Cycle 1
Health 2025-08-20 · Fire 2025-08-20
30 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Pleasant Grove, UT
Mission at Alpine Rehabilitation Center
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $125,737 in total fines with 30 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
25 East Alpine Drive, Pleasant Grove, UT
(801) 785-3568
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Mission Health Services
Operator or chain grouping
Approved since
1981-12-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
1.52
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
2.92
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.25
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
3.42
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,423
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9874
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.58
Baseline 71.43% · Performance 38.46% · Measure score 6.58 · Achievement 6.17 · Improvement 6.58
Adjusted total nurse staffing
0
Baseline 3.97 hours · Performance 2.75 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.7% |
8.2%
5.5 pts worse
|
Numerator 2 · Denominator 74 |
| Staff flu vaccination coverage | 10.91% |
42%
31.1 pts worse
|
Numerator 12 · Denominator 110 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.2
0.7 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
96.8%
3.8 pts worse
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 93.8% · Q3 91.7% · Q4 91.9% · 4Q avg 93.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
98.0%
2.7 pts worse
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 12.6% |
2.6%
10 pts worse
|
3.3%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 18.8% · Q3 11.1% · Q4 8.1% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
16.1%
14.5 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
3.8%
2.1 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 45.3% |
24.1%
21.2 pts worse
|
19.6%
25.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 40.7% · Q3 50.0% · Q4 53.3% · 4Q avg 45.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 61.1% |
15.4%
45.7 pts worse
|
16.7%
44.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.2% · Q2 66.7% · Q3 50.0% · Q4 64.0% · 4Q avg 61.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.9% |
18.3%
10.4 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q3 3.9% · Q4 3.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.5% |
13.6%
7.1 pts better
|
14.9%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.8%
1.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.9% |
22.4%
6.5 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 28.2% · Q3 25.0% · Q4 31.9% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.1%
2.4 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 1.9% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.9% |
93.3%
11.4 pts worse
|
81.7%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 81.2% · Q3 72.0% · 4Q avg 81.9% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.7% |
91.0%
25.3 pts worse
|
79.7%
14 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-02-16 · Fire 2022-02-16
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-08-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-10-01
D · Potential for more than minimal harm
2023-11-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-31
Inspection history
Recent health citations
K · Immediate jeopardy
2025-08-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-20
K · Immediate jeopardy
2025-08-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-20
K · Immediate jeopardy
2025-08-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-20
K · Immediate jeopardy
2025-08-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-20
K · Immediate jeopardy
2025-08-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-20
H · Actual harm
2025-08-20
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-20
H · Actual harm
2025-08-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-10-20
F · Potential for more than minimal harm
2025-08-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-20
F · Potential for more than minimal harm
2025-08-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-20
F · Potential for more than minimal harm
2025-08-20
F843 · Administration Deficiencies
Health
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.
Corrected 2025-10-20
F · Potential for more than minimal harm
2025-08-20
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-08-20
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-08-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-08-20
F728 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-08-20
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-08-20
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-08-20
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-10-20
E · Potential for more than minimal harm
2025-08-20
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-08-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-20
G · Actual harm
2023-11-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-15
F · Potential for more than minimal harm
2023-11-30
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-11-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-11-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-11-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-30
F887 · Infection Control Deficiencies
Health
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.
Corrected 2024-01-15
E · Potential for more than minimal harm
2022-02-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-10
D · Potential for more than minimal harm
2022-02-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-10
D · Potential for more than minimal harm
2022-02-16
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-04-10
D · Potential for more than minimal harm
2022-02-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-04-10
D · Potential for more than minimal harm
2022-02-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-04-10
D · Potential for more than minimal harm
2022-02-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-04-10
D · Potential for more than minimal harm
2022-02-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-10
Penalties and ownership
What sits behind the stars
$118,294
2025-08-20
Fine
Fine · fine $118,294
Fine
$7,443
2023-11-30
Fine
Fine · fine $7,443
Fine
Ownership
Gunnison Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Bartholomew, Brenda
Corporate Officer · Individual
Ellis, Ashley
Operational/Managerial Control · Individual
Keele, Eddie
Operational/Managerial Control · Individual
Mission Health Services
Operational/Managerial Control · Organization
Murray, Brian
Corporate Officer · Individual
Taylor, Jacob
Operational/Managerial Control · Individual
Wootton, Zachary
Operational/Managerial Control · Individual
Workman, David
Operational/Managerial Control · Individual
Zimbelman, Michelle
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Stonehenge of American Fork
American Fork, UT
4-star overall rating with 4-star inspections with $21,590 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Monument Healthcare American Fork
American Fork, UT
3-star overall rating with 2-star inspections with $35,437 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Cascades at Orchard Park
Orem, UT
4-star overall rating with 3-star inspections with $11,992 in total fines with 4 recent health deficiencies
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