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Nursing HomeMedicaid Investigative

Mission at Alpine Rehabilitation Center

On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

25 East Alpine Drive, Pleasant Grove, UT 8406252 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.5/5

based on 38 Google reviews

5
4
3
2
1
Mission at Alpine Rehabilitation Center Nursing Home in Pleasant Grove, UT — Street View
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10/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Special Focus Facility (under heightened CMS scrutiny)
  • Abuse citation on record
  • Low overall rating (2/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (30 vs median 7)
  • High staff turnover (67%)
  • High RN turnover (57%)

Bottom 25% in UT · Below recommended RN staffing · Significantly below average staffing · Worst in MISSION HEALTH SERVICES chain · $125,737 in fines · Special Focus Facility (CMS) · Abuse citation

Source: Medicare data

What this means for your family

Mission at Alpine is highly recommended for its compassionate, patient-centered staff, particularly for those needing memory care. While the facility is physically dated, the quality of care is consistently high; however, families should be mindful of the building's age and ensure they have a clear understanding of the facility's discharge policies during the intake process.

Google Reviews

Google Reviews

38 reviews on Google
Mission at Alpine is consistently praised for its exceptionally compassionate and attentive staff, who are frequently described as treating residents like family. While the facility is widely acknowledged to be dated and in need of physical renovations, families emphasize that the quality of care and the warm, homelike environment far outweigh the aesthetic shortcomings.

Quality Themes

Tap a score for details
Food8.0Staff10.0Clean9.0Activities7.0Meds8.0Memory9.0Comms9.0ValueN/A

Strengths

  • Exceptionally compassionate and attentive nursing staff
  • Strong, proactive communication with family members
  • Homelike, welcoming atmosphere
  • Effective assistance with Medicaid and administrative paperwork

Concerns

  • Outdated and worn physical building conditions (mentioned by 7 reviewers)
  • Inconsistent discharge or transition communication (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'17(2)'20(2)'22(1)'24(3)'26(1)

Distribution · 39 analyzed

5
30
4
6
3
0
2
0
1
3

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the building's age, what is your current plan for facility maintenance or any upcoming renovations to improve the living environment?
  • 2I noticed the facility has a very welcoming atmosphere in reviews; how do you incorporate that warmth into the daily activity schedule for residents?
  • 3With the recent focus on staffing metrics, how do you ensure that the high level of compassionate care mentioned by families remains consistent across all shifts?
  • 4How do you manage the transition process for new residents to ensure that communication with families remains clear and proactive from day one?
  • 5In light of the recent health inspection reports, what specific steps is the leadership team taking to address those findings and improve quality of care?
  • 6How does your nursing team coordinate with local hospitals to ensure that medical emergencies or changes in condition are handled smoothly and communicated to us immediately?

Personalized based on this facility's data


Key Review Excerpts

The staff is extremely caring and really good about listening to your concerns. The RN Sarah that was on shift when Theresa stayed there went way beyond to see that the staff took really good care of her.

Memory care family member · 2025★★★★★

It is an older/outdated building but I think it’s probably perfect for the majority of residents who have dementia or other mental disabilities. The staff interacted with the residents very well and were very kind and patient.

Respite care family member · 2025★★★★★

They help me successfully navigate Medicaid rules on behalf of my mother, which is incredibly helpful.

Long-term resident's family · 2025★★★★★
Source: 38 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.52hrs
70%
Registered nurses for medical care
Total Nursing
3.27hrs
80%
All nurses + aides combined
Staff Turnover
76%
Lower is better (< 30% = good)
RN Turnover
71%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
5/ 5
Better Than Avg

8

measures

Worse Than Avg

6

measures

Mixed Results

2

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility62.8%
Worse than Avg
Here
62.8%
US
15.4%
UT
14.6%
Utah
7.0%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility51.8%
Worse than Avg
Here
51.8%
US
19.5%
UT
24.7%
Utah
23.0%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility3.1%
Better than Avg
Here
3.1%
US
15.3%
UT
16.8%
Utah
18.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility1.6%
Better than Avg
Here
1.6%
US
12.1%
UT
16.5%
Utah
14.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility1.9%
Better than Avg
Here
1.9%
US
14.4%
UT
12.1%
Utah
11.9%
⚠️

Residents who fell and were seriously hurt

↓ Lower is better
This Facility10.3%
Worse than Avg
Here
10.3%
US
3.2%
UT
2.6%
Utah
2.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility65.7%
Worse than Avg
Here
65.7%
US
79.7%
UT
91.0%
Utah
89.1%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility82.5%
Mixed vs Avgs
Here
82.5%
US
81.8%
UT
93.8%
Utah
95.4%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

30deficiencies
2penalties
Well above state avg (9.1)
12 complaint-triggered
$125,737 in fines

30 deficiencies over 3 years, significantly above the UT average of 9.1. 12 were complaint-triggered. 2 Medicare penalties totalling $125,737.

Aug 20, 2025Complaint
10
0600Immediate jeopardy · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0607Immediate jeopardy · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0609Immediate jeopardy · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Immediate jeopardy · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0689Immediate jeopardy · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0943Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0740Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Aug 20, 2025Routine
22
0835Actual harm · PatternCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0867Actual harm · PatternCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0865Potential for harm · WidespreadCorrected

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

0550Potential for harm · WidespreadCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0843Potential for harm · WidespreadCorrected

Administration Deficiencies

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.

0605Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0728Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

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.

0803Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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.

0809Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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.

0944Potential for harm · PatternCorrected

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

0004Potential for harm · PatternCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

0039Potential for harm · PatternCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0800Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Nov 30, 2023Complaint
2
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0600Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nov 30, 2023Routine
6
0727Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0883Potential for harm · PatternCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

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.

0039Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Feb 16, 2022Routine
7
0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Federal Penalties

Fine

Aug 20, 2025

$118,294

Fine

Nov 30, 2023

$7,443

Ownership & Operations

Who Operates This Facility

Owner / Operator

Mission at Alpine Rehabilitation Center

Organization Type

nonprofit

Chain Affiliation

Chain Name

Mission Health Services

Chain Size

7 facilities nationwide

Chain avg rating: 3.3/5 · Rank 4 of 4 (Worst)

Ownership & Management

Key personnel

Bartholomew, BrendaOfficer / DirectorMurray, BrianOfficer / DirectorMission Health ServicesManagerEllis, AshleyManagerKeele, EddieManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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