Pinnacle Nursing And Rehabilitation Center

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 out of 30 sampled residents, a resident's nasogastric (NG) tube feed did not have the formula bag labeled with the complete date and time of the administration. Resident identifier: 54.Resident 54 was admitted to the facility on [DATE REDACTED] with diagnoses which included, cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia. Resident 54's medical record was reviewed 1/26/26 through 1/29/26. On 1/25/26, resident 54's physician ordered an Enteral Feed every shift continuous tube feeding Jevity 1.2 with a rate of 30 mL (milliliter) an hour continuously for 24 hours. On 1/26/26 at 12:10 PM, an observation was made of resident 54's tube feed.

The tube feed bag was labeled, 1/26 [two letter initials]. On 1/28/26 at 9:51 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 54 was on a continuous tube feeding. RN 1 stated that the night shift nurses switched the tube feed bags and that they should be labeled with the date, the time the tube feed started, and initial the tube feed bag. RN 1 stated that 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. On 1/29/26 at 8:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that tube feeding bags should be labeled with the complete date and time it was started and signed by the nurse who started it. The DON stated that she expected staff to label tube feed bags with all of this information.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Nursing and Rehabilitation Center

1340 East 300 North Price, UT 84501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

activity. The AD stated that, whenever a resident needed a brief change, she or her staff radioed the nursing team to request a brief change. On 01/29/2026 at 9:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected brief changes to be completed as soon as possible, or within approximately 10 to 15 minutes. The DON further stated that while earpieces sometimes did not transmit, she expected that if Activities or Physical Therapy staff brought a resident back to their room, they would also push the call light to ensure a double system was in place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Nursing and Rehabilitation Center

1340 East 300 North Price, UT 84501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

for resident 50 to have his dressings changed three times a week and updated resident 50's care plan. On 1/29/26 at 8:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if

a nurse found any skin abnormalities they should clean and dress the area, notify the family and the physician, and complete a risk management form. The DON stated the nurse should put in an order for dressing changes until the wound nurse assessed it and changed the order.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Nursing and Rehabilitation Center

1340 East 300 North Price, UT 84501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility did not ensure that residents who were continent of bladder received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain. Specifically, for 1 out of 30 sampled residents,

the resident was given a PureWick external catheter without an order or directions for use. Resident identifier: 53. Resident 53 was admitted to the facility on [DATE REDACTED] with diagnoses which included, unsteadiness on feet, difficulty in walking, and muscle weakness. Resident 53's medical record was reviewed 1/26/26 through 1/29/26. On 1/26/26 at 1:44 PM, a concurrent interview and observation was made of resident 53 and her room. There was a suction canister on the bedside table with a suction tube that contained a dark amber fluid. Resident 53 stated that she was continent when she came to the facility, but was non-weight bearing for a few weeks and was given a PureWick catheter to use so she did not have to get up to use the toilet. Resident 53 stated that staff changed the PureWick device a few times a week. A

review of resident 53's medical record did not contain an order for a PureWick device or directions for use.

Resident 53's care plan did not include a PureWick device. On 1/28/26 at 10:21 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 53 was continent of urine when she was first at the facility, but now had a PureWick device. CNA 1 stated that she was told of resident 53 using a PureWick through a CNA report. CNA 1 stated that resident 53 wore briefs in addition to the PureWick, On 1/28/26 at 11:18 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that there was a resident that used a PureWick in the facility and that this was a newer thing. The CNA Coordinator stated that CNAs had been trained on how to use the device and if CNAs had questions they could ask. On 1/28/26 at 2:04 PM, an interview was conducted with Registered Nurse (RN)

1. 2. RN 2 stated that resident 53 had a PureWick device and had been using it for a couple of weeks. RN 2

stated that resident 53 did not want to have brief changes and was non-weight bearing for a couple of weeks. RN 2 stated that resident 53 was now weight bearing and was in physical therapy. RN 2 stated that PureWicks should have a doctor's order. RN 2 stated that she had not received any training from the facility regarding the use of the PureWick. RN 2 stated that she was unsure how often the PureWick device should be changed. On 1/28/26 at 2:06 PM, an interview was conducted with RN 3. RN 3 stated that the PureWick device should be changed every 24 hours and that the canister was cleaned once a week. RN 3 stated that

a resident should have the use of a PureWick care planned. On 1/28/26 at 2:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 53 had been using a PureWick for the past two weeks and it was a new thing for the facility to use. The DON stated that resident 53 was using the PureWick device for dignity as she had been bed bound and non-weight bearing for a short period of time. The DON stated that they had tried to use the bed pan for resident 53, but she did not like it.

The DON stated that a PureWick device required a doctor's order and resident 53 did not have an order.

