Pinnacle Nursing and Rehab: Infection Control Failures - UT
Resident 54 is a woman with cerebral palsy, severe malnutrition, and a nasogastric feeding tube that delivers nutrition directly into her stomach. The Enhanced Barrier Precautions sign posted at the entrance to her room told every person walking in what protective equipment they were required to wear before touching her or her medical equipment. On January 26, inspectors watched a registered nurse walk past that sign, pull on gloves, pick up the end of a feeding tube from an IV pole, and reconnect it to the resident's NG tube, all without putting on a gown.
That observation, made at 2:55 in the afternoon, is at the center of a complaint inspection completed January 29 at Pinnacle Nursing and Rehabilitation Center.
The nurse was not the only one. The next morning, a speech therapist came in to work with Resident 54 on eating and swallowing. She knelt on the floor. She fed the resident yogurt, apple juice, and a peach, adjusted her position in bed, and spent roughly half an hour working closely with her. She left the room without ever having worn a gown.
The inspection report notes that Resident 54 also had a diagnosis of unspecified dysphagia, a swallowing disorder, and cachexia, a condition of severe muscle wasting associated with serious illness. The speech therapist's notes from that session describe a patient who struggled to keep food in her mouth, losing part of nearly every swallow. She was alert and upright in bed. She refused applesauce and chocolate Ensure.
What inspectors found when they arrived at 2:52 PM on January 26, before the nurse entered, was its own problem. The tube feeding pump was beeping and showing inactive status. One end of the feeding tube was hanging uncapped and resting against the metal IV pole. The tube had been left that way long enough for inspectors to document it before anyone came to address it.
When the registered nurse was interviewed two days later, she confirmed what inspectors had seen. She said she knew she was supposed to wear both a gown and gloves whenever she handled the feeding tube. She said she had reconnected it without the gown.
The CNA Coordinator, interviewed the same morning, explained that the sign on the door existed precisely to remove any ambiguity. Residents with wounds, catheters, feeding tubes, or any indwelling device required full PPE, she said. The sign told staff what to wear and for which activities.
The Director of Nursing said the same thing when interviewed the following day. Enhanced Barrier Precautions applied any time a staff member hooked up or handled a tube feeding, she said. Any time the speech therapist was feeding Resident 54, a gown should have been worn.
The facility's own leadership, in other words, described a clear requirement. Two different staff members, on two consecutive days, did not follow it.
Enhanced Barrier Precautions exist for residents at elevated infection risk, including those with indwelling devices like feeding tubes. The purpose is to reduce the chance that bacteria carried on clothing or skin are transferred to a vulnerable patient during close contact. An uncapped tube left touching a non-sterile surface represents the kind of contamination risk the precautions are designed to prevent.
The inspection covered 30 sampled residents. Inspectors identified this lapse in the care of one of them. CMS classified the violation as having the potential for minimal harm.
Resident 54 came to Pinnacle already severely malnourished, dependent on a tube for nutrition, and unable to reliably swallow food placed in her own mouth. The staff working most closely with her, on the days inspectors were watching, did not put on the gown the sign on her door told them to wear.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pinnacle Nursing and Rehabilitation Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Pinnacle Nursing and Rehabilitation Center in Price, UT was cited for violations during a health inspection on January 29, 2026.
Resident 54 is a woman with cerebral palsy, severe malnutrition, and a nasogastric feeding tube that delivers nutrition directly into her stomach.
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.