Mission at Alpine Rehab: Elopement Care Plan Failures - UT
The pattern began in the summer of 2024. The first documented sign of trouble came on August 5, when the resident tried to climb over a fence by standing on a planter. The administrator, interviewed by inspectors in August 2025, said interventions should have been put in place right then. They weren't.
Four days later, on August 9, the resident eloped a second time. Staff updated the care plan three days after that, on August 12. The new approaches told staff to discuss the resident's behavior with them when reasonable, explain why the behavior was inappropriate, speak calmly, divert attention, remove the resident from the situation if needed, and monitor behavior episodes to try to identify what was driving them.
Then it happened again. On August 20, 2024, the resident eloped a third time. No new approaches were added to the care plan. Nothing changed on paper.
The fourth elopement came on October 2, 2024. This time, staff did update the care plan, and they did it the same day. The new intervention focused on windows: evaluate all windows to make sure they are secured for wander safety, and re-secure the window the resident had gone through. An incident report from July 11, 2024 had already noted that window stops were placed at all windows, which raises the question of how the resident reached a window that needed re-securing three months later.
When inspectors returned to the facility in August 2025, nearly a year after the elopements, they began asking who had been responsible for keeping the care plan current. A licensed practical nurse, interviewed on August 14, said she did not know who updated the care plans.
The director of nursing, interviewed on August 18, described the facility's process in general terms. After an incident, she said, staff would review what happened, discuss it in the morning meeting, and then add new interventions to the care plan.
The third elopement happened. There was no new intervention in the care plan. The process the director of nursing described did not produce a result.
The care plan that existed before the third elopement had been written with approaches for a resident who had already escaped once. It included reorientation strategies, structured activities like toileting and walking, memory boxes and signs, and re-education about the safety risks of leaving. Those were the tools staff had when the resident walked out a third time.
The facility is located on East Alpine Drive and operates a dedicated memory care unit. The resident's room, the specific window, and the precise method of the third and fourth escapes are not detailed in the inspection report. What the report documents is the gap: an elopement occurred, the care plan was not revised, and when inspectors asked a nurse who was responsible for updating it, she had no answer.
The deficiency was cited under the federal tag governing care planning, with a harm level of minimal harm or potential for actual harm, affecting some residents.
Memory care residents who elope face serious risk. Disorientation, traffic, weather, and the inability to ask for help or explain who they are make unsupervised time outside a facility dangerous in ways that are difficult to predict and easy to underestimate.
The administrator acknowledged to inspectors that the fence-climbing incident on August 5 should have triggered new interventions. It did not. The second elopement, four days later, did. The third elopement, eleven days after that, did not. The fourth elopement, six weeks later, did.
The resident eloped four times. The care plan was updated twice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mission At Alpine Rehabilitation Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
Mission at Alpine Rehabilitation Center in Pleasant Grove, UT was cited for violations during a health inspection on August 20, 2025.
The pattern began in the summer of 2024.
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.