Mission at Alpine Rehabilitation Center
25 East Alpine Drive, Pleasant Grove, UT 84062 · Utah County · 52 certified beds · avg 37 residents/day · certified since Dec 15, 1981
Abuse citation flag (CMS)SFF Candidate
Part of chain: MISSION HEALTH SERVICES (7 facilities, chain avg rating 3.4★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Aug 20, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Aug 20, 2025 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Aug 20, 2025 · F-0609 · triggered by a complaint
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Aug 20, 2025 · F-0610 · triggered by a complaint
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Aug 20, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Aug 20, 2025 · F-0835
The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Aug 20, 2025 · F-0867
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Why it matters: Without a working quality program, the same care problems tend to repeat instead of getting fixed.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 30, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 15, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (44)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 20, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 20, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Aug 20, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 20, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 20, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 20, 2025 | ▲ H · Actual harm, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Aug 20, 2025 | ▲ H · Actual harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Aug 20, 2025 | F · Potential for harm, facility-wide | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 20, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 20, 2025 | F · Potential for harm, facility-wide | The facility did not have an agreement with at least one Medicare- or Medicaid-certified hospital to ensure residents can be transferred quickly when they need hospital care. |
| Aug 20, 2025 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Aug 20, 2025 | E · Potential for harm, repeated | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Aug 20, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Aug 20, 2025 | E · Potential for harm, repeated | The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. |
| Aug 20, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Aug 20, 2025 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Aug 20, 2025 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint |
| Aug 20, 2025 | E · Potential for harm, repeated | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Nov 30, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 30, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Nov 30, 2023 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 30, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 30, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Feb 16, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 16, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (7 → 30).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 7 | 0 | E |
| 2023 | 7 | 1 | G ▲ |
| 2025 | 30 | 7 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $125,737.
| Date | Type | Amount / length |
|---|---|---|
| Aug 20, 2025 | Fine | $118,294 |
| Nov 30, 2023 | Fine | $7,443 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Utah avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.57 | 3.87 | 3.95 | top 50% in Utah; bottom 40% in the U.S. |
| Registered Nurse hours | 0.65 | 1.17 | 0.69 | bottom 9% in Utah; top 42% in the U.S. |
| Weekend total nurse staffing | 3.15 | 3.39 | 3.50 | top 43% in Utah; bottom 39% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.35 | 0.88 | 0.48 | bottom 1% in Utah; bottom 42% in the U.S. |
| Total nursing staff turnover (%) | 65.1 | 50.7 | 45.8 | bottom 17% in Utah; bottom 10% in the U.S. |
| RN turnover (%) | 62.5 | 40.6 | 42.9 | bottom 13% in Utah; bottom 19% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.13, RN 0.57, weekend 2.77. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
Non profit - Other
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bartholomew, Brenda | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2021 |
| Ellis, Ashley | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2021 |
| Ellis, Ashley | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2021 |
| Keele, Eddie | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2023 |
| Mission Health Services | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Mission Health Services | Organization | ADP of the SNF | NOT APPLICABLE | 06/04/2025 |
| Murray, Brian | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2017 |
| Taylor, Jacob | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/16/2024 |
| Taylor, Jacob | Individual | ADP of the SNF | NOT APPLICABLE | 07/16/2024 |
| Wootton, Zachary | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2024 |
| Wootton, Zachary | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2024 |
| Workman, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2023 |
| Workman, David | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
| Zimbelman, Michelle | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Zimbelman, Michelle | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Stonehenge of American Fork | 2.7 mi | American Fork, UT | ★★★★☆ | 4/5 | |
| Monument Healthcare American Fork | 3.2 mi | American Fork, UT | ★★★☆☆ | 2/5 | |
| Cascades at Orchard Park | 4.1 mi | Orem, UT | ★★★★☆ | 4/5 | |
| Stonehenge of Orem | 4.4 mi | Orem, UT | ★★★★★ | 5/5 | |
| Orem Rehabilitation and Nursing Center | 6.7 mi | Orem, UT | ★★★☆☆ | 2/5 | |
| Aspen Ridge of Utah Valley | 7.3 mi | Orem, UT | ★★★★★ | 5/5 | |
| Provo Rehabilitation and Nursing | 8.5 mi | Provo, UT | ★☆☆☆☆ | 1/5 | abuseSFF |
| Pointe Meadows Health and Rehabilitation | 9.3 mi | Lehi, UT | ★★★★★ | 4/5 | |
| Draper Rehabilitation and Care Center | 13.0 mi | Draper, UT | ★★★★☆ | 4/5 | |
| Stonehenge of Springville | 14.4 mi | Springville, UT | ★★★★★ | 4/5 | |
| Neurorestorative | 14.5 mi | Riverton, UT | ★★★★☆ | 3/5 | |
| Rocky Mountain Care - Riverton | 16.6 mi | Riverton, UT | ★★★★☆ | 3/5 |
Compare this facility with the 3 closest →
All facilities in Pleasant Grove →
Facility data as of CMS processing date 2026-08-01. CCN 465088.