The DON stated that the use of a PureWick should be care planned.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Nursing and Rehabilitation Center

1340 East 300 North Price, UT 84501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review it was determined the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments during visits. Specifically, for 1 out of 30 sampled residents, the physician did not include an evaluation of the resident's condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen. Resident identifier: 53. Resident 53 was admitted to the facility on [DATE REDACTED] with diagnoses which included, unsteadiness on feet, difficulty in walking, and muscle weakness. Resident 53's medical record was reviewed 1/26/26 through 1/29/26. A review of resident 53's progress notes revealed: a. On 12/4/25 at 3:23 PM, a nursing note documented, Resident was seen by [Name redacted]. b. On 1/13/26 at 5:26 PM, a nursing note documented, [Name redacted] in to see resident. MD [medical doctor] reviewed labs, medication and answered all questions. Will continue to monitor. It should be noted that the physician progress note for 1/13/26 was unable to be located in resident 53's medical record. On 1/29/26 at 8:06 AM, an interview was conducted with the Health Information Management (HIM) Director. The HIM Director stated that one of the facility physicians does not write or dictate any medical records for the residents that he sees. The HIM Director stated that she would have to call the physician's office and request resident progress notes. The HIM Director stated that it was hard to track the resident's records down because the physician did not write in the resident's medical record. On 1/29/26 at 8:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that

the facility would send a form with the resident and the physician would write what he did at that appointment. The DON stated if the facility required in-depth notes they would call the physician's office and ask for the progress notes. The DON stated that the physician would send a worksheet back with the resident that included orders. The DON stated that after they requested the physician notes they would then scan the records into the resident's medical record. The DON stated that it was hard to get progress notes from the physician.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pinnacle Nursing and Rehabilitation Center

1340 East 300 North Price, UT 84501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 30 sampled residents, Enhanced Barrier Precautions (EBP) were not worn for a resident with a Nasogastric (NG) feeding tube and the end of the NG tube was uncapped and touching an intravenous pole. Resident identifier: 54. Resident 54 was admitted to the facility on [DATE REDACTED] with diagnoses which included, cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia. Resident 54's medical record was reviewed 1/26/26 through 1/29/26. On 1/26/26 at 11:39 AM, an observation was made of resident 54. Resident 54 had an EBP sign on the door. On 1/26/26 at 2:52 PM, an observation was made of resident 54. Resident 54's tube feeding was beeping with a status of inactive. One end of the feeding tube was attached to an Intravenous (IV) pole uncapped and touching the metal pole. On 1/26/26 at 2:55 PM, an observation was made of Registered Nurse (RN) 1. RN 1 entered resident 54's room and donned gloves. RN 1 was observed to pick up the end of the feeding tube from the IV pole and reattached to the nasogastric (NG) tube. RN 1 was observed to not don a gown while attaching the tube feed. On 1/27/26 at 11:17 AM, an observation was made of resident 54 and the Speech Therapist (ST). The ST donned gloves and knelt on the floor. The ST began to administer different fluids and foods to resident 54. The ST was observed to feed multiple fluids and foods to resident 54 and to adjust resident 54 in her bed. On 1/27/26 at 11:47 AM, the ST was observed to exit resident 54's room. It should be noted that the ST did not wear a gown during the period of time she was in resident 54's room. A review of resident 54's speech therapy notes on 1/27/26 documented, . Patient was seen upright in bed with good alertness and attention. Patient tolerated x8 [times 8]trials of L4 [level 4] yogurt with anterior loss of bolus on 100% of trials. Patient tolerated x6 [times 6] trials of LO [level O] apple juice with anterior loss of bolus on right side (patient head was tilted more that way throughout trials). Patient trialed x1 L6 peach (cut in half} with some success, however, difficult to determine safety d/t [due to] patient unable to hold bolus in oral cavity as compared to other PO [oral] trials. Patient refused PO trials with applesauce and chocolate ensure. On 1/28/26 at 9:51 AM, an interview was conducted with RN 1. RN 1 stated that resident 54 had a feeding tube that was a continuous tube feed. RN 1 stated that whenever she was dealing with the feeding tube she needed to wear

a gown and gloves. RN 1 stated that she reconnected resident 54's feeding tube on 1/26/26 and did not wear a gown. On 1/28/26 at 11:16 AM, an interview was conducted with the Certified Nursing Assistant (CNA) Coordinator. The CNA Coordinator stated that any resident with wounds, catheters, feeding tubes, or anything indwelling required Personal Protective Equipment (PPE). The CNA Coordinator stated that the sign on the door indicated to staff what PPE they were required to wear and for what activities. On 1/29/26 at 8:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that EBP was to be followed when residents have any open area on the skin, a port, or a feeding tube. The DON stated that staff should be wearing gowns and gloves when they hooked up or handled a tube feeding. The DON stated that anytime resident 54 was being fed by the ST, a gown should be worn.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet