Based on review of facility policy, clinical records, facility documents, staff documentation, and coroner's report and staff interviews, it was determined the facility failed to provide emergency life-saving interventions as required for one resident who was choking and still breathing where professional licensed staff did not attempt life-saving interventions to Resident R1 as required. This failure placed all 100 residents that may have needed emergency life-saving interventions, at a high risk for death and resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Foreign Body Airway Obstruction Management, last reviewed 8/3/23, revealed, Facility personnel will be trained on the procedure for Foreign-Body Airway Obstruction [Heimlich Maneuver]. The Heimlich Maneuver is used on conscious adults and thrusts are to continue even if the resident loses consciousness in an attempt to dislodge an obstruction. Review of facility documents entitled, Job Description-Registered Nurse Supervisor revealed that Registered Nurse (RN) Supervisors are expected to assist with or institute emergency measures for sudden adverse developments in residents. Review of Resident R1's clinical record revealed an admission date of 8/08/23, with diagnoses that included alcoholic myopathy (disease of muscle tissue), muscle weakness, unsteadiness on feet, and dysphagia (difficulty swallowing). Review of physician's orders revealed that Resident R1's diet was regular textures with meats cut into bite size pieces, allowed thin liquids with direct supervision and meal trays, nectar thick liquids at bedside. Resident R1 was followed by Speech Therapy from 9/12/23-10/11/23. Therapy notes indicated that due to documented physical impairments and associated functional deficits, without skilled therapeutic interventions Resident R1 was at risk for: aspiration (food or liquid entering the airway) and that Resident R1 required supervision/assistance at mealtime due to swallowing safety 50 percent to 75 percent of the time. Review of Resident R1's care plan revealed that he/she was to be monitored and staff to document and report to the physician for signs and symptoms of dysphagia, pocketing, choking, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. The care plan also indicated Resident R1 appears concerned during meals. Review of Resident R1's POLST [Pennsylvania Orders for Life-Sustaining Treatment] dated 8/09/23, revealed FIRST follow these orders, THEN contact physician, Certified Registered Nurse Practitioner [CRNP] or Physician Assistant. This is an Order Sheet based on the person's medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect. The POLST was signed by both the physician and Resident R1 and Section A revealed that if the person has no pulse and is not breathing DNR [Do Not Attempt Resuscitation] Allow Natural Death. Section B revealed Medical Interventions person has pulse and/or is breathing as Limited Additional Interventions. Section B was signed by both the physician and Resident R1 revealed the resident wanted oral suction and manual treatment of airway obstruction. Review of information submitted by the facility dated 10/11/23, revealed, Registered Nurse Supervisor [Employee E1] response STAT [immediately/without delay] to D wing lounge and noted that Resident R1 was nonresponsive, lips cyanotic, resident taking gasps. Review of progress notes revealed documentation completed by RN Employee E1 on 10/11/23 at 12:12 p.m., which stated, writer called to d lounge. [Resident R1] nonresponsive, lips cyanotic, resident taking gasp. No spo2 [blood oxygen level] obtainable . in house and paged to room. Resident seen one hour prior by CRNP [Certified Registered Nurse Practitioner]. CRNP at her side. No chest movement. No pulse. POLST verified several times. CRNP states CTB [ceased to breath] at 11:40 a.m. Brother .notified. Brother coming to see resident. Review of facility investigation documentation revealed the following written staff interviews: Review of Certified Nursing Assistant [CNA] Employee E2's written statement revealed on 10/11/23, I was feeding another resident. He/She was starting to spit out food after a few bites. I took him/her up by the nurse's station and then I had to talk to the Therapy lady up at the nurse's station. I didn't come back in like usual to feed a couple other residents in there. Review of CNA Employee E3's written statement revealed, on 10/11/23, at 11:30 a.m. I helped pass a few trays in D-Lounge. When I left the D-Lounge [CNA Employee E7] was still passing trays. I left to toilet a resident on another hall who had