Pinnacle Nursing and Rehab: Infection Control Failures - UT
The resident in that room, identified in inspection records only as Resident 54, is among the most medically fragile patients at Pinnacle Nursing and Rehabilitation Center. She has cerebral palsy, severe protein-calorie malnutrition, a condition called cachexia that causes the body to waste away, and a swallowing disorder serious enough to require a nasogastric feeding tube threaded through her nose and down into her stomach. A sign on her door told every person who entered exactly what protective equipment they were required to wear.
At 2:52 p.m. on January 26, inspectors observed the tube feeding machine beeping, its status showing inactive. One end of the feeding tube hung loose, uncapped, touching the metal pole. Three minutes later, a registered nurse entered the room, pulled on gloves, picked the tube end up off the pole, and reconnected it to the nasogastric tube. She did not put on a gown.
The nurse, identified in the report as RN 1, later told inspectors she knew exactly what she was supposed to do. She stated that whenever she handled the feeding tube, she needed to wear both a gown and gloves. She confirmed she had reconnected the tube that afternoon. She confirmed she had not worn a gown.
The lapse wasn't limited to one nurse on one afternoon.
The following morning, a speech therapist arrived to work with Resident 54 on eating and swallowing. She pulled on gloves and knelt on the floor. For the next thirty minutes, she administered yogurt, apple juice, and pieces of peach, adjusting the resident's position in bed, leaning in close, trial after trial. The resident struggled to keep food in her mouth, losing portions of nearly every attempt. At 11:47 a.m., the speech therapist walked out of the room. She had not worn a gown at any point during the session.
The speech therapist's own notes from that visit described a patient with significant difficulty holding food in her oral cavity, with bolus loss on every single yogurt trial and consistent loss of liquid to one side. This is a patient whose care requires sustained physical closeness. It is also a patient whose door sign existed precisely to protect her.
Enhanced Barrier Precautions, the protocol Resident 54's care required, are designed for residents whose conditions make them especially vulnerable to infection. The CNA Coordinator told inspectors that the sign on the door was there to tell staff what PPE they needed to wear and for which activities. The Director of Nursing told inspectors that staff should be wearing gowns and gloves whenever they connected or handled a tube feeding, and that a gown was required any time the speech therapist was feeding Resident 54.
Every staff member interviewed knew the requirement. None of them identified a reason it hadn't been followed.
The uncapped tube end touching the IV pole compounds the picture. An open nasogastric tube is a direct pathway. Whatever the pole carried, whatever the air in that room carried, had unobstructed contact with the line that feeds directly into this woman's stomach.
Federal inspectors cited the facility for failing to maintain an infection prevention and control program, classifying the violation as having minimal harm or potential for actual harm. One resident was affected among the thirty sampled during the inspection, which ran from January 26 through January 29.
Resident 54 came to Pinnacle already carrying diagnoses that leave her with almost no reserve. Severe malnutrition, wasting, a damaged swallow reflex, a tube as her primary source of nutrition. The sign on her door was the last line between her and one more thing going wrong. It was there every time someone walked in. It did not work.
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 21, 2026 · Our methodology
Pinnacle Nursing and Rehabilitation Center in Price, UT was cited for violations during a health inspection on January 29, 2026.
A sign on her door told every person who entered exactly what protective equipment they were required to wear.
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.