility.
The facility's own policy, dated April 1, 2022, states that simple masks require a minimum of five liters per minute to prevent residents from rebreathing carbon dioxide. The masks can deliver oxygen concentrations between 35 and 50 percent when used correctly.
The nurse who treated Resident #58 used less than half the minimum required flow rate. By the time paramedics arrived, the rate had somehow dropped to one-fifth of the minimum — creating a dangerous situation where the resident was essentially rebreathing exhaled carbon dioxide.
Resident #58 had multiple conditions that made respiratory care critical. The admission assessment showed cognitive decline with a score of 11 on a standard mental status exam. Heart failure with an ejection fraction of 42 percent meant the heart was pumping below normal capacity. The resident also had a history of falls, high blood pressure, previous heart attack, and difficulty swallowing.
The April 4 assessment noted that shortness of breath with minimal exertion required maximum assistance with basic hygiene and toileting needs. Continuous oxygen was prescribed specifically to manage the resident's breathing difficulties.
When that system failed, the consequences were immediate and serious. The resident's oxygen saturation — a measure of how much oxygen the blood carries — dropped into the dangerous range. Normal levels run between 95 and 100 percent. Anything below 90 percent typically requires immediate medical attention.
The inspection was triggered by a complaint filed as case number 2562366. Federal regulators classified the violation as causing "minimal harm or potential for actual harm" to residents.
The facility had all the equipment needed for proper respiratory care sitting in its supply room. It had access to a respiratory therapist through its contracted service. It had written policies specifying the correct flow rates for different oxygen delivery systems.
What it didn't have was nursing staff who knew how to use any of it correctly when a resident's life depended on it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Mary of the Woods from 2025-08-28 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
ST MARY OF THE WOODS in AVON, OH was cited for violations during a health inspection on August 28, 2025.
Resident #58 came to St Mary of the Woods on April 1 with acute respiratory failure, Parkinson's disease, and heart failure.
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.