Mission at Alpine Rehab: Immediate Jeopardy Fall - UT
The note, timestamped 11:14 a.m., described a resident discovered lying on the floor at Mission at Alpine Rehabilitation Center, a skilled nursing and rehabilitation facility at 25 East Alpine Drive. Federal inspectors reviewed that note during a complaint inspection completed August 20, 2025, and what they found across the facility's records earned the highest level of concern available under federal oversight: immediate jeopardy to resident health or safety.
Immediate jeopardy is not a routine citation. It is the designation inspectors apply when a facility's failures have placed residents in a situation where serious injury, serious harm, or death is likely unless the problem is corrected immediately. Inspectors determined the harm extended beyond a single resident. Their finding listed residents affected as "some."
The inspection report, filed under deficiency tag F0689, covers the federal standard requiring nursing homes to ensure their environment is free from accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. A resident found on the floor is, in the language of that standard, the outcome the regulation exists to prevent.
What the truncated inspection narrative does not fully reveal, because the document was cut before the findings were complete, is the full sequence of what inspectors documented. The July 14 progress note is the entry point. It places a resident on the floor of a facility that was, at that moment, responsible for keeping them safe.
Falls in nursing homes carry consequences that compound. A resident who falls once is at higher risk of falling again. A resident who falls and is not assessed immediately, or whose care plan is not adjusted in response, faces that elevated risk without the protection a proper response would provide. The inspection found enough to declare that the situation rose to immediate jeopardy, a threshold that requires a facility to act before inspectors leave the building or face the prospect of federal sanctions including termination from Medicare and Medicaid.
Mission at Alpine Rehabilitation Center is a 115-bed facility. It serves residents in short-term rehabilitation and long-term care. The complaint that triggered this inspection came from outside the facility, from someone who contacted regulators directly rather than waiting for a scheduled survey. The Centers for Medicare and Medicaid Services assigned the inspection the event identification number printed on the deficiency form.
The plan of correction, which facilities are required to submit in response to cited deficiencies, was not included in the materials available from this inspection. The agency noted that anyone seeking information about the facility's corrective response should contact Mission at Alpine or the Utah state survey agency directly.
What the record contains is this: on a July morning, a resident was on the floor. A nurse documented it. Weeks later, federal inspectors read that note and kept reading, and what they found across however many pages preceded page 57 of a 70-page inspection report was enough to determine that some number of residents at this facility faced immediate jeopardy.
The resident found on the floor on July 14 had a nurse present to write the note. Whether they had everything else they needed, before the fall and after it, is what the investigation turned on.
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.
Immediate jeopardy is not a routine citation.
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.