Federal inspectors found the violation during a complaint investigation at Pinnacle Nursing and Rehabilitation Center on January 26. The patient, identified as Resident 54, depends on continuous tube feeding through a nasogastric tube due to severe malnutrition and difficulty swallowing.
The feeding bag displayed only "1/26" with two initials. No start time appeared anywhere on the label.
Resident 54 was admitted with multiple serious conditions including cerebral palsy, dysphagia, severe protein-calorie malnutrition, and cachexia. The day before inspectors arrived, the patient's physician had ordered continuous tube feeding with Jevity 1.2 formula at 30 milliliters per hour, 24 hours daily.
When inspectors observed the patient's feeding setup at 12:10 PM on January 26, they discovered the incomplete labeling that violated professional care standards.
Two days later, Registered Nurse 1 explained the facility's feeding procedures to inspectors. Night shift nurses switch the tube feed bags and must label them with the date, start time, and their initials, the nurse said.
"If the tube feed bag was not labeled with all of the information then you would not know when the tube feed was actually started," the nurse told inspectors.
The missing information creates safety risks for patients who require precise nutrition monitoring. Without knowing exactly when feeding began, nurses cannot track how long formula has been hanging or ensure proper rotation schedules.
On January 29, the Director of Nursing confirmed the facility's labeling requirements during an interview with inspectors. Tube feeding bags should display the complete date, start time, and signature of the nurse who initiated the feeding, she said.
The director stated she expected staff to include all required information on feeding bag labels.
The violation affected what inspectors classified as "few" residents, though they cited the facility for failing to meet professional quality standards. Continuous tube feeding requires careful monitoring because formula can become contaminated if left hanging too long, and patients like Resident 54 depend entirely on these feedings for nutrition.
For patients with severe malnutrition and swallowing difficulties, any disruption in feeding schedules or contaminated formula poses serious health risks. Resident 54's conditions make proper feeding protocols especially critical.
The inspection occurred as part of a complaint investigation, though the nature of the original complaint was not detailed in the report. Federal inspectors reviewed medical records from January 26 through January 29 and conducted observations and interviews with nursing staff.
Pinnacle Nursing and Rehabilitation Center is located at 1340 East 300 North in Price. The facility must submit a plan of correction to address the tube feeding labeling deficiency.
The violation represents what inspectors termed "minimal harm or potential for actual harm," but highlights gaps in basic safety protocols for the facility's most vulnerable patients. Without complete labeling, nurses cannot properly monitor feeding schedules or ensure patient safety.
Resident 54 continues to require continuous nutritional support through the feeding tube. The patient's complex medical conditions demand precise adherence to feeding protocols that were not followed during the inspection period.
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.
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