Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission At Alpine Rehabilitation Center during CMS and state inspections, most recent first.
Multiple residents with severe cognitive impairment were involved in repeated incidents of sexual contact and elopement without proper assessment of their capacity to consent or adequate supervision. Staff and administration failed to document capacity evaluations, relied on superficial signs of consent, and did not conduct thorough abuse investigations, resulting in unaddressed abuse and neglect.
Surveyors found that the facility did not have or implement adequate policies and procedures to prevent abuse, neglect, or theft, particularly regarding sexual abuse and elopement. Multiple residents with severe cognitive impairment were involved in incidents of sexual contact or attempted sexual contact without documented assessments of their capacity to consent or proper investigations. The facility failed to report or thoroughly investigate these incidents, and did not have written protocols defining sexual abuse or procedures for evaluating consent.
Surveyors found that the facility did not promptly report or investigate multiple incidents of alleged abuse, neglect, elopement, and injuries of unknown origin involving residents with severe cognitive impairment. These included unreported sexual contact between cognitively impaired residents, several resident elopements—some resulting in injury, and a resident injury during transport. Staff and administration often failed to recognize or act on the need for immediate reporting to the State Survey Agency, as required by regulations.
Surveyors found that the facility did not thoroughly investigate or report multiple incidents involving abuse, neglect, elopement, and injuries of unknown origin. Several residents with severe cognitive impairment were involved in incidents of sexual contact, elopement, and unexplained injuries, but the facility failed to conduct formal investigations or notify the State Survey Agency as required. Staff and administration acknowledged that these events were not properly handled or documented.
Multiple residents with cognitive impairment eloped from the facility, with some incidents requiring staff to intervene to prevent harm. Two residents experienced falls without subsequent updates to their care plans, and one resident was injured during transport due to improper wheelchair securement. Staff responses and documentation were inconsistent, and not all incidents were reported or investigated as required.
Three residents with complex medical and behavioral needs experienced multiple incidents, including falls, choking, and elopement, without timely updates to their care plans. Despite documentation of these events and staff discussions, care plans were not revised to include new interventions or reflect current needs, and some interventions remained outdated or inappropriate for the residents' conditions.
The facility did not provide staff with required training on abuse, neglect, exploitation, or misappropriation of resident property, nor on proper reporting procedures. Staff interviews and review of in-service records showed that education was inconsistent and did not cover key topics such as definitions of abuse, reporting protocols, or consent. The administrator confirmed that current training did not ensure staff understanding or compliance.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Two residents with cognitive impairment and complex medical histories experienced significant weight loss due to the facility's failure to provide necessary mealtime cueing, adaptive equipment, and consistent monitoring. Staff did not always follow care plan interventions, and there were gaps in documentation and understanding of snack and supplement intake, resulting in inadequate support for maintaining nutritional status.
The facility did not provide necessary behavioral health care and services to a resident, resulting in unmet behavioral health needs.
Failure to Protect Cognitively Impaired Residents from Abuse, Neglect, and Unassessed Sexual Contact
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, specifically failing to ensure that residents with severe cognitive impairment were free from sexual abuse and neglect. Several residents with diagnoses such as dementia, Alzheimer's disease, traumatic brain injury, and other cognitive disorders were involved in repeated incidents of sexual contact without documented assessments of their capacity to consent. In multiple cases, residents with severe cognitive impairment were found engaging in sexual acts or intimate behaviors with other residents, and staff determined these interactions to be consensual based on superficial observations, such as the absence of resistance or distress, rather than formal capacity assessments. There was no evidence in the medical records that any of the involved residents had been evaluated for their ability to consent to sexual activity, despite clear documentation of severe cognitive deficits and fluctuating mental status. The report details several specific incidents, including residents being found undressed together, engaging in sexual acts, or being discovered in each other's rooms. In one case, a resident with a BIMS score of 3 and a MOCA score of 7, both indicating severe cognitive impairment, was repeatedly found in intimate situations with other residents, some of whom also had severe cognitive impairment. Staff and administration often relied on the residents' apparent comfort or lack of protest to determine consent, even when family members and staff acknowledged the residents' confusion and inability to understand their circumstances. In another case, a resident with a traumatic brain injury and aphasia was found in a sexual situation with another cognitively impaired resident, and the facility failed to conduct or document an abuse investigation or implement effective safety measures to prevent recurrence. Additionally, the facility failed to prevent neglect in the form of elopement, as two residents were able to leave the facility and return without staff knowledge. The lack of supervision and failure to update or implement appropriate care plan interventions for residents at risk of elopement further contributed to the finding of neglect. The surveyors identified these failures as Immediate Jeopardy, citing the facility's lack of adherence to Centers for Medicare and Medicaid Services recommended practices to prevent abuse and neglect, and the absence of thorough investigations and documentation regarding incidents of sexual contact and elopement among cognitively impaired residents.
