Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pinnacle Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cerebral palsy, dysphagia, severe protein-calorie malnutrition, and cachexia was receiving continuous NG tube feeding with Jevity 1.2 at a prescribed hourly rate. During observation, the tube feeding bag was found labeled only with a date and staff initials, without the required start time. In interviews, an RN stated that nurses are expected to label tube feed bags with the date, start time, and initials, and the DON confirmed that bags should include the complete date and time started and be signed by the nurse, showing that the observed practice did not meet professional standards of quality.
A resident with dementia, impaired mobility, and bowel/bladder incontinence remained in soiled clothing for over an hour and a half after staff were notified of the need for a brief change. The care plan required incontinence briefs to be changed every two hours and as needed, but multiple staff entered or passed by the room for other tasks, including meal delivery and activity calendar checks, without providing incontinence care. The resident, who had severely impaired cognition, initially believed her brief had been changed but then realized it had not. Incontinence care was finally provided only after a prolonged delay, despite established rounding practices and communication from activities staff to nursing.
A resident with Type 2 DM and restless leg syndrome reported having open leg sores for at least a week, with bleeding through bandages onto socks, yet there was no documentation of leg wounds, assessments, or wound care orders in the medical record. Observation showed a discolored lower leg with a saturated bandage leaking serosanguineous drainage and additional uncovered draining areas. Although an RN later performed a dressing change and stated the wounds needed to be documented for daily assessment, no timely wound care orders or progress notes were entered, and the resident reported that dressings were not changed on a subsequent day. This occurred despite a care plan goal for intact skin and interventions requiring daily body checks and immediate nurse notification of any new skin breakdown.
A continent resident with mobility limitations was provided a PureWick external catheter for several weeks while non‑weight bearing, with surveyors observing a bedside suction canister containing dark amber fluid and the resident reporting the device was changed only a few times per week. Record review showed no physician order or directions for use and no care plan addressing the PureWick, despite staff acknowledging that such a device requires an order and should be care planned. CNAs learned of the device use only through CNA report, one RN reported no facility training and uncertainty about change frequency, while another RN described expected change and cleaning intervals, and the DON confirmed the device had been used without an order or inclusion in the care plan.
A resident with gait instability and muscle weakness was seen by a physician on multiple occasions, as documented in nursing notes, but the corresponding physician progress note for at least one visit was missing from the medical record, leaving no documented evaluation of the resident’s condition or total program of care, including meds and treatments. The HIM Director reported that one physician does not write or dictate notes in the facility record, requiring staff to request progress notes from the physician’s office, and the DON described a process in which a form and worksheet with orders are sent back with the resident, with detailed notes obtained later and scanned into the chart, noting it is difficult to obtain these progress notes.
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an NG feeding tube and significant comorbidities, including cerebral palsy, dysphagia, and severe protein-calorie malnutrition. Surveyors observed an RN reconnect an uncapped feeding tube that had been touching a metal IV pole while wearing only gloves and no gown, despite an EBP sign on the door. On another occasion, a speech therapist provided multiple PO trials and repositioned the resident while wearing gloves but no gown. In interviews, the RN, CNA Coordinator, and DON all confirmed that residents with feeding tubes require PPE, including gowns and gloves, when handling tube feedings or feeding the resident under EBP.
Incomplete Labeling of Continuous Tube Feeding Bag
Penalty
Summary
The deficiency involved the facility’s failure to ensure that enteral feeding services met professional standards of quality for one resident. The resident had diagnoses including cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia, and had a physician’s order dated 1/25/26 for continuous NG tube feeding with Jevity 1.2 at 30 mL per hour over 24 hours. On 1/26/26 at 12:10 PM, observation of the resident’s tube feeding revealed that the feeding bag was labeled only with the date “1/26” and two-letter staff initials, without the time the feeding was started. In an interview on 1/28/26 at 9:51 AM, RN 1 stated that night shift nurses were responsible for changing the tube feed bags and that bags should be labeled with the date, the time the tube feed was started, and the nurse’s initials, and acknowledged that without complete labeling, the start time of the feeding could not be known. On 1/29/26 at 8:13 AM, the DON confirmed that tube feeding bags were expected to be labeled with the complete date and time started and signed by the initiating nurse, indicating that the observed labeling did not meet the facility’s expectations.
