Mission at Alpine Rehabilitation Center
25 East Alpine Drive, Pleasant Grove, UT 84062
Mission at Alpine Rehabilitation Center is a nursing home in Pleasant Grove, Utah. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionAugust 20, 2025 (1 year ago)
- Health citations since February 16, 202244 (Utah average 26)
- Fines in the past three years2, $125,737 in total
- CMS flagsSpecial Focus Facility candidate, CMS abuse icon
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CMS flags
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of March 25, 2026
Fine
CMS changed the fine from August 20, 2025 from $181,990 to $118,294.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
Fine
CMS changed the fine from August 20, 2025 from $72,510 to $181,990.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on August 20, 2025
30 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
8 of 97 Utah homes (8%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $118,294 on August 20, 2025.
Show the 30 citations
Citation F0600. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on October 20, 2025.
CMS has cited this home for F0600 2 times since 2023.
Citation F0607. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on October 20, 2025.
Citation F0609. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on October 20, 2025.
Citation F0610. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on October 20, 2025.
Citation F0689. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 20, 2025.
CMS has cited this home for F0689 3 times since 2022.
Citation F0835. Severity H: actual harm, pattern.
The rule CMS cited:
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
CMS lists it as corrected on October 20, 2025.
Citation F0867. Severity H: actual harm, pattern.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on October 20, 2025.
Citation F0550. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on October 20, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 20, 2025.
CMS has cited this home for F0812 2 times since 2022.
Citation F0843. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
CMS lists it as corrected on October 20, 2025.
Citation F0865. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a plan that describes the process for conducting QAPI and QAA activities.
CMS lists it as corrected on October 20, 2025.
Citation F0605. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on October 20, 2025.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on October 20, 2025.
CMS has cited this home for F0656 2 times since 2022.
Citation F0728. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
CMS lists it as corrected on October 20, 2025.
Citation F0803. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
CMS lists it as corrected on October 20, 2025.
Citation F0809. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
CMS lists it as corrected on October 20, 2025.
Citation F0943. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on October 20, 2025.
Citation F0944. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on October 20, 2025.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on October 20, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on October 20, 2025.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on October 20, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 20, 2025.
CMS has cited this home for F0677 2 times since 2022.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on October 20, 2025.
CMS has cited this home for F0692 2 times since 2022.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on October 20, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on October 20, 2025.
Citation F0800. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
CMS lists it as corrected on October 20, 2025.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on October 20, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 20, 2025.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on October 20, 2025.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on October 20, 2025.
CMS has cited this home for F0883 2 times since 2023.
Fire safety inspection on August 20, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation E0004. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on October 1, 2025.
Citation E0039. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on October 1, 2025.
CMS has cited this home for E0039 2 times since 2023.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 3.1 to 2.7 hours per resident per day.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of June 26, 2024
Fine
CMS changed the fine from November 30, 2023 from $11,450 to $7,443.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of February 29, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.2 to 2.2 hours per resident per day.
Health inspection on November 30, 2023
7 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
17 of 97 Utah homes (18%) got a citation at the actual harm level in 2023.
CMS fine of $7,443 on November 30, 2023.
Show the 7 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on January 15, 2024.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
CMS lists it as corrected on January 15, 2024.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on January 15, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on January 15, 2024.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on January 15, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on January 15, 2024.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
CMS lists it as corrected on January 15, 2024.
Fire safety inspection on November 30, 2023
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation E0039. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on December 31, 2023.
Health inspection on February 16, 2022
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 10, 2022.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 10, 2022.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on April 10, 2022.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 10, 2022.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on April 10, 2022.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 10, 2022.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 10, 2022.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (801) 785-3568
- Last standard health inspection
- August 20, 2025 (1 year ago)
- Certified beds
- 52
- Residents per day, on average
- 38.7
- Ownership type
- Non profit - Other
- Legal business name
- Gunnison Valley Hospital
- Chain
- Mission Health Services
- Takes part in
- Medicare and Medicaid
More health citations than the Utah average (44 vs 26).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- MISSION HEALTH SERVICESOperational/managerial control · not applicable · since 04/01/2017
- ELLIS, ASHLEYOperational/managerial control · not applicable · since 06/01/2021
- KEELE, EDDIEOperational/managerial control · not applicable · since 04/01/2023
- TAYLOR, JACOBOperational/managerial control · not applicable · since 07/16/2024
- WOOTTON, ZACHARYOperational/managerial control · not applicable · since 04/01/2024
Show 2 more
- WORKMAN, DAVIDOperational/managerial control · not applicable · since 06/01/2023
- ZIMBELMAN, MICHELLEOperational/managerial control · not applicable · since 04/01/2017
Questions
When was Mission at Alpine Rehabilitation Center last inspected?
CMS lists August 20, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Mission at Alpine Rehabilitation Center have?
CMS lists 44 health citations since February 16, 2022. CMS also calls these deficiencies.
Has Mission at Alpine Rehabilitation Center been fined?
CMS lists 2 fines in the past three years, $125,737 in total.
What is the CMS star rating of Mission at Alpine Rehabilitation Center?
Its CMS overall star rating is 2 of 5.
Is Mission at Alpine Rehabilitation Center a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.