**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of open and closed medical records, review of hospital records, review of the facility investigation, review of the hazardous chemical policy, review of in-service education, review of Material Safety Data Sheets (MSDS), review of facility self-reported incidents, observations of the housekeeping cart, interviews with staff, interviews with residents, and review of an emergency medical services report, the facility failed to properly store hazardous chemicals when a reasonable risk to resident safety was present. This resulted in Immediate Jeopardy and Actual Harm with subsequent death on 06/12/25 when Resident #55, who was known to have a history of depression and prior suicide attempts, consumed liquid from a bottle of mild acid disinfectant (Drano) bowl cleaner that had been left in the resident's bathroom unsecured by Housekeeper #800. Resident #55 was identified to have intentionally ingested an unknown quantity of the chemical, resulting in the resident's hospitalization and subsequent death due to complications from the ingestion of the chemical/liquid. Additionally, a concern that did not rise to Immediate Jeopardy occurred on 07/10/25 at 9:02 A.M. when observation of the housekeeping cart revealed only one-half of the housekeeping cart was locked where cleaning supplies were stored. The cleaning supplies were accessible from the opposite side of the cart, which had a keyhole but no key to secure it. Contained in the cart were two marked bottles of mild acid disinfectant bowl cleaner and a marked bottle of window cleaner. This affected one resident (#55) reviewed for potential self-harm and had the potential to affect all 41 residents residing in the facility. The facility census was 41.On 07/09/25 at 1:18 P.M., Corporate Nurse #560, Regional Nurse #570, the Administrator, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 06/12/25 at approximately 11:30 P.M. when Resident #55 was found by Certified Nursing Assistant (CNA) #251 to have had an emesis. CNA #251 reported the resident's emesis to Licensed Practical Nurse (LPN) #265 who immediately assessed Resident #55. LPN #265 noted the emesis appeared blue in color and a smell of mint. LPN# 265 asked the resident if she consumed mouthwash. Resident #55 stated she had ingested Drano. LPN #265 asked her where she got it from, and the resident pointed to a bottle of cleaning solution in a white drawstring bag on her bedside table. LPN #265 contacted the physician, called nine-one-one (911), and stayed with Resident #55 until Emergency Medical Services (EMS) arrived at 11:40 P.M. Resident #55 was hospitalized and passed away at the hospital on [DATE] due to complications as a result of the ingestion of the chemical liquid. The Immediate Jeopardy was removed on 07/11/25 when the facility implemented the following corrective actions: On 06/12/25 at 11:30 P.M., CNA #251 informed LPN #265 Resident #55 had an emesis. LPN #265 went to Resident #55's room and observed blue-colored emesis on the bed and around Resident #55's mouth. Resident #55 told LPN #265 she drank Drano and showed the bottle to her. LPN #265 asked the resident where she got the bottle of cleaning solution from, and the resident pointed to her bedside table where the bottle was in a white drawstring bag. On 06/12/25 at 11:40 P.M., EMS arrived at the facility to transport Resident #55 to a local hospital. On 06/13/25 at 8:30 A.M., Social Service Director (SSD) #209, Housekeeping Director #207, Activity Director #246, Minimum Data Set (MDS) Nurse #206, Staffing Coordinator (SC) #237 and admission Director (AD) #227 began performing room searches looking for any chemicals or other poisonous substances in residents' rooms using the facility's floor plan as guide. On 06/13/25 at approximately 9:00 A.M., the Administrator interviewed the resident's roommate, Resident #59, regarding the incident. Resident #59 stated I heard her talking about wanting to die. The resident denied reporting this to anyone and did not observe the resident drink the toilet bowl cleaner.On 06/13/25 at approximately 9:00 A.M., a statement was taken from Housekeeper #800, who had been assigned to clean Resident #55's room. Housekeeper #800 admitted to leaving the chemical in an unsecured area in the resident's room and was terminated effective 06/13/25. On 06/13/25 beginning at 9:00 A.M., MDS Nurse #206 and Assistant Director of Nursing (ADON) #203 began reviewing progress notes for all residents, specifically looking for anything out of the ordinary or related to suicidal