Mission at Alpine: Resident Escaped 3 Times - UT
The 47-year-old resident, who suffered from metabolic encephalopathy and severe cognitive deficits, was found by police walking 1.5 blocks from the facility in October 2024. In another escape two months earlier, a staff member discovered him wandering on State Street and brought him back just as nurses were beginning to search for him.
Federal inspectors classified the facility's failure to report the escapes as an immediate jeopardy violation during an August 2025 complaint investigation.
Resident 47 had been identified as a high wandering risk since his admission. His cognitive assessment scored a 3 out of 15 points, indicating severe impairment. A social services note from June 2024 documented that he "is often walking around the building and outside in the backyard" but noted that "staff is able to check on him frequently."
The first documented escape occurred on August 9, 2024. A nursing note recorded that the resident "was found on state street by a staff member and brought back to the facility just as the nurse was looking for the resident." When asked how he left, the resident said he exited through the front door but couldn't remember who let him out.
Eleven days later, he escaped again.
Physical therapy staff found him still on facility grounds at 6:05 PM on August 20. The resident gave conflicting accounts of his escape route, saying he went through the front door but also claiming he jumped over the fence. Staff discovered an outside chair pushed against the west fence, which they believed he used to climb over.
The nursing note stated: "messaged management aboutgetting the outside chairs perminantely secured to the ground and kept away from the fences to prevent this happening again in the future."
The chairs were temporarily secured, but the measure proved insufficient.
On October 2, 2024, Pleasant Grove police found the resident walking toward a local store, 1.5 blocks from the facility. Officers called Mission at Alpine, and a staff member retrieved him.
The facility's administrator acknowledged the reporting failures during an August 19, 2025 interview with federal inspectors. He stated that all three elopements "should have been reported to the State Survey Agency" but weren't.
The administrator also admitted to another late reporting incident involving a different resident who fell in the facility's transportation van on August 18, 2025.
Federal regulations require nursing homes to immediately notify state survey agencies when residents leave the facility without authorization. The reporting requirement exists because cognitively impaired residents face serious risks when they wander into traffic, become lost, or encounter dangerous weather conditions.
Resident 47's medical record showed multiple serious conditions beyond his cognitive impairment, including type 2 diabetes, major depressive disorder, generalized anxiety disorder, and chronic pancreatitis. His metabolic encephalopathy and delirium stemmed from known physiological conditions that affected his ability to think clearly and remember his surroundings.
Despite the documented wandering risk and previous escapes, the resident continued to find ways to leave the secured facility. The August 20 incident revealed gaps in the facility's security measures, as an unsecured chair provided the means for escape.
The nursing staff's response to that incident included increasing safety checks to every hour and temporarily securing outdoor furniture. However, the October escape demonstrated that these measures remained inadequate for preventing a determined resident with severe cognitive impairment from leaving the facility.
The three unreported escapes occurred over a span of less than two months, suggesting a pattern of inadequate supervision and security protocols. Each incident placed the vulnerable resident at risk of injury, becoming lost, or encountering dangerous situations in the community.
Federal inspectors found that some residents at Mission at Alpine faced immediate jeopardy due to the facility's failure to properly report and address serious safety incidents. The inspection was conducted in response to complaints about the facility's operations.
The resident's case illustrates the challenges nursing homes face in caring for patients with severe cognitive impairment and wandering behaviors. However, federal officials determined that Mission at Alpine's failure to report the escapes violated regulations designed to protect vulnerable residents and ensure appropriate oversight of facility safety measures.
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
- View all inspection reports for Mission At Alpine Rehabilitation Center
- Browse all UT nursing home inspections
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: June 17, 2026 · Our methodology
Mission at Alpine Rehabilitation Center in Pleasant Grove, UT was cited for violations during a health inspection on August 20, 2025.
Federal inspectors classified the facility's failure to report the escapes as an immediate jeopardy violation during an August 2025 complaint investigation.
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.
Frequently Asked Questions
- What happened at Mission at Alpine Rehabilitation Center?
- Federal inspectors classified the facility's failure to report the escapes as an immediate jeopardy violation during an August 2025 complaint investigation.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Pleasant Grove, UT, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Mission at Alpine Rehabilitation Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 465088.
- Has this facility had violations before?
- To check Mission at Alpine Rehabilitation Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.