Pin Oaks Living Center
1525 West Monroe · Mexico, MO · 65265 · 5735817261
124 certified beds For profit - Corporation Chain: James & Judy Lincoln
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- 6 citations involved actual harm to residents.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
4 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.43 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.59 | 0.55–0.75 |
| Weekend hours / resident-day | 3.11 | ≈ weekday level |
| Nursing turnover / year | 40% | median 45% |
| Fines (3-yr window) | 1 · $26,650 |
Inspection citations (63 in the current record)
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Actual harm · G February 5, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 10, 2026 · Quality of Life and Care
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Actual harm · G January 7, 2026 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected January 28, 2026 · Nursing and Physician Services
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Potential for harm · E January 7, 2026 · found via complaint
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected February 10, 2026 · Resident Rights
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No harm found · C January 7, 2026 · found via complaint
Post nurse staffing information every day.
Corrected January 28, 2026 · Nursing and Physician Services
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Actual harm · G November 18, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 17, 2026 · Quality of Life and Care
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Actual harm · G November 18, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected January 28, 2026 · Nursing and Physician Services
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Potential for harm · E November 18, 2025 · found via complaint
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected March 17, 2026 · Resident Rights
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Potential for harm · D November 18, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 18, 2025 · Resident Assessment and Care Planning
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No harm found · C November 18, 2025 · found via complaint
Post nurse staffing information every day.
Corrected January 28, 2026 · Nursing and Physician Services
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Potential for harm · D November 14, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected December 23, 2024 · Resident Rights
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Potential for harm · D November 14, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected December 23, 2024 · Resident Rights
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Potential for harm · D November 14, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected December 23, 2024 · Resident Rights
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Potential for harm · D November 14, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 23, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 14, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 23, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 14, 2024
Respond appropriately to all alleged violations.
Corrected December 23, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 14, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 23, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 14, 2024
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected December 23, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 14, 2024
Provide activities to meet all resident's needs.
Corrected December 23, 2024 · Quality of Life and Care
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Potential for harm · D November 14, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 23, 2024 · Quality of Life and Care
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Potential for harm · D November 14, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 23, 2024 · Quality of Life and Care
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Potential for harm · D November 14, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected December 23, 2024 · Quality of Life and Care
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Potential for harm · D November 14, 2024
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected December 23, 2024 · Quality of Life and Care
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Potential for harm · F November 14, 2024
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected December 23, 2024 · Nursing and Physician Services
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Potential for harm · E November 14, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected December 23, 2024 · Pharmacy Service
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Potential for harm · E November 14, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected December 23, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 18, 2025 | Fine | $26,650 |
| November 18, 2025 | Payment Denial | 34 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 265481 · certified since March 1, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.