Failure to Provide Timely Incontinence Care After Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to a resident, resulting in the resident remaining in soiled clothing for one hour and 33 minutes after staff were notified. The resident had diagnoses including COPD, muscle weakness, and dementia, with an MDS BIMS score of 7 indicating severely impaired cognition. The resident’s care plan identified bowel and bladder incontinence related to impaired mobility and dementia, with a goal to remain free from skin breakdown due to incontinence and interventions specifying incontinence brief use with changes every two hours and as needed. On the day of the incident, the resident was observed at 11:55 AM with soiled pants as she was assisted into her room, and a staff member used an earpiece to request assistance for a brief change. Subsequent continuous observations showed multiple staff entries into and past the resident’s room without providing the needed incontinence care. At 12:02 PM, a CNA entered only to ask about meal location and then exited without checking or changing the brief. At 12:21 PM, another CNA walked by the room without entering. At 12:55 PM, the resident reported she believed her brief had been changed, then checked and realized it had not. At 1:23 PM, a CNA entered only to deliver a meal tray and left, and another staff member entered to check the activities calendar and exited without addressing incontinence needs. At 1:28 PM, staff brought the roommate into the room and a CNA brought in a Hoyer lift and closed the door; by 1:38 PM, CNAs exited the room and indicated the resident was “all good,” and at 1:39 PM the resident was observed in a recliner with different pants, indicating the change had finally occurred. Interviews confirmed that rounding was expected every one to two hours, that the resident commonly had a wet brief after activities, and that activities staff radioed nursing when a brief change was needed, but the incontinence care for this resident was not provided in a timely manner after the initial notification.
Failure to Assess, Treat, and Document Resident Leg Wounds per Standards and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and the resident’s care plan for skin integrity. A resident with Type 2 diabetes and restless leg syndrome reported having open sores on his lower leg for at least a week and stated he had informed a nurse, who applied bandages, but he continued to bleed through the bandages onto his socks. On observation, the resident’s right lower extremity below the knee was reddish-purple with a large bandage saturated with serosanguineous drainage leaking onto his sock, and two additional draining areas were uncovered. There was no documentation in the medical record of any leg wounds, wound assessments, or wound treatment orders, despite the resident’s report that bandages had been applied previously. Further observations and interviews showed that the resident’s wounds were not being consistently assessed or documented. During a dressing change, an RN told the resident she needed to ensure his wounds were documented in the computer to be assessed daily, but there was still no wound care order or progress note documenting his skin condition in the record the following day, and the resident reported that no nurse had assessed or changed his bandages that day. The resident’s care plan, initiated months earlier, included a goal for intact skin and interventions such as daily body checks and immediate nurse notification of any new skin breakdown, redness, blisters, bruises, or discoloration, but these interventions were not effectively implemented or documented for this resident’s leg wounds. Interviews with nursing leadership confirmed that required steps such as documenting skin changes, entering wound care orders, and completing appropriate notes were not carried out as expected for this resident.
