Mission at Alpine Rehab: Immediate Jeopardy Violation - UT
The care plan for the resident, identified in inspection records only as Resident 11, was initiated on March 24, 2025. It listed a cluster of behaviors inspectors would later scrutinize: aggression, agitation, yelling profanities repeatedly, pulling leaves and branches off plants in the facility courtyard, and hypersexuality or expressions of affection in group settings. The plan noted she got dirt on her clothing several times daily. The behaviors were documented as related to her history of traumatic brain injury and intellectual disabilities, combined with anxiety and depression.
Immediate jeopardy is the most serious finding federal inspectors can make. It means the facility's failures have placed one or more residents in a situation where serious injury, harm, or death is likely unless immediate corrective action is taken.
The inspection was a complaint survey, meaning someone had contacted regulators before inspectors arrived. The full 70-page report documents findings across multiple deficiency tags. The narrative released under citation F0600, which covers abuse, neglect, and exploitation protections, ran to the top of the severity scale.
Inspectors found that some residents were affected, not just Resident 11.
What the inspection report does not spell out in the excerpt available is exactly what happened to Resident 11 beyond what her care plan described. What it does establish is that a woman with documented cognitive and behavioral vulnerabilities, whose daily life included sitting on the ground in the courtyard and interacting in group settings with behaviors her own care plan flagged as hypersexual, was at the center of a finding that inspectors considered immediately dangerous.
Care plans at nursing facilities are meant to be living documents, updated as a resident's needs change, shared with the staff who provide daily care, and followed. A care plan that accurately describes a resident's risks is only meaningful if the facility acts on it. The inspection record indicates that gap, between what was documented and what was done, is where the immediate jeopardy finding took root.
Mission at Alpine Rehabilitation Center operates at 25 East Alpine Drive in Pleasant Grove, a city of roughly 40,000 people in Utah County. The facility's CMS identification number is 465088.
The inspection was completed August 20, 2025. The statement of deficiencies was printed April 13, 2026.
Resident 11 came to Mission at Alpine with a history that would require careful, consistent management from any facility that accepted her. Traumatic brain injury can alter impulse control, judgment, and social behavior in ways that are difficult to predict and harder to reverse. Intellectual disabilities compound those challenges. Her care plan acknowledged all of it. The question inspectors came to answer was whether the facility had done anything meaningful with that acknowledgment, and the answer they recorded was serious enough to carry the most urgent classification in federal nursing home oversight.
The plan of correction for the deficiency, as required by CMS, would be available through the nursing home or the Utah state survey agency. What it cannot correct is the period between March 24, when the care plan was initiated, and August 20, when inspectors arrived and found what they found.
Resident 11 spent those months at a facility that knew exactly what she was living with.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
Mission at Alpine Rehabilitation Center in Pleasant Grove, UT was cited for immediate jeopardy violations during a health inspection on August 20, 2025.
The care plan for the resident, identified in inspection records only as Resident 11, was initiated on March 24, 2025.
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.