Mission at Alpine Rehabilitation Center

25 East Alpine Drive · Pleasant Grove, UT · 84062 · 8017853568

52 certified beds Non profit - Other Chain: Mission Health Services

Why this verdict

  • Carries CMS’s abuse warning icon.
  • Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (5 citations).
  • Inspection record is far worse than the national median (deficiency count and severity).
  • Federal penalties on record: $118,294 in fines in the last 24 months.

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Red flags

Special Focus Facility candidate

CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.

CMS abuse warning

CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.

5 immediate-jeopardy citations in the most recent inspection cycle

Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.

4 abuse-related citations at the actual-harm level

Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.

2 actual-harm citations in the most recent cycle

Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.

$118,294 in federal fines in the last 24 months

1 fine — CMS fines are reserved for verified, serious non-compliance.

76% of nursing staff left within a year

High turnover disrupts continuity of care; the national median is 45%.

Score breakdown

Inspection record 30% of score 0
Serious harm & abuse 20% 0
Staffing 20% 54
Federal penalties 15% 45
Trend 10% 18
Context 5% 35

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 2 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 5 of 5

Total nurse hours / resident-day3.273.48 min · 4.1 strong
RN hours / resident-day0.520.55–0.75
Weekend hours / resident-day2.98≈ weekday level
Nursing turnover / year76%median 45%
Fines (3-yr window)2 · $125,737

Inspection citations (44 in the current record)

  • Immediate jeopardy · K August 20, 2025 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected October 20, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Immediate jeopardy · K August 20, 2025 · found via complaint

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Corrected October 20, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Immediate jeopardy · K August 20, 2025 · found via complaint

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Corrected October 20, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Immediate jeopardy · K August 20, 2025 · found via complaint

    Respond appropriately to all alleged violations.

    Corrected October 20, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Immediate jeopardy · K August 20, 2025 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected October 20, 2025 · Quality of Life and Care

  • Actual harm · H August 20, 2025

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    Corrected October 20, 2025 · Administration

  • Actual harm · H August 20, 2025

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    Corrected October 20, 2025 · Administration

  • Potential for harm · F August 20, 2025

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Corrected October 20, 2025 · Resident Rights

  • Potential for harm · D August 20, 2025

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected October 20, 2025 · Resident Rights

  • Potential for harm · E August 20, 2025

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

    Corrected October 20, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D August 20, 2025

    Ensure each resident receives an accurate assessment.

    Corrected October 20, 2025 · Resident Assessment and Care Planning

  • Potential for harm · D August 20, 2025

    PASARR screening for Mental disorders or Intellectual Disabilities

    Corrected October 20, 2025 · Resident Assessment and Care Planning

  • Potential for harm · E August 20, 2025

    Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

    Corrected October 20, 2025 · Nursing and Physician Services

  • Potential for harm · D August 20, 2025

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

    Corrected October 20, 2025 · Pharmacy Service

  • Potential for harm · D August 20, 2025

    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

    Corrected October 20, 2025 · Nutrition and Dietary

  • Potential for harm · E August 20, 2025

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

    Corrected October 20, 2025 · Nutrition and Dietary

  • Potential for harm · E August 20, 2025

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

    Corrected October 20, 2025 · Nutrition and Dietary

  • Potential for harm · F August 20, 2025

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected October 20, 2025 · Nutrition and Dietary

  • Potential for harm · D August 20, 2025

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Corrected October 20, 2025 · Resident Assessment and Care Planning

  • Potential for harm · F August 20, 2025

    Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

    Corrected October 20, 2025 · Administration

  • Potential for harm · F August 20, 2025

    Have a plan that describes the process for conducting QAPI and QAA activities.

    Corrected October 20, 2025 · Administration

  • Potential for harm · D August 20, 2025

    Provide and implement an infection prevention and control program.

    Corrected October 20, 2025 · Infection Control

  • Potential for harm · D August 20, 2025

    Implement a program that monitors antibiotic use.

    Corrected October 20, 2025 · Infection Control

  • Potential for harm · D August 20, 2025

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

    Corrected October 20, 2025 · Infection Control

  • Potential for harm · E August 20, 2025

    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

    Corrected October 20, 2025 · Administration

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
August 20, 2025Fine$118,294
November 30, 2023Fine$7,443

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 465088 · certified since December 15, 1981. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.