**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from accidents and hazards by failing to ensure wound cleanser containing chemicals were secure when not in use for 1 (Resident #1) of 5 residents with wound care needs.On August 3 and 4, 2025, [Brand Name] Wound Care Cleanser was observed unattended in Resident #1's room at different times by three staff members. The wound cleanser was not removed. Resident #1 consumed the wound cleanser, complained of burning to his mouth and stomach resulting in Resident #1 being transferred to a higher level of care.The facility failed to ensure residents were free from accidents and hazards by failing to ensure wound cleanser containing chemicals were secure when not in use led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #1, who had a diagnosis of dementia, at a likelihood of serious harm, such as gastrointestinal irritation, nausea, vomiting, or diarrhea. The Administrator in Training was provided the Immediate Jeopardy Template on August 12, 2025 at 4:09 PM. The Immediate Jeopardy began on August 4, 2025 and was removed on site on August 6, 2025.Findings include: During an interview on August 11, 2025 at 9:00 AM, the Director of Nursing (DON) stated, I was notified on 8/5, [August 5, 2025] that a resident [Resident #1] had potentially ingested wound cleanser by the night shift nurse. He [Resident #1] reported to the nurse he had drank some [wound cleanser] and his mouth was burning. He did not say why only stated he knew it was wound cleanser, and he drinks whatever is in front of him. He is still in the hospital as far as I am aware. He went to [Name of Hospital]. He was a short-term patient. I have not heard any updates. His wife came in Friday and got his belongings. We don't typically leave wound cleanser in the room. A newer Licensed Practical Nurse (LPN) took the wound cleanser in the room. The MD [Medical Doctor] and poison control informed the nurse to send him out for eval [evaluation] due to the ingredients and due to his throat burning. Poison control compared it to potential laundry soap. He [Resident #1] came in Friday afternoon and this happened on Monday. He was in an isolation room.During an interview on August 11, 2025 at 2:40 PM, Staff E, Certified Nursing Assistant (CNA) stated, I worked the four hour shift that day, 7:00 pm to 11:00 pm. I notified the nurse [Staff C, Licensed Practical Nurse] that the wound cleanser was in the room because I was assisting the resident to the bathroom and it fell off the bedside table. When asked why she did not remove it from the room she stated, I was not sure why she [the nurse] did not remove it, maybe because I thought the nurse was not through with it or had left it for later. I really don't know why I did not remove it.During an interview via telephone on August 11, 2025 at 2:42 PM, Resident #1's physician stated, It was life-threatening and could have been worse. The staff called the poison control and due to the ingredients poison control recommended he be sent to the hospital and that is what the facility did.During a telephone interview on August 11, 2025 at 2:44 PM, Staff A, CNA, stated, The resident [Resident #1] was in the isolation room, and I had just come back from break and went to check on him and he was lying in bed, and he stated his mouth was burning and he held up the bottle and read it to me: ‘wound cleanser' and that he had been ‘drinking wound cleanser.' I took the wound cleanser from him and notified the nurse who then called someone, not sure who, if it was the doctor or poison control. EMS [Emergency Management Services] arrived 20 to 30 minutes later. During an interview on August 11, 2025 at 3:18 PM, Staff D, CNA, stated, I saw the wound cleanser in the room that day [August 4, 2025]. When asked why she did not remove it from the room she stated, We as CNAs are not allowed to touch it, only nurses. I notified his nurse, Staff C, LPN, who stated she would take care of it.During an interview on August 12, 2025 at 11:54 AM, Staff E, CNA, stated, I had come on [August 4, 2025 at] 7pm - 11PM to work and it was sometime around 8PM - 8:30 PM when his [Resident #1] bed alarm started going off. I walked into his room, and he was walking to the bathroom, and he didn't seem very stable. His bedside table was in the path to the bathroom. I stepped around it to get to him and the wound cleanser fell to the ground. After, I got him back in bed. I put the wound cleanser back on the table because I didn't think anything about it because CNAs do not do wound care. I know that I should have just taken it out of the room. I was not told in report that he tried to drink urine or anything else of the sort. He didn't show any signs like that when