Mission At Alpine Rehabilitation Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety
On 3/24/25, resident 11 had a care plan initiated for “Resident exhibits/at risk for behaviors such as aggression, agitation, hypersexuality/affection at times, yelling profanities repeatedly, sitting herself on the ground or floors, digging around in the dirt of the flower beds/pulling leaves and branches off of plants in courtyard, and at times getting dirt on her clothing several times daily r/t [related to] history of hypersexuality in group settings, anxiety, depression, history of TBI, intellectual disabilities,
Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0607
F 0607
limited due to her TBI but she would repeat phrases, could say yes or no, nod head yes or no, and give a thumbs up. CNA 6 stat[TRUNCATED]
Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0609
F 0609 Level of Harm - Immediate jeopardy to resident health or safety
On 8/18/2025 at 1:55 PM, the Admin stated he did report the incident with resident 7 falling over in the van but it was reported late.
POTENTIAL FOR HARM ELOPEMENT
Residents Affected - Some
- 8. Resident 47 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which
included metabolic encephalopathy, type 2 diabetes mellitus, delirium due to known physiological condition, major depressive disorder, generalized anxiety disorder, chronic pancreatitis, essential hypertension, and cognitive communication deficit.
Resident 47's medical record was reviewed from 8/4/25 through 8/20/25.
An admission MDS assessment dated [DATE REDACTED] indicated resident 47 had a BIMS score of 3. A BIMS score between 0 and 7 indicated severe cognitive impairment. It further indicated wandering behaviors were not exhibited.
A Social Services Note dated 6/7/24 indicated, “…[Resident 47] is a high wander risk. He is often walking around the building and outside in the backyard. Staff is able to check on him frequently and provide activities to reduce risk of wandering. [Resident 47] has not left facility unattended.”
A Nursing Progress Note dated 8/9/24 indicated, “Resident was found on state street in [City name redacted] by a staff member and brought back to the facility just as the nurse was looking for the resident.
Resident was asked how he got out of the facility and the resident reports he exited the front door. He reports he does not remember who let him out…”
A Nursing Progress Note dated 8/20/24 indicated, “resident attempted to elope and was found still
on the facility premisis [sic] by a physical therapy personelle [sic] around 1805 [6:05 PM]. when asked how
he got out he was not an accurate hisotrian [sic] and said he went through the front door but also said he jumped over the fence. upon further investigation, staff found an outside chair pushed up against the west fence and this is how we presume he got outside. Notified administration, ADON [Name redacted], and will continue checking his where abouts every hour. messaged management aboutgetting [sic] the outside chairs perminantely [sic] secured to the ground and kept away from the fences to prevent this from happening again in the future. Chairs are temporarily secured and unable to be moved at this time.”
A Nursing Progress Note dated 10/2/24 indicated, “Resident was found 1.5 blocks from the facility walking towards the [Store name redacted] by the [City name redacted] police. Facility was called and a staff member went and picked resident up and brought him back to the facility…”
On 8/19/25 at 12:25 PM, an interview was conducted with the Admin. The Admin stated the elopements on 8/9/24, 8/20/24, and 10/2/24 should have been reported to the State Survey Agency.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0610
F 0610
It should be noted that no investigation documentation was provided.
Level of Harm - Immediate jeopardy to resident health or safety
On 8/12/25 at 1:19 PM, an interview was conducted with the administrator (Admin). The Admin stated the investigations were primarily done by talking with the nurses and looking into the events. The Admin stated
they did a formal investigation on 7/6/25 for resident 36. The Admin stated he wasn’t totally aware of
the elopement section of the reportable so because of that not being clear, he didn’t report them.
The Admin stated because resident 36 was with a staff member they didn’t report the elopements.
The Admin stated he did not report or investigate the incidents for resident 42 or report them to the state.
The Admin stated that yes, these incidents should have been investigated and reported to the state survey agency.
Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0656
F 0656
a. Memory care unit;
Level of Harm - Minimal harm or potential for actual harm
b. Orient and reorient on an ongoing basis;
Residents Affected - Some
c. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; and d. Re-educate resident regarding safety and risk of leaving.
Approaches were updated after the second documented elopement on 8/9/24 and initiated on 8/12/24 which included: a. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; b. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner.
Divert attention. Remove from situation and take to alternate location as needed; c. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
No new Approaches were updated on the care plan after the third documented elopement on 8/20/24.
Approaches were updated after the fourth documented elopement on 10/2/24 and initiated on 10/2/24 which included: a. Evaluate all windows to make sure they are secured within guidelines for wander safety. Re-secure window resident went through.
An incident report dated 7/11/24 indicated, “Window stops placed at all windows…”
On 8/14/25 at 2:42 PM, LPN 4 stated she did not know who updated the care plans.
On 8/18/25 at 12:45 PM, an interview was conducted with the DON. The DON stated after an incident occurs, it would be reviewed to see what happened, discussed in morning meeting, and then new interventions would be put into the care plan.