ideations or behaviors, between the dates of 05/13/25 and ending on 06/13/25.On 06/13/25 at approximately 9:30 A.M., SSD #209 identified three like residents (#10, #17, and #39) based on their diagnoses and history of suicidal ideations. SSD #209 completed face-to-face interviews with Residents #10, #17, and #39 on their psycho-social well-being and history of trauma, with no concerns identified. Beginning on 06/13/25 at 9:30 A.M., SSD #209 completed psycho-social and trauma assessments on all residents. On 06/13/25 at 9:57 A.M., upon facility room searches, the following were found in the resident's rooms: Resident #2 had Snuggle Fabric Softener, Resident #3 had Dawn Power Wash, Resident #17 had Lysol Spray, Resident #29 had Febreze, and Resident #22 had Lysol Spray. MD #525 and MD #515 were notified and placed orders for the five residents to have laboratory testing completed. The residents were educated, and the items were immediately removed from resident rooms. This process was overseen by the Administrator. On 06/13/25 at or around 1:18 P.M., the Administrator educated all facility staff, both in person and via phone, of the facility policy regarding chemical ingestion and safe storage of chemicals. The DON educated facility staff on recognizing and reporting suicidal behavior. On 06/13/25 at approximately 2:00 P.M., all facility residents had a head-to-toe assessment completed, including vital signs and pain assessments. These assessments were completed by MDS Nurse #206. On 06/13/25 at approximately 3:00 P.M., resident room rounds were completed by the Housekeeping Director #207, SC #237, AD #227, MDS Nurse #206, SSD #209 and Activity Director #246 to ensure no chemicals were left out throughout the day. On 06/13/25 at approximately 4:00 P.M., the facility's floor map and census report were compared to ensure both morning and afternoon room searches had occurred for all residents. All room searches were noted as completed once in the morning and once in the afternoon. This process was overseen by the Administrator. On 06/13/25 at 5:00 P.M., an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with MD #525 and the Interdisciplinary Team (IDT) to discuss the incident. The safety committee would continue to monitor the safety plan and would evaluate the plan at each QAPI meeting monthly and as necessary. Beginning on 06/13/25, ongoing facility round audits specific to chemical storage were implemented three times a week for three weeks, then once five times weekly indefinitely. Each department head is assigned rooms to check off to ensure compliance. If any concerns were to be identified, they would be immediately reported to the DON or Administrator and would be addressed immediately. On 06/13/25, a sign was posted by the visitor sign-in sheet and at the nurse's station by the leave of absence book notifying visitors to check with the Administrator before bringing in any items. These signs were placed by the Administrator. On 06/13/25, the facility implemented a plan for the DON or designee to identify residents with a diagnosis of suicidal ideation (SI) on an ongoing basis. These residents would be reviewed monthly at the facility QAPI meetings. On 06/13/25, the facility implemented a plan that on admission, any new admission identified to have a history of suicidal ideations would be identified by noting the history of suicidal ideations under the special instructions tab in the electronic medical record. These residents would have every one-hour safety checks completed for 72-hours post-admission which would be completed by the assigned nurse. An order would be placed to assess the resident for suicidal ideations on an ongoing basis and care plans would be updated to reflect the history of suicidal ideations. This would be completed by the DON or designee. On 07/10/25 at 9:02 A.M., the housekeeping cart that only locked on one side was removed from use and placed into a service hallway. An additional lock was placed on the cart on 07/10/25 at 11:18 A.M. by Housekeeping Director #207 which prevented access without a key or code. The housekeeping cart was then returned to service. On 07/10/25 at approximately 5:00 P.M., education was provided to all facility staff on suicide prevention precautions. Training included education for three specific residents (#10, #17 and #39) noted by the facility as in house residents who had a history of suicidal ideations. This training was provided by the DON or designee and was completed on 07/11/25. Although the Immediate Jeopardy was removed on 