Pinnacle Nursing and Rehab: Infection Control Failures - UT
The resident at the center of the findings, identified in inspection records only as Resident 54, had been admitted to the facility with cerebral palsy, severe protein-calorie malnutrition, cachexia, and a swallowing disorder. She was receiving continuous nutrition through a nasogastric tube. A sign posted on her door told staff what protective equipment they were required to wear before entering her room.
The sign was there. The gowns were not.
On the afternoon of January 26, inspectors observed the feeding tube alarm beeping with a status of inactive. One end of the tube had come loose and was hanging uncapped against the metal IV pole. At 2:55 PM, Registered Nurse 1 entered the room, pulled on gloves, picked the tube end up from the pole, and reconnected it to the nasogastric tube. She did not put on a gown.
Two days later, the nurse confirmed what inspectors had seen. She told them she knew she was required to wear both a gown and gloves whenever she handled the feeding tube. She had not worn a gown when she reconnected it on January 26.
The next morning, on January 27 at 11:17 AM, a speech therapist entered Resident 54's room to conduct feeding trials. The therapist put on gloves and knelt on the floor. Over the next thirty minutes, she administered multiple rounds of food and liquid, including yogurt, apple juice, and a peach cut in half, adjusting the resident's position in bed between trials. The resident lost portions of nearly every attempt, with notes documenting anterior loss of bolus on all eight yogurt trials and loss on the right side during juice trials. The resident refused applesauce and chocolate Ensure entirely.
The speech therapist left the room at 11:47 AM. She had not worn a gown at any point.
The CNA Coordinator told inspectors that any resident with wounds, catheters, feeding tubes, or indwelling devices required full personal protective equipment, and that the sign on the door was specifically designed to tell staff what they needed to wear and when. The Director of Nursing said the same thing in plainer terms: anytime the speech therapist was feeding Resident 54, a gown should have been worn. Anytime staff connected or handled a tube feeding, gowns and gloves were both required.
Enhanced Barrier Precautions exist because residents with feeding tubes, open skin, and indwelling devices are at elevated risk for acquiring and spreading infections. The precautions are not suggestions for staff to weigh against convenience. They are the barrier between a vulnerable resident and pathogens that travel on clothing.
Resident 54 was already severely malnourished and unable to hold food in her mouth. Her body had little reserve.
The inspection found the lapse affected one of thirty sampled residents and rated the level of harm as minimal. But the failures were not a matter of a missing signature or a misfiled form. A nurse touched an uncapped tube that had been resting against a metal pole and reattached it to a resident's stomach without the protection the door sign told her she needed. A therapist knelt on the floor, handled food, repositioned a fragile resident, and walked out thirty minutes later without ever putting on a gown.
Both of them knew what was required. The Director of Nursing confirmed it. The CNA Coordinator confirmed it. The nurse confirmed it herself.
The sign was on the door.
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.
She was receiving continuous nutrition through a nasogastric tube.
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.