Mission at Alpine: Resident Missed Breakfast, Staff Issues - UT
The incident occurred on August 13 at Mission at Alpine Rehabilitation Center, where Resident 12 required assistance eating and "tended to get agitated but would calm down after he ate," according to Registered Nurse 5.
The Dietary Manager told inspectors she didn't know what happened, but when she cut the meal cards that morning, Resident 12's card disappeared. She expected the certified nursing assistant to notify her if their resident didn't receive a meal.
Nobody did.
CNA 1, assigned to ensure residents ate, told inspectors the times listed on meal documentation "are not accurate and do not reflect the times the resident ate because she waits until the end of her shift to document."
The practice meant hours could pass before anyone recorded whether vulnerable residents had eaten. Director of Nursing staff told inspectors that residents needing eating assistance should finish meals by 9:00 AM.
LPN 4 confirmed that CNAs were supposed to notify nurses if residents didn't eat. The system failed Resident 12 entirely on August 13.
The inspection revealed a facility where meal documentation happened as an afterthought rather than real-time monitoring. CNA 1's admission that she documented meal times inaccurately raised questions about how many other residents' nutritional needs were tracked improperly.
For Resident 12, who required help eating and became agitated when hungry, missing breakfast meant starting the day without necessary nutrition and potentially becoming distressed. RN 5's observation that the resident calmed down after eating suggested regular meals were crucial for his wellbeing.
The dietary manager's explanation that the meal card "disappeared somehow" offered no accountability for how a dependent resident's nutrition was overlooked. Her expectation that CNAs would report missing meals conflicted with the reality that CNA 1 waited until shift's end to document anything.
Federal inspectors cited the facility for failing to ensure residents received adequate nutrition, noting the violation caused minimal harm but affected few residents. The August 20 inspection followed a complaint about the facility's practices.
Mission at Alpine's meal system relied on paper cards that could vanish and staff who admitted to inaccurate record-keeping. For residents like Resident 12, who depended entirely on others for basic nutrition, such gaps in oversight created unnecessary risk.
The facility's own policies required residents needing assistance to finish eating by 9:00 AM, yet no system ensured this happened when meal cards went missing. The breakdown affected a resident who couldn't advocate for himself and whose agitation when hungry made timely meals essential for his comfort and care.
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: June 20, 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 Dietary Manager told inspectors she didn't know what happened, but when she cut the meal cards that morning, Resident 12's card disappeared.
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.