I was taking care of him. He was trying to urinate in the sink. I only worked four hours that night and had no additional encounters with him.During an interview on August 12, 2025 at 12:14 PM, Staff C, LPN, stated The day before he drank the wound cleanser, I was his nurse. The CNA [Staff D] came to me and told me he was trying to drink his urine. I went to the room and went to move the urinal out of the way. The wife was at bedside and said no don't do that he needs it there. I called the doctor and told him that he was trying to drink his urine. The doctor told me he has a history of that it is in the records from the hospital and to increase his Trazadone. The care plan was updated by [Director of Nursing's Name]. The care plan was not updated by me; it was done by her [Director of Nursing]. The reason they care planned it was because he tried to drink the urine and that they were told by the wife to leave the urinal there and not to move it even if he drinks it. The care plan was to leave the urinal at bedside. His wife said he wanted it right there and that is why we care planned it. I was aware before he drank the wound cleanser that no medications or biologicals including wound cleanser were allowed at the bedside, but I didn't if think about wound cleanser, I know now.During an interview on August 12, 2025 at 2:05 PM, the Assistant Director of Nursing stated, We provide training on hire that no medications or biologicals can be left at bedside unsecured.During an interview on August 12, 2025 at 2:08 PM, the Director of Nursing stated, We educate quarterly and during orientation that medications, treatments, and biologicals cannot be left at bedside unattended. All staff had been educated prior to this incident, and we are reeducating now.Review of Resident #1's electronic clinical records showed Resident #1 was admitted to the facility on [DATE] with diagnoses that included: other viral pneumonia; orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down); chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath); hypertensive heart failure and chronic kidney disease (heart failure that develops as a consequence of high blood pressure and long standing disease of the kidneys leading to renal failure); chronic systolic congestive heart failure (occurs when the heart's main pumping chamber, the left ventricle, weakens and can't contract forcefully enough to pump sufficient blood throughout the body); chronic kidney disease; anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin a protein found in red blood cells, to carry oxygen through the body) in chronic kidney disease; atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls); chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow); unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; hyperlipidemia (a condition where there are elevated levels of fats in the blood); hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone); insomnia (a common sleep disorder characterized by difficulty falling asleep); unspecified glaucoma (a group of eye conditions that can cause blindness); and presence of cardiac pacemaker (a small battery powered electronic device implanted in the chest to help regulate a slow heartbeat).Review of Resident #1's interim care plan, initiated 8/3/2025, documented Resident #1 had impaired visual function, limited physical mobility or was at risk for mobility decline, was resistive to care and refused treatments, would consume liquids that are not considered drinkable, was prescribed antianxiety, diuretic, hypnotic and antidepressant medications, and was at risk of suffering from pain.Review of the facility investigation file, incident date August 4, 2025, revealed Resident #1 was admitted to the facility on [DATE]. At approximately 9:00 PM on August 4, 2025 was found to be ingesting wound cleanser in his room by Staff A, CNA. It was unknown where Resident #1 acquired the wound cleanser. The total amount consumed was unknown, however, the bottle was 8 ounces total. Resident #1 knew the bottle contained wound cleanser based on the statements Resident #1 made to Staff A, CNA including Oh this is wound cleanser, it burns. As a precaution, Resident #1's physician was contacted. Resident #1's physician advised to monitor Resident #1. Staff B, Registered Nurse, reached out poison control. Resident #1 was taken to the hospital for treatment.Review of Resident #1's electronic clinical records revealed a change of condition evaluation, dated August 5, 2025 at 22:26 [10:26 PM], that documented Resident #1 was noted to have consumed an 8 ounce bottle of wound cleanser and concluded confusion lead to unknowingly consuming wound cleanser. The change of condition evaluation documented