07/11/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include:Review of the closed medical record for Resident #55 revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, paranoid personality disorder , mild cognitive impairment, insomnia and schizoid personality disorder. A diagnosis of delusion disorder was added 05/15/25 and diagnoses of suicidal ideations and post-traumatic stress disorder (PTSD) were added on 06/13/25. Review of the prior-to-admission hospital record for Resident #55 revealed an emergency room Provider Note dated 12/19/24 and timed at 12:10 P.M. which revealed Resident #55 was admitted from an assisted living facility with complaints of a fall and facial injuries. Resident #55 stated she was trying to reach her rollator walker (an assistive device with a seat) when she fell forward hitting her face. Resident #55 stated she did not feel safe going back to the assisted living facility. Resident #55 had stopped taking her medication for a month because she was concerned the facility was poisoning her. The note referenced, per Resident #55's son, that the resident had a history of suicide attempts in the past including a gunshot wound to the face. The hospital records included additional psychiatric history which revealed the resident had additional prior suicide attempts including in the 1980's when she attempted to overdose on pills, and in the 1990's when she attempted to kill herself by drinking anti-freeze. Resident #55 sustained a self-inflicted gunshot wound (GSW) to the face in 2011 and attempted to overdose on Tylenol (an over-the-counter mild pain reliever) in 2013. Review of a Suicide Risk flowsheet dated 12/23/24, contained in outside hospital records, noted Resident #55 was high risk for suicide. Review of a hospitalist progress note dated 12/24/24 revealed Resident #55's current diagnoses included right eye blindness, permanent facial deformity from self-inflicted GSW, depression, suicidal ideations and attempts, and paranoid personality disorder. Review of the hospital After Visit Summary (AVS) dated 12/26/24 revealed the reason for the visit was listed as dizziness and fall and referenced a diagnosis of a stroke. The AVS included Suicidal Thoughts Instructions which included the National Suicide Hotline number. The summary also revealed a 1:1 sitter was removed on 12/21/24 and Resident #55 was not suicidal at that time. The resident was discharged from the local hospital to the nursing facility on 12/26/24.Review of the care plan dated 12/27/24 for Resident #55 revealed multiple goals related to suicidal ideations which included the resident would be kept safe until transfer to a psychiatric facility, the resident would no longer have suicidal ideations, and the resident would remain free from self-inflicted injury. Interventions included but were not limited to, removing all items which resident could harm self with and explain to the resident and family that frequent monitoring would be done and why. This care plan was not visible in Resident #55's electronic medical record at the time of the record review on 07/08/25 at 2:32 P.M.; but was provided to the surveyor on 07/09/25 at 1:12 P.M. Review of Resident #55's Baseline Care Plan screen in the electronic medical record revealed three baseline care plan assessments. The assessments dated 01/13/25 and 01/16/25 were listed as in progress and an additional assessment dated [DATE] was listed as incomplete. There was no evidence a baseline care plan for Resident #55 had been completed after her admission to the facility on [DATE]. Review of the progress notes revealed results of the Patient Health Questionnaire 2-9 (PHQ-2-9) (a more detailed screening to identify individuals who may be at risk for depression) dated 03/26/25 and timed at 8:39 A.M. which indicated Resident #55 answered yes to the statement Thoughts that you would be better off dead, or of hurting yourself in some way with a frequency of 7-11 days. The overall score was 18. A score of 15-19 indicated moderately severe depression. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #55 was cognitively impaired. The assessment noted the resident had inattention and disorganized thinking. In additional, the assessment included Resident #55 required substantial (staff) assistance for toileting. Review of Resident #55's Treatment Administration Record (TAR) dated May 2025 revealed behavior monitoring was in place for behaviors including calling 911 and accusations for poisoning. The TAR was marked 16 times for affirming behaviors occurring. There was no evidence facility staff had assessed or tracked Resident #55's mood, checked her room, or completed more frequent monitoring related to the identification of self-harm or suicidal ideation. Review of Resident #55's TAR dated June 2025 revealed behavior monitoring was in place for behaviors including calling 911 and accusations for poisoning. The TAR was marked eight times for affirming behaviors occurring. There was no evidence facility staff had assessed or tracked Resident #55's mood, checked her room, or completed more frequent monitoring related to the identification of self-harm or suicidal ideation. Review of a progress note dated 06/10/25 at 2:07 P.M. revealed Resident #55's son had reported that Resident #55's sister passed away and he was going to inform her later that day.Review of an incident report dated 06/12/25 and timed at 11:34 P.M. revealed LPN #265 stated a staff member notified her Resident #55 was vomiting. Upon entering the room, a blue liquid substance was noted on resident's bed, pillow and mouth. The note included Resident #55 admitted to drinking Drano. LPN #265 asked where the bottle was and she pointed to the bedside table. The nurse grabbed the black bottle and called the physician and 911. The incident report noted the resident's son and the DON were both notified of the resident's change in condition.Review of Emergency Medical Services (EMS) run report dated 06/12/25 and timed 11:40 P.M. revealed EMS were dispatched by 911 for a resident who ingested a cleaning product. Resident #55 was lying in bed with blue colored vomit surrounding her. Staff reported she was acting appropriately one hour prior. Staff found a bottle of cleaning product next to the resident, half full. The cleaning product was secured and taken with crew. The report noted Resident #55 was confused and unable to answer questions. Staff reported her baseline was alert and oriented with erratic behavior. Resident #55 was loaded into ambulance and vitals signs were taken. Resident #55 was noted to be tachycardic (elevated heart rate) and hypertensive (elevated blood pressure). Poison control was contacted and advised they should protect her airway and check for burns. No airway burns were noted. Resident #55 vomited copious amounts and was suctioned. A nasopharyngeal airway (a flexible tube inserted into the nasal passage to maintain an open airway) was placed in right nostril. Oxygen was administered at six liters per minute. Intravenous (IV) access was established and Narcan was administered via IV. Resident #55's airway was suctioned frequently due to her being unable to expel the vomit adequately. Resident #55's lung sounds were reassessed with slight crackles (popping or crackling sounds heard during breathing, usually upon inhalation, caused by the opening of small airways and alveoli that have been collapsed by fluid, exudate, or lack of aeration) heard in the lower lobes bilaterally. The report noted that a handoff report was given to the emergency room doctor and transfer of care was made. Arrival to hospital was on 06/13/25 at 12:17 A.M. Review of the hospital records for Resident #55 revealed an admitting history and physical dated 06/13/25at 4:40 A.M., listed the chief complaint as intentional ingestion of acid and attempt to self-harm. Past medical history included paranoid psychosis, schizoaffective disorder and bipolar (disorder). The record indicated Resident #55 had a history of self-harm including medication ingestion as well as an attempt with a firearm. The hospital record indicated Resident #55 reported she felt like she was being abused at the nursing facility and became overwhelmed and reportedly intentionally ingested half a bottle of drain cleaner. The records noted Resident #55 had a hoarse, gurgling voice with significant secretions, but was able to nod yes to pain. The records noted Resident #55 was yellow slipped (used for mentally ill patients subject to involuntary hospitalization who are not medically cleared for psychiatric care) in the emergency department and not allowed to leave against medical advice (AMA). Review of the facility's investigation revealed the facility began to investigate the incident on 06/13/25. As part of the investigation, all resident progress notes were audited and reviewed for the past 30 days. As a result of this audit, the facility discovered a progress note dated 06/07/25 in Resident #55's record accusing a nurse of being a murderer and abuser. The facility initiated a Self-Reported Incident (SRI) on 06/13/25 upon learning of the note. Review of a facility SRI tracking number 261593 revealed