Pin Oaks Living Center: Fall Goes Unreported - MO
The director of nursing found out about it after the resident was already gone.
The fall happened on September 18, 2025. Inspectors pieced together what followed — or rather, what didn't — during a complaint investigation on November 18. By that point, the fall was two months old, the resident had left the building, and the event still existed in the facility's records only because the RN Educator had created it herself on October 2, two weeks after it occurred, after someone finally told her.
LPN J was the charge nurse on duty when the resident fell. She did not create a fall event. She did not write a nursing note. She did not notify the physician, the responsible party, or the director of nursing. She passed the resident to the next nurse, RN F, with what she described as a verbal handoff — she told RN F that neurological checks needed to be completed, and she assumed RN F would take it from there.
RN F took over the unit for a short period. By the time inspectors interviewed her on November 18, she did not specifically recall the resident falling. She did not specifically recall treating the resident for a skin tear. She knew she had completed neurological checks at some point — those checks are typically done after an unwitnessed fall or a fall involving a head injury — but she could not say with certainty why she had done them. "If he/she completed neurological checks on the resident, there must have been a reason to do them," inspectors recorded her saying, "but he/she was unsure of what the reason was."
She was also unsure why, if a fall had occurred on her watch, no fall event had been created, no nursing note written, no physician notified.
The RN Educator told inspectors she learned about the fall only after the resident had been discharged home. She created the fall event herself on October 2. She said she would have expected the charge nurse to write a progress note, notify the responsible party, notify the physician, and notify the director of nursing any time a resident fell with an injury.
Nobody had.
The director of nursing said she was unaware the resident had fallen at all until after the discharge. She told inspectors she would have expected to be notified, along with the physician and the emergency contact, any time a resident fell and sustained an injury. The administrator said the same: any fall should trigger notifications to the physician, the emergency contact, the DON, and the QA nurse, and should be documented in the electronic health record.
None of that happened. The resident had a skin tear. Neurological checks were initiated, which suggests someone believed the fall was either unwitnessed or involved a head injury. Then the resident moved through two nurses, neither of whom completed the paperwork, and eventually went home. The fall event that now exists in the record was created by someone who wasn't there, two weeks later, after the fact.
CMS rated the harm level as minimal or potential for actual harm, affecting a few residents. That rating reflects the regulatory framework, not necessarily what the resident or family experienced in the weeks between the fall and the moment anyone in a position of authority learned it had happened.
The resident's family, listed as the responsible party, was never called.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pin Oaks Living Center from 2025-11-18 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 21, 2026 · Our methodology
PIN OAKS LIVING CENTER in MEXICO, MO was cited for violations during a health inspection on November 18, 2025.
The director of nursing found out about it after the resident was already gone.
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.