been asking to go at the time trays arrived. Trying to self-transfer. After toileting resident, I was at the desk when I heard [CNA Employee E7] yell for LPN [Licensed Practical Nurse Employee E4] in D-Lounge. That is when I heard [Resident R1] choking. His/her code status was looked up and RN [Employee E1] was called. I did not go down to the lounge at this time, I moved residents in the hall to make a path for anybody who needed to get there quickly. Review of LPN Employee E4's written statement on 10/11/23, revealed, called to the lounge by other LPN [Employee E5]. This nurse went into lounge LPN [Employee E5] and CNA [Employee E7] were in the lounge. They stated they weren't sure what was going on with [Resident R1]. His/her color was dusky. His/her eyes were big. I asked [Resident R1] if he/she was choking, [Resident R1] looked at me and then went unresponsive. I ran to look at POLST and told LPN [Employee E5] to call RN [Employee E1]. POLST said DNR. I ran and got RN [Employee E1], and we ran back to the lounge. Review of LPN Employee E5's written statement on 10/11/23, revealed, I was walking down D hall to pass 11 a.m. meds. I stopped in the lounge to ask an aide [Employee E7] a question. When I walked in the resident looked like he/she was going to cough, but she didn't make any noise. Then the resident looked like she was choking. [CNA Employee E7] patted her on the back a couple of times. Resident started looking blue. I ran and grabbed my pulse ox. Resident coughed quietly. [CNA Employee E7] did Heimlich. Resident just turned more blue. I yelled for the resident's nurse, [LPN Employee E4] came. I called [RN Supervisor Employee E1] on the phone to come now. [He/she] came pretty quick. We checked resident was a DNR. She was blue but was still taking a quick breath now and then. The nurse practioner came. We got her in a chair and took her to her room. They called her time of death. The lunch tray cart was in the lounge while they were eating. Review of Occupational Therapist Employee E6's written statement on 10/11/23 at 11:40 a.m., revealed, called C/D lounge by RN [Employee E1] walking down to C/D lounge- entered C/D lounge resident sitting in dining room armed chair with drool noted on lips, lips lightly blue, and cool to touch, arms resting relaxed at sides, eyes barely open. No active movement observed occasional gasp (whole body) therapist supported resident in upright position-CNA [Employee E7] was behind resident having stated completed Heimlich and upon walking to dining room audibly heard back thrusts being performed, RN [Employee E1], LPN [Employee E5], CNA [Employee E7], LPN [Employee E4] transferred resident out of armed chair into broda wheelchair. Assist from CNA staff Tray without Rije cups. Hot dog pieces all gone but one and bun intact. OT only drink consumed. Subsequent interview conducted with RN Employee E1 on 10/31/23, at approximately 9:15 a.m., revealed that he/she gave a statement that was sent to the Department of Health; he/she stated it was a bad day and he/she was monitoring in the dining room at the time of the incident. He/She got called to D-wing Lounge and went there after gathering the CRNP, upon arrival the resident took like two gasps of air and then stopped breathing, he/she was a DNR so did not initiate CPR (cardiopulmonary resuscitation). Subsequent interview with LPN Employee E4 on 10/31/23, at 12:35 p.m., revealed, that he/she had no training on emergency response such as a STAT call over the intercom. He/she was in the facility at time of incident and heard another LPN Employee E5 yelling. He/she went to the lounge and saw Resident R1 going unresponsive, he/she was unsure if the resident was choking at that time and then looked down at Resident R1's meal and noticed a hot dog in front of Resident R1 and that it was not a normal hotdog it was a jumbo hotdog. He/She then smacked Resident R1 on the back and did a finger sweep which he/she did not find anything. He/she stated that Resident R1 is known for eating too fast and attempting to eat too much food at once, so Resident R1 had to be monitored for safety. He/She stated that Nursing Assistant Employee E7 was the only staff member in the D-Wing Lounge at that time and did not see anyone performing the Heimlich on Resident R1. He/She stated that there was no crash cart/suctioning brought to the lounge and that Resident R1 was a DNR with a limited POLST. Subsequent interview with LPN Employee E5 on 10/31/23, at 12:56 p.m., revealed that he/she had no training on emergency response such as a CPR or STAT code. LPN Employee E5 stated that when he/she entered the lounge the resident looked funny, and his/her body was flopping; Resident R1 was blue in color. LPN Employee E5 stated they ran to get the pulse ox and called the RN Employee E1 on the portable phone while in the lounge. LPN Employee E5 stated that CNA Employee E7 was performing the Heimlich 3 or 4 times and Resident R1 was slow breathing; Resident R1 was slow breathing when RN Employee E1 entered the room, described the breaths as slow with longer than normal gaps in-between, but confirmed that Resident R1 was still moving air. He/she did not see anyone else perform the Heimlich on Resident R1; the crash cart/suctioning was not brought to the lounge. Interview conducted on 10/31/23, at 11:00 a.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed, they both responded to the D-Wing Lounge after hearing the alert over the intercom. They stated they entered at the same time as the RN Employee E1 and CRNP Employee E8 and it happened in seconds. Advised there was not any time to call 911 and as they entered, Resident R1 took a couple of more breaths and then he/she was gone. They were unable to provide a statement regarding a timeline and advised the crash cart/suctioning was not taken to the lounge. The DON confirmed they have not conducted any type of competencies or mock drills regarding STAT situations with staff since he/she has been employed there, which has been over 1 year. Statement received via e-mail from CRNP Employee E8 on 10/31/23, at 1:42 p.m. revealed, The patient was seen early morning 10/11/23 in stable condition. I was called to the small lounge on the D Hall due to the patient being unresponsive. Upon arrival to the lounge the patient was slumped over in a chair. She had no pulse or respirations. It was communicated to me that she is a DNR. Nursing staff reported they were not aware of the patient eating any food from her lunch tray. She was taken back to her room and the coroner was notified. The facility investigation lacked a written statement for CNA Employee E7 who was the staff member that was in the D-Wing Lounge at the time Resident R1 started to choke and attempted the Heimlich, while yelling for assistance from additional staff. Review of the Resident R1's autopsy report completed by the coroner dated 10/11/23, revealed there was 3.5 x 2.5 x 2 centimeters [cm--2.54 centimeters equal to one inch] piece of hotdog lodged and blocking the larynx/trachea and numerous large pieces of hotdog in the stomach. Review of Resident R1's death certificate identified the main cause of death as asphyxiation (being deprived of oxygen which can result in suffocation and death) related to choking on a bolus (ball like mixture of food and saliva) of food. The facility's Licensed Professional Staff failed to provide emergency life-saving interventions which would have included but are not limited to, continuing the Heimlich Maneuver and/or utilizing suction for one resident who was choking and still breathing. This failure placed all 100 residents that may have needed emergency life-saving interventions, at a high risk for death and resulted in an Immediate Jeopardy (IJ) situation. The NHA was notified of the IJ situation on October 31, 2023, at 4:39 p.m. and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA and the DON on October 31, 2023, and approved at 6:31 p.m. The plan included: 1. Facility already implemented process improvement plan through QAPI committee on October 19, 2023. 2. Facility completed training with staff on responding to emergency choking situations, completed on October 11, 2023. 3. Facility is working with Healthcare Coalition and Superior Ambulance in getting onsite CPR certification class scheduled, began calls to schedule on October 11, 2023. 4. Facility implemented that all licensed staff obtain CPR certification online until and in-person onsite class is confirmed. Certifications are obtained and housed in employees personnel file, implemented on October 11, 2023. 5. Facility has eliminated the use of Lounge Dining and have all residents dining in the main dining room where suctioning is available and additional staff are present effective October 12, 2023. 6. Audits are being completed five days per week for four weeks, then three days per week f or four weeks, then weekly for four weeks. All audits will be taken to QAPI. On November 1, 2023, between 10:45 a.m. and 3:15 p.m. observations, staff interviews, and review of facility policy, and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on November 1, 2023, 2:45 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services