Chariton Park Health Care Center

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

said residents were served meals with plastic utensils because metal silverware could be used as a weapon. During an interview on 11/17/25 at 3:40 P.M., the Administrator said all metal silverware had to be accounted for after the meal before residents could go to smoke break. The residents preferred to use plastic utensils, because if the metal silverware count was not correct, the residents' smoke break was delayed until the metal silverware was accounted for. The residents did not want to wait to smoke so they requested to use plastic utensils. She did not expect residents to pick up meat with their fingers to eat it.

There were butter knives available upon a resident's request. Complaint #2629015

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chariton Park Health Care Center

902 Manor Drive Salisbury, MO 65281

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

mildly impaired;-He/She exhibited physical, verbal, and other behaviors one to three days out of the previous seven-day look back period. Review of the resident's progress notes, dated 11/10/25 at 8:55 A.M., showed at approximately 8:30 A.M., peers (Resident #2 and Resident #3) were in the vending room purchasing a soda when Resident #1 entered the room. Without provocation, Resident #1 forcefully slammed peer's (Resident 2's) head against the vending machine. Peer (Resident #2) fell to the floor at which point Resident #1 struck him/her (Resident #2) multiple times in the face with a closed fist. Review of

the facility's investigation, dated 11/10/25, showed the following:-The resident attacked Resident #2 unprovoked on the secure unit. The resident was noted to have struck Resident #2's head against the vending machine then struck Resident #2 while he/she was on the ground several times in the face with a closed fist. Resident #2 sustained lacerations to the right side of his/her face on the eyebrow and right lower lip;-Law enforcement was notified, and the resident was taken into custody;-Injuries were obtained as the result of abuse. During an interview on 11/17/25 at 11:48 A.M., Resident #2 said he/she was in the vending room when Resident #1 attacked him/her from behind. As he/she pushed the button on the vending machine, Resident #1 clobbered him/her while slamming him/her into the soda machine. He/She fell to the ground, and Resident #1 began punching him/her. He/She sustained a laceration of the right eyebrow which required three sutures and a laceration of the right upper lip that required one suture. Review of Resident #2's progress note, dated 11/10/25 at 8:50 A.M., showed the following:-The resident had a 1.5 by 0.5 centimeter (cm) laceration located on his/her right eyebrow;-The resident had a 1 cm by 0.5 cm laceration on his/her right lip. During an interview on 11/17/25 at 11:30 A.M., Resident #3 said he/she was getting a soda and talking to Resident #2 in the snack room. Suddenly, Resident #1 came into the snack room in a full force run and started hitting Resident #2. Review of Resident #13's written statement, provided by the facility, dated 11/10/25, showed he/she was talking to Resident #1. Resident #1 then went to the vending room and started hitting Resident #2. Resident #1 pushed Resident #2 into the snack machine and then to the floor. Review of Certified Nurse Assistant (CNA) F's written statement, provided by

the facility, dated 11/10/25, showed he/she was in the nurse's station when he/she heard screaming from

the dining room. He/She found Resident #2 on the floor in the vending room bleeding, and Resident #1 walked to the back of the dining room. Residents said Resident #1 beat up Resident #2. During an interview

on 11/18/25 at 11:15 A.M., the resident's guardian said prior to admission, he/she spoke to the facility's Director of Nursing (DON) and explained that the resident had intermittent explosive disorder and wanted to make sure they would be able to meet the resident's needs. The resident had a history of assaulting residents at previous facilities. During an interview on 12/3/25 at 1:30 P.M., the Director of Nursing said the following:-The resident required one-on-one supervision in the past, but was on 15-minute face checks at

the time of the altercation with Resident #2;-She considered Resident #1 striking Resident #2 as abuse;-Resident #2 suffered lacerations above his/her right eye and upper lip that required sutures. During

interview on 12/3/25 at 1:30 P.M., the Administrator said the following:-She believed the interventions in place to protect others from Resident #1 were effective, until they were not on 11/10/25 when Resident #1 suddenly hit Resident #2;-Resident #1 said Resident #2 said something to him/her, but Resident #2 had not;-Resident #1's behavior was unpredictable;-Resident #2 received a busted lip that required sutures as a result of the altercation;-She felt any type of hitting was considered abuse. Complaint # 2664800

