Pin Oaks Living Center
Inspection Findings
F-Tag F0658
F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
staff member (Registered Nurse F) took over;-He/She did not specifically recall the resident falling;-If he/she started the neurological checks, it would have been for an unwitnessed fall or for a fall with a head injury;-He/She did not specifically recall treating the resident for a skin tear;-If a resident has a fall, the normal procedure was to complete an assessment and nursing note, complete a fall event, notify the physician, notify the responsible party and notify the DON;-He/She only covered the unit for a short period of time and would have passed on to the oncoming nurse the event details; he/she did not complete any of
the steps of facility procedure following the resident's fall; -The oncoming nurse should have made a nursing note at the minimum due to completing the neurological checks;-He/She would have passed on in report the need for the neurological checks and would have assumed the nurse taking over would have completed the nursing note, fall event form, notified the physician, notified the responsible party and DON.
During an interview on 11/18/25 at 4:30 P.M., RN F said the following: -He/She did not specifically recall taking care of the resident;-He/She was unsure if the resident had a fall while he/she was assigned to care for the resident;-If he/she completed neurological checks on the resident, there must have been a reason to do them, but he/she was unsure of what the reason was;-Neurological checks were usually completed with
an unwitnessed fall or a fall with a head injury and should have a nurses note documented when doing neurological checks;-If a resident has a fall, there should be a fall event and nurses notes completed, physician notified if needed and responsible party notified;-If the resident had a fall while he/she was the charge nurse, he/she was unsure why the fall event, nurses note, and notifications were not completed.
During an interview on 11/18/25 at 2:22 P.M., the RN Educator said the following:-She was notified the resident had a fall while at the facility after the resident had been discharged home;-A fall event had not been created by the charge nurse LPN J; -She created a fall event for the fall that occurred on 09/18/25 when he/she was made aware of the fall on 10/02/25;-She would expect the charge nurse to make a progress note, notify the responsible party, notify the physician and notify the DON with any fall with injury.
During an interview on 11/18/25, at 5:19 P.M., the DON said the following:-She was unaware the resident had a fall at the facility until after the resident was discharged ;-She would expect the charge nurse to complete a fall event for any fall and complete treatment as necessary;-If a resident falls and receives an injury, she would expect to be notified, as well as notifying the physician for orders and notifying the emergency contact. During an interview on 11/18/25 at 5:20 P.M., the administrator said the following:-If a resident falls, or has a condition change, she would expect nursing staff to notify the physician, emergency contact, DON and the Quality Assurance (QA) nurse;-Any resident fall should be documented in the electronic health record. #2626059
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
11/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pin Oaks Living Center
1525 West Monroe Mexico, MO 65265
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)
PIN OAKS LIVING CENTER in MEXICO, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MEXICO, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PIN OAKS LIVING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.