it was initiated on 06/13/25 but listed a discovery date of 06/07/25. The SRI indicated Resident #55 had accused Registered Nurse (RN) #217 as being a murderer and an abuser. The SRI listed Resident #55 was unable to be interviewed as she was at the hospital at the time the allegation was identified. The facility investigation included a witness statement from Housekeeper #800. The statement dated 06/13/25 and authored by Housekeeper #800 revealed he went into Resident #55's room and started cleaning. The resident came in the room to use the bathroom at approximately 10:30 A.M. The statement included, he thought he got everything out of the room, but forgot a cleaning product in Resident #55's bathroom. Housekeeper #800 noted he got sidetracked by his manager to get his physical done. Housekeeper #800 reiterated he got sidetracked and stated he was sorry and was new to the facility. Review of a witness statement dated 06/13/25 taken by the Administrator from Resident #39 revealed she heard Resident #55 talking about wanting to die. Resident #39 stated she did not report it and she did not see Resident #55 with the toilet bowl cleaner.Review of a witness statement dated 06/13/25 taken by the DON from CNA #251 revealed she entered Resident #55's room and noticed Resident #55 had an episode of emesis. She stated she went to get the nurse right away and the nurse began assessing the resident. Review of a witness statement dated 06/13/25 taken by the DON from LPN #265 revealed a CNA made her aware Resident #55 had an episode of emesis. LPN #265 observed emesis on bed and pillow. The emesis appeared blue in color. She stated it smelled like mint. She asked Resident #55 if she drank mouthwash and asked what happened. Resident #55 stated she drank Drano. LPN #265 asked here where she got it from and the resident pointed to her bedside table which had a bottle cleaning solution in a white draw string bag. The statement referenced that Resident #55 denied pain, was alert and oriented to person, place and time and able to answer questions. LPN #265 called the physician and 911. She stayed with the resident until EMS arrived. Review of a hospitalist progress note dated 06/29/25 at 11:49 A.M. revealed Resident #55 received a gastrointestinal (GI) consultation and had an urgent esophagogastroduodenoscopy (EGD) [a a procedure used to examine the lining of the esophagus, stomach, and duodenum]. Resident #55 was identified to have grade 2a (indicating superficial ulcerations, erosions, friability, blisters, exudates, hemorrhages, or whitish membranes) esophagitis (inflammation or irritation of the esophagus, the tube that carries food from your throat to your stomach) with no bleeding. The consultation note referenced the resident had significant gastritis with possible necrosis (dead tissue) versus retained dark gastric contents. The report ordered to continue nothing by mouth and advised against placement of a gastrostomy tube (a feeding tube placed directly into the stomach) or a jejunostomy tube (a feeding tube placed directly into the jejunum part of the small intestine) given the resident's high risk for perforation. Total Parenteral Nutrition (TPN) [a method of feeding that delivers essential nutrients directly into a patient's bloodstream via a catheter inserted into a vein, bypassing the digestive system] was started. The note indicated the anticipated healing time after a caustic ingestion injury was between six to eight weeks and the resident would then need to be re-evaluated by the GI provider. Interview on 07/07/25 at 12:24 P.M. with LPN #203 revealed Resident #55 was currently in the hospital after ingesting toilet bowl cleaner which was left in the bathroom by a housekeeper. The LPN revealed Resident #55 had been placed on hospice as she was not able to have surgery for placement of a feeding tube. LPN #203 stated Resident #55 had a history of suicide attempts and mentioned she had shot herself in the face around ten to 15 years ago.Interview on 07/07/25 at 4:00 P.M. with LPN #217 revealed Resident #55 would make accusations the doctor was poisoning her. LPN #217 denied knowledge of Resident #55 making any suicidal statements. Interview on 07/07/25 at 4:10 P.M. with the Administrator and Regional Nurse #570 revealed it was Housekeeper #800's first day working on his own (without a trainer) when he left the cleaning solution in Resident #55's bathroom when the resident had come in to use the bathroom. They stated the housekeeper forgot to return to Resident #55's room to retrieve it. The Administrator denied knowledge