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chariton Park Health Care Center

902 Manor Drive Salisbury, MO 65281

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident had anxiety that warranted the use of the PRN antipsychotic medication at 7:49 A.M. During an

interview on 11/18/25 at 9:36 A.M., Licensed Practical Nurse (LPN) B said staff documented the administration of PRN medications on the resident's MAR and in the progress notes. When he/she administered PRN medications, he/she documented the PRN was utilized during the shift Resident #1 may have requested PRN medications if he/she felt angry or agitated, however, he/she may not have exhibited any behaviors. During an interview on 11/19/25 at 11:45 A.M., the Director of Nursing said she expected staff to utilize hot rack charting. Hot rack charting included documentation of behaviors and utilization of PRN medications and non-pharmacological interventions attempted prior to utilizing the PRN medications.

The resident's psychiatric provider directed staff to use PRN medications around the clock to get better control of the resident's behaviors. During an interview on 11/20/25 at 2:15 P.M., the Administrator said nurses should document why they administered the PRN medications in the resident's progress notes.

During an interview on 11/24/25 at 10:30 A.M., the resident's psychiatric provider/Nurse Practitioner E said

the resident received PRN medications for behaviors. She directed staff to utilize the PRN medications around the clock if the resident had a day where he/she was violent. If it was a day where the resident was calm, staff did not use them around the clock. If the resident showed non-verbal signs of irritability, including pacing, body gestures, and verbal outbursts, she directed staff to utilize the PRN medications. She expected staff to document the resident's behaviors when the PRN medications were administered because it would help him/her to know how to better treat the resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chariton Park Health Care Center

902 Manor Drive Salisbury, MO 65281

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

November 2025, showed the resident did not have an order for Adderall. During an interview on 11/18/25 at 3:10 P.M., Resident #6 said he/she received meth from Resident #3 a couple of weeks ago (unable to recall

the date). He/She was drug tested yesterday (11/17/25) and tested positive for methamphetamines. Review of Resident #5's undated written statement, provided by the facility, showed Resident #3 gave him/her (Resident #5) a dab pen which he/she hit a couple of times then threw away. During an interview on 11/20/25 at 8:49 A.M., Nursing Assistant (NA) J said staff should check a resident's belongings and remove any contraband upon admission. He/She worked the night Resident #3 was admitted . Staff did not go through the whole process of checking the resident's belongings properly, because another resident was attempting to elope, staff were admitting two other residents, and no other staff were available to help. By

the time the other situations had calmed down, Resident #3 was asleep, and he/she did not want to disturb him/her to search his/her belongings. During an interview on 11/20/25 at 11:10 A.M., the Director of Nursing (DON) said CNAs typically completed an inventory of the residents' belongings upon admission and removed of any items the residents were not allowed to have at the facility. She was unaware CNAs were unable to complete the inventory of Resident #3's belongings upon the resident's arrival and admission to the facility. She expected staff to keep the resident's belongings at the nurse's station until staff were able to search and complete an inventory of the belongings. During an interview on11/18/25 at 3:40 P.M., the Administrator said Resident #3 first said he brought a THC dab pen and bath salts to the facility and gave the dab pen to Resident #5. Resident #3 later reported he also had pills that he/she took and shared with Resident #6 and Resident #7. Resident #3, Resident #6, and Resident #7 tested positive for methamphetamines, and Resident #5 tested positive for THC. She was unaware staff was unable to search the resident's belongings when he/she was admitted to the facility. She expected staff to complete

the search upon a resident's arrival to the facility. She expected staff to keep the resident's belongings away from the resident until they had completed the search.

Event ID:

Facility ID:

If continuation sheet