On 8/19/25 at 12:25 PM, an interview was conducted with the Administrator (Admin). The Admin stated interventions should have been implemented after the resident attempted to hop over the fence by standing
on the planter on 8/5/24.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0677
F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
awake at about 8:30 AM this morning.On 8/14/25 at 10:30 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated resident 12 could not feed himself. RN 5 stated resident 12 tended to get agitated but would calm down after he ate.On 8/14/25 at 2:42 PM, an interview was conducted with LPN 4.
LPN 4 stated the CNA's were assigned to ensure each resident ate and if a resident did not eat, they were supposed to let the nurse know.On 8/19/25 at 1:11 PM, an interview was conducted with CNA 1. CNA 1 reviewed the Meal Task document and stated the times that are listed on the document are not accurate and do not reflect the times the resident ate because she waits until the end of her shift to document.On 8/19/25 at 1:29 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she did not know what happened but resident 12 missed breakfast on 8/13/25 because when she cut the meal cards, his card disappeared somehow. The DM stated it was her expectation that the CNA would notify her if their resident did not get a meal.On 8/20/25 at 9:42 AM, an interview was conducted with the Director of Nursing (DON). The DON stated residents who needed assistance to eat should eat by 9:00 AM.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689
A Nursing Progress Note dated 7/14/25 at 11:14 AM indicated, “Resident fouond [sic] lying on flo[TRUNCATED]
Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0692
F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
integrity r/t recent surgery, incontinence, altered mobility, impaired cognition. Date Initiated: 06/17/2025 Revision on: 07/15/2025”; with the Approaches, “Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: 07/15/2025”.
On 8/20/25 at 11:36 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated there was
a snack provided at 7:00 PM every day but he did not think the snacks were documented.
On 8/19/25 at 1:29 PM, an interview was conducted with the DM. The DM stated the CNAs passed out the snacks. The DM stated if a resident missed the 7:00 PM snack, the resident could ask for snacks and that there were sandwiches in the fridge. The DM stated she could not answer what should be done about residents who missed the 7:00 PM snack and could not say if they were hungry or not.
On 8/20/25 at 1:14 PM, a telephone interview was conducted with the Registered Dietician (RD). The RD stated there was a concern for resident 25’s weight loss. The RD stated she received reports that he was not eating well and that the DM kept a close eye on the residents. The RD stated she was unsure where snack intakes were documented but the nurses and CNAs paid attention to that.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0740
F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
The Admin stated that the last time the SRS service provider was in the facility was January 30th. The Admin stated that the RA was in charge of arranging the SRS services for the residents. The Admin stated that he was not sure if resident 11 had ever had SRS services since being at the facility and he would guess that had not been provided to her yet. The Admin stated that if the PASRR level II identified that SRS services were recommended for a resident they would need to arrange for those services to be provided.
The Admin stated that he would expect those services to be arranged within a couple of weeks of getting
the PASRR level II recommendations. The Admin stated that he was responsible for ensuring that they had
a contract with a provider for the SRS services. [Cross-refer F-F600, F-F645]
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission at Alpine Rehabilitation Center
25 East Alpine Drive Pleasant Grove, UT 84062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0943
F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Based on interview and record review, the facility did not provide training to their staff that at a minimum educated staff on activities that constituted abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and resident abuse and neglect prevention. Findings included: On 8/6/25 at 11:58 AM, an
interview was conducted with Nursing Assistant (NA) 6. NA 6 stated they did education at the facility. NA 6 stated they just went over things that needed to be fixed. Usually the teaching was done during the in-service or the daily huddle that they had with everyone. NA 6 was not sure what the Quality Assurance and Performance Improvement (QAPI) meetings were about or if there was education that went over that stuff. On 8/19/25 at 1:33 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated they did get education at work but he was unsure what QAPI was. RN 2 stated they did education when there was something that needed to be corrected.During an interview on 8/19/25 at 9:15 AM, the Administrator stated there had been training done on abuse every month. The Administrator stated they discussed the types of abuse that could happen in a facility. The Administrator stated they did not have a way to determine if the information was understood by the staff but they just kept educating on it monthly. The Administrator stated the staff in-services did not provide education on a person's ability to give consent so the staff were not educated on that area. The Administrator stated that he had sent over the facility in-services to the survey team.It should be noted, none of the in-service staff trainings from 1/16/25 through 7/17/25 that were provided by the facility on 8/19/25 included agendas for abuse training. Agendas for dementia, assault, de-escalation and speech/space/grace trainings were provided but none of these trainings defined abuse, explained types of abuse, what to do when abuse occurred, who to report the abuse to and who had
the ability to give consent.A follow up interview was conducted on 8/20/25 at 8:57 AM with the Administrator. The Administrator stated they have tried to ensure everyone understood the teaching when it was provided, but staff may not practice what was taught when they were working. The Administrator stated
they were trying to make sure the education encompassed the entire problems addressed during QAPI.
The Administrator stated that the abuse training needed to be updated and they were trying to make that better. [Cross refer to F-F600]
Event ID:
Facility ID:
If continuation sheet
Mission at Alpine Rehabilitation Center in Pleasant Grove, UT inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Pleasant Grove, UT, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Mission at Alpine Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.