of Resident #55 expressing suicidal ideations to her since she met her a few months ago. Interview on 07/08/25 at 2:32 P.M. with SSD #209 revealed she was aware of Resident #55's past suicide attempts and suicidal ideations prior to 06/12/25. She stated the resident believed things such as that she was going to be poisoned or that she did not have a bowel movement in 12 weeks. Resident #55 did not like to be challenged with her thoughts. SSD #209 stated Resident #55 would always say, I'm going to die soon. Continued interview and record review with SSD #209 revealed she started at the facility in October 2024 and Resident #55 was admitted in December 2024. SSD #209 revealed there was no social service assessment or what she referred to as her 72-hour note upon admission. She stated the son wanted Resident #55 to be followed by psychiatric services; however, the resident would refuse to sign even after she promised she would sign consent if the son visited. At the time of review of the care plan with SSD #209 revealed no evidence of a care plan regarding mood or behaviors specifically history of suicide attempts. A care plan was provided on 07/09/25.Interview on 07/08/25 at 3:30 P.M. with MDS Nurse #206 revealed she started at the facility at the end of February 2025. She stated she did most of the care plans though other departments may do some. MDS Nurse #206 stated she was not aware of Resident #55's history of suicide attempts prior to the 06/12/25 incident. A subsequent interview on 07/09/25 at 11:34 A.M. with LPN #217 revealed Resident #55 used a rollator walker, but could have walked without it. She often toileted herself. LPN #217 revealed she was aware of Resident #55's history of suicidal ideations. Interview on 07/09/25 at 11:43 A.M. with CNA #263 revealed Housekeeper #800 was still in training on 06/12/25. Telephone interview on 07/09/25 at 12:52 P.M. with MD #525 revealed he was unaware of any issues with Resident #55 except for her accusing others of poisoning her. She consistently refused certain medications and psychiatric services. MD #525 stated she did not have any specific recommendations for the facility in managing suicidal ideation behaviors as it had never come to that point until the incident.During an interview on 07/09/25 at 1:12 P.M. with Corporate Nurse #560, Regional Nurse #570, the Administrator, and the DON the Corporate Nurse presented a care plan dated 12/27/24 which included notations about Resident #55's suicidal ideations and interventions. The care plan was not visible to the surveyor during review or to SSD #209 when attempting to review it earlier in the investigation. Regional Nurse #570 stated sometimes you can't see everything. The surveyor questioned how the staff could care for residents (including Resident #55) if they did not have access to necessary information. Regional Nurse #570 stated it may be an information technology (IT) issue. Regional Nurse #570 then stated Resident #55 did not voice suicidal ideation but also stated the son told the facility it was inevitable. The surveyor questioned whether or not Resident #55 needed more care, such as one-on-one care or more frequent checks, if suicide/attempts were considered inevitable, despite Resident #55 not voicing suicidal ideations. There was no response. It was also acknowledged in this interview there was no evidence in the corrective action file provided as of this time of like-residents being identified as part of any abatement plan.Interview and review of records on 07/09/25 at 2:45 P.M. with CNA #219 revealed Resident #55 did not need a lot of care as she would come out of her room when she wanted to. CNA #219 was not aware of Resident #55's history of suicidal ideations/attempts. She was not aware of any current residents with suicidal ideations. She reviewed Resident #55's tasks in the electronic medical record (EMR). It was blank under the section special instructions. CNA #219 showed the surveyor two other residents who had special instructions which included visitors needing a password to speak to resident and that resident was not allowed to receive calls from certain people. CNA #219 stated this was where she would look for anything out of the norm. CNA #219 stated they mainly learned (of resident needs) through word of mouth. Interview on 07/09/25 at 3:50 P.M. with LPN #217 stated she did not know about the care plan interventions for Resident #55. She stated the facility was a behavioral place, not a nursing home, and needed to be treated like that. Interview on 07/09/25 at 3:57 P.M. with Resident #39 revealed she did not recall anything about Resident #55 making comments about wanting to die. Review of Resident #39's medical record revealed she was cognitively impaired. Interview on 07/09/25 at 4:01 P.M. with LPN #241 revealed anything special about a resident would be on the TAR or given through verbal report. She stated she did not routinely care for Resident #55 but knew Resident #55 refused medications regularly. Interview on 07/09/25 at 4:10 P.M. with LPN #265 revealed she was aware of Resident #55's history of suicidal ideations and attempts. She stated she knew Resident #55 from when she resided in the facility Assisted Living. LPN #265 stated she was the nurse assigned to care for Resident #55 on 06/12/25 and denied the resident making any comments about suicidal ideations. She described it as a normal day of activities for Resident #55. She stated she did not check on Resident #55 any more or less than other residents, but stated she did scan rooms as she was up and down the hallways throughout her shift. The LPN stated there was nothing unusual in the resident's room. LPN #265 stated the CNA came to get her after Resident #55 had an emesis. When she walked into the room she noticed it smelled like mouthwash. The emesis was a blue color which was on the bed. She asked the resident if she drank mouthwash with the resident responding she drank drano. There was a bag in her bottom drawer of the nightstand with a black bottle in it. She was uncertain how much Resident #55 drank but stated there was at least half of the cleaning solution left in the container. She stated she called 911 and the the physician. She stayed with the resident until EMS transported her to the hospital. LPN #265 was not aware of other residents with history of suicidal ideations.Observation on 07/09/25 at 4:35 P.M. with Housekeeping Director #207 revealed a bottle of the cleaner Resident #55 drank. It was labeled mild acid disinfectant bowl cleaner and was in a one-quart bottle. The precautionary statement included it was hazardous to humans and domestic animals . It had instructions on it if swallowed which included calling poison control, sipping water if able, to not induce vomiting unless instructed by poison control, and to not give anything by mouth to an unconscious individual. Housekeeping Director #207 stated she believed at the time of the incident with Resident #55 on 06/12/25, the bottle was less than half full. She stated the housekeeper was terminated. Housekeepers were to have two bottles on their cart of the toilet bowl cleaner and one bottle of window cleaner. She stated the housekeeping carts were to be locked. Housekeeping Director #207 revealed she was not aware of Resident #55's history of suicidal ideations but stated she wished she had known. She stated they did rounds after the incident to look for chemicals, saying the checklist form already listed to check for chemicals on the front side. She stated she had a meeting with her team and reviewed the checklist again with them having them sign a new one.Interview on 07/09/25 at 4:50 P.M. with the Administrator revealed she agreed the correct or full care plan not being visible for staff reference was a concern. When asked about Resident #55's interventions on the care plan regarding more frequent checks and removing items from her room revealed she could not provide evidence of these interventions being completed. Interview on 07/09/25 at 5:45 P.M. with Regional Nurse #570 revealed the facility's initial abatement plan provided to the surveyor indicated there were no like residents with a history of suicidal ideations who were reviewed and assessed on 06/13/25. However, Regional Nurse #570 provided the names of three residents (#10, #17 and #39) who were identified as like residents based on their diagnosis of suicidal ideations. The facility provided evidence that these three residents had psychosocial assessments and post-traumatic stress assessment, and care plan reviews following surveyor request. Regional Nurse #570 stated these three residents' assessments were contained in a separate file and she stated she thought she had previously provided these to the surveyor. Interview on 07/10/25 at 8:15 A.M. with CNA #205 revealed she was not aware of any residents with history of suicidal ideations, nor was she familiar enough with Resident #55's history. She stated she received education on chemical storage on 06/13/25 but not other like residents. A subsequent interview and observation on 07/10/25 at 8:49 A.M. with CNA #219 revealed she did [TRUNCATED]