Unordered and Uncareplanned Use of PureWick Device for Continent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a continent resident received appropriate services to maintain continence and that the use of a PureWick external catheter was properly ordered and care planned. Resident 53 was admitted with unsteadiness on feet, difficulty in walking, and muscle weakness, and reported being continent of urine upon admission. During a surveyor observation, a suction canister with dark amber fluid and suction tubing was noted at the bedside, and the resident stated she had been non‑weight bearing for a few weeks and was given a PureWick catheter so she did not have to get up to use the toilet. She reported that staff changed the PureWick device a few times a week. Review of the medical record showed no physician order for the PureWick device and no directions for its use, and the resident’s care plan did not include the PureWick. Staff interviews confirmed that the resident had been continent when first at the facility and later began using a PureWick device, with a CNA learning of this only through CNA report and noting the resident also wore briefs. The CNA Coordinator acknowledged there was a resident using a PureWick and that this was new for the facility, stating CNAs had been trained and could ask questions. RN 2 confirmed the resident had used the PureWick for a couple of weeks due to being non‑weight bearing and not wanting frequent brief changes, and stated that PureWicks should have a doctor’s order, but she had not received facility training on its use and was unsure how often it should be changed. RN 3 stated the device should be changed every 24 hours, the canister cleaned once a week, and that use of a PureWick should be care planned. The DON reported the resident had used the PureWick for about two weeks for dignity while bedbound and non‑weight bearing, acknowledged that a doctor’s order was required and that the resident did not have one, and stated that the use of a PureWick should be care planned.
Failure to Ensure Physician Review and Documentation of Resident’s Total Program of Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician reviewed a resident’s total program of care, including medications and treatments, and documented an evaluation of the resident’s condition at required visits. Resident 53, admitted with unsteadiness on feet, difficulty in walking, and muscle weakness, had nursing notes indicating that a physician saw the resident on two occasions. A nursing note dated 12/4/25 documented that the resident was seen by a physician, and another nursing note dated 1/13/26 documented that the physician reviewed labs and medications and answered questions, with a plan to continue monitoring. However, the physician progress note for the 1/13/26 visit could not be located in the resident’s medical record, and there was no documented physician evaluation of the resident’s condition and total program of care, including medications and treatments, and no documented decision about the continued appropriateness of the current medical regimen. During interviews, the HIM Director reported that one of the facility physicians does not write or dictate any medical records for the residents he sees, requiring the facility to call the physician’s office to request progress notes, and stated that it was hard to track resident records because the physician did not write in the resident’s medical record. The DON explained that the facility sends a form with the resident for the physician to write what was done at the appointment and that, if more detailed notes are needed, staff must call the physician’s office to obtain progress notes, which are then scanned into the resident’s record. The DON also stated that the physician sends back a worksheet with orders and that it is difficult to obtain progress notes from this physician. These practices resulted in missing physician documentation for Resident 53’s visit and a lack of evidence that the physician reviewed and evaluated the resident’s total program of care as required.
Failure to Follow Enhanced Barrier Precautions for Resident With NG Feeding Tube
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and safe handling of a nasogastric (NG) feeding tube for one resident. The resident was admitted with cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia, and had an NG feeding tube with continuous tube feeding. Surveyors observed that the resident’s room had an EBP sign on the door, but on one occasion the tube feeding pump was beeping with an inactive status and one end of the feeding tube was uncapped and touching a metal IV pole. A registered nurse entered the room, donned only gloves, picked up the uncapped end of the feeding tube from the IV pole, and reattached it to the NG tube without wearing a gown, despite the resident being on EBP. On another occasion, a speech therapist entered the same resident’s room, donned gloves but did not wear a gown, and conducted a feeding session. The therapist knelt on the floor and administered multiple trials of different fluids and foods, adjusted the resident in bed, and then exited the room without donning a gown at any time. Speech therapy documentation confirmed that the resident received multiple oral trials of yogurt, apple juice, and a peach, with noted anterior loss of bolus and difficulty determining safety due to the resident’s inability to hold the bolus in the oral cavity. In interviews, the RN, CNA Coordinator, and DON all stated that residents with feeding tubes or other indwelling devices required PPE including gowns and gloves, and that EBP should be followed for residents with feeding tubes, with gowns required when handling tube feedings or feeding the resident. These observations and statements show that staff did not follow the facility’s EBP requirements for this resident.
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Nursing homes near Price
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkdale Health And Rehab | 1.6 mi | — | 0 | 0 |
| San Rafael Health And Rehabilitation | 39.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.