Resident #1's abdominal/gastrointestinal symptoms of abdominal pain and oral cavity mouth burning. The change of condition evaluation documented Resident #1 continued moaning stating his mouth was burning and his stomach was burning, and Resident #1 was noted to have excessive secretions, for example, spit coming from his mouth.Review of Resident #1's electronic clinical records revealed a transfer form, dated August 4, 2025, that documented Resident #1 was transferred to the hospital following ingestion of wound cleanser.Review of Resident #1's hospital records, dated August 4, 2025, revealed Resident #1's visit diagnosis as ingestion of substance, undetermined intent, initial encounter (primary). The hospital report documented When asked why he drank this patient states, I do not know, I do not know anything. The hospital report documented Resident #1 was placed under [NAME] Act and will require admission for observation and acute kidney injury. Assessment and Plan: Acute chemical ingestion (dermal wound cleanser) posing a threat to bodily function in the near term without treatment. Hx [History] of dementia. Discussed with poison control, no further guidance. Continue to monitor for GI [gastrointestinal] upset/mouth irritation.Review of the [Brand Name] Material Safety Data Sheet for the wound cleanser read, Section 2 Hazard Identification. Overview. A personal care product that is safe for use by consumers under all normal and intended circumstances. Health Effects: Contact with the eyes may cause minor irritation, redness or stinging. Contact with skin should not be irritating when used as intended. It is not expected to be irritating to the respiratory system through inhalation. An accidental ingestion of this product may cause gastrointestinal irritation, nausea, vomiting or diarrhea. Section 4. First Aid Measures. Ingestion: The accidental ingestion of the product may necessitate medical attention. In the case of ingestion, dilute with fluids and do not induce vomiting. In the event of an extreme case of ingestion consult a physician or local poison control center.The Immediate Jeopardy (IJ) was removed onsite as of August 6, 2025 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On August 5, 2025 the facility held a Quality Assurance and Performance Improvement (QAPI) meeting and completed a root cause analysis (RCA) related to the unsecured chemical (wound cleanser) in Resident #1's room. The RCA yielded that an unidentified staff member failed to follow the facility policy and left the unsecured wound cleanser in Resident #1's room accessible to Resident #1. On August 5, 2025 immediate education was overseen by the Director of Nursing and completed with 143 of 145 staff members regarding proper storage and/or removal of unsafe substances from Resident's rooms. On August 5, 2025 immediate education was overseen by the Director of Nursing and completed with 31 nursing staff (12 Registered Nurses and 14 Licensed Practical Nurses) regarding proper use and storage of treatment cleansers or any other items deemed harmful or hazardous. On August 5, 2025 education overseen by the Director of Nursing was completed with nursing staff to include room rounds with shift change report to ensure resident safety related to wound cleanser and or biologicals unattended or in reach of residents.On August 13, 2025, a review of facility audits documented an initial audit overseen by the Director of Nursing of all residents' rooms for unsecured hazardous and potentially hazardous products was completed on August 5, 2025.On August 13, 2025, a review of facility audits completed by Unit Managers through August 6, 2025 documented Unit Managers were auditing each room daily to verify there were no biologicals found in the residents' rooms.On August 13, 2025, a review of facility training records documented a total of 31 nursing staff members (including 12 Registered Nurses and 14 Licensed Practical Nurses) were forwarded electronic training overseen by the Director of Nursing on August 5, 2025 related to the standard of not leaving any type of medication or treatment at residents' bedsides unsupervised.During staff interviews conducted August 11, 2025 through August 13, 2025, 1 Minimum Data Set Registered Nurse, 7 Registered Nurses, 14 Certified Nursing Assistants, 1 Assistant Director of Nursing, 4 Licensed Practical Nurses, 1 Maintenance Director, 1 Social Worker, 1 Housekeeping Director and 2 dietary aides all verified receiving education and verbalized understanding of the importance of securing potentially hazardous substances and not leaving potentially hazardous substances in residents' rooms or leaving the potentially hazardous substances accessible to residents.