Failure to Implement Abuse Prevention and Consent Assessment Policies
Penalty
Summary
Surveyors identified that the facility failed to implement and follow written policies and procedures to prevent abuse, neglect, and theft, specifically regarding sexual abuse, capacity to consent to sexual activity, and elopement. The facility did not have written definitions or protocols for evaluating a resident's capacity to consent to sexual relationships, nor did it have adequate procedures for investigating and reporting allegations of abuse. Multiple incidents involving residents with severe cognitive impairment engaging in sexual contact or being found in compromising situations were documented without evidence of proper assessment of their ability to consent or thorough investigation of the events. Several residents with diagnoses such as dementia, traumatic brain injury, and other cognitive disorders were involved in incidents of sexual contact or attempted sexual contact. For example, one resident with a BIMS score indicating severe cognitive impairment was found in multiple situations involving physical intimacy with other residents, none of whom had documented assessments of their capacity to consent. Another resident with a history of neurocognitive disorder and severe cognitive impairment was found in other residents' rooms and beds, sometimes with residents who were partially undressed or engaged in physical contact. In one case, a resident was found with her underwear down and another resident attempting to initiate sexual contact, but there was no documentation of an abuse investigation or capacity assessment. The facility's records showed repeated failures to document or conduct assessments for capacity to consent to sexual activity, despite clear evidence of cognitive impairment and repeated incidents. Incident reports and progress notes often described the events as consensual or inconclusive without supporting documentation or proper evaluation. In some cases, incidents were not reported to the State Survey Agency or law enforcement as required, and there was no evidence of timely or thorough investigation into allegations of abuse or neglect. These failures were cited at the Immediate Jeopardy level due to the facility's lack of effective policies and procedures to prevent and address abuse, neglect, and elopement.
Failure to Timely Report Abuse, Neglect, Elopement, and Injuries
Penalty
Summary
Surveyors identified that the facility failed to immediately report, within the required two-hour timeframe, multiple alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and elopement to the State Survey Agency. In several cases, incidents involving sexual contact between cognitively impaired residents were not reported or investigated, despite both residents having severe cognitive impairment as indicated by low BIMS and SLUMS scores. Staff and administration assumed the interactions were consensual, even though the residents' cognitive status called their ability to consent into question. Additionally, an incident involving a resident being found undressed with another resident, and another case where a resident was found in another's bed, were not reported or investigated as potential abuse or sexual assault. The facility also failed to report multiple incidents of resident elopement. Several residents with severe cognitive impairment and a history of wandering or elopement were able to leave the facility grounds unsupervised, sometimes by climbing or breaking through fences. In some cases, residents were found by staff or police outside the facility, and in one instance, a resident sustained a skin tear during an elopement. These incidents were not reported to the State Survey Agency as required, and in some cases, the administration was unaware of the reporting requirements for elopement events. Additional deficiencies included failure to report injuries of unknown origin and incidents during transportation. One resident with severe cognitive impairment was observed with a large bruise to the eye, and the cause could not be determined, but the incident was not reported for investigation. Another resident fell out of a wheelchair during transport due to improper securing, resulting in a head abrasion, and this incident was reported late. In all these cases, the facility did not follow required protocols for timely reporting and investigation of potential abuse, neglect, or injury, as confirmed by staff and administrative interviews and record reviews.
Failure to Investigate and Report Abuse, Neglect, Elopement, and Injuries
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate and report multiple allegations of abuse, neglect, and mistreatment involving several residents. Incidents included sexual contact between residents with severe cognitive impairment, elopements, injuries of unknown origin, and fractures. In several cases, residents with diagnoses such as dementia, psychotic disorders, and traumatic brain injuries were involved in situations where their ability to consent was questionable, yet no formal investigations were conducted. For example, one resident with a BIMS score indicating severe cognitive impairment was found in close proximity or engaging in physical contact with other residents on multiple occasions, but the facility did not document any investigation into these incidents. In another case, a resident was found with another resident in a compromising situation, and although staff separated them, no investigation was initiated, and the event was not reported to the State Survey Agency. The facility also failed to investigate and report multiple elopement incidents. Residents with significant cognitive impairment and a documented history of wandering or elopement risk were able to leave the facility premises on several occasions. In some instances, residents were found outside the facility or even on public streets, and staff had to intervene to bring them back. Despite these events, there was no evidence of a formal investigation or reporting to the State Survey Agency. Staff interviews confirmed that these incidents were not investigated or reported as required, and the administrator acknowledged that these events should have been handled differently. Additionally, the facility did not investigate injuries of unknown origin. For example, a resident with severe cognitive impairment was observed with a large bruise to her right eye, and although the incident was noted in the medical record, there was no documentation of an investigation to determine the cause. The DON stated that such injuries should be investigated and reported if the cause is unknown, but no investigation was provided. The administrator also confirmed that investigations were primarily informal and that some incidents were not reported due to a lack of clarity on reporting requirements.
Failure to Prevent Elopement, Falls, and Transport Injuries Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that residents received adequate supervision to prevent accidents, resulting in multiple incidents involving elopement, falls, and injuries. Three residents with cognitive impairment eloped from the facility, with two of these incidents reaching the level of immediate jeopardy. In one case, a resident with severe cognitive impairment and a history of elopement repeatedly escaped the facility by breaking through or climbing over fences, sometimes requiring staff intervention to prevent the resident from entering traffic. Documentation showed that staff were aware of the resident's behaviors, but interventions were limited to verbal redirection and monitoring, and not all incidents were reported or investigated as required. Another resident with vascular dementia and agitation also eloped on multiple occasions by climbing over fences, resulting in a skin tear during one incident. Despite these events, there was no evidence that the resident's elopements were investigated or reported to the state survey agency. Additionally, this resident experienced several falls, including incidents where the resident hit his head or was found on the floor, but the care plan was not updated to reflect new interventions after these falls. Staff interviews confirmed that interventions were not consistently added to the care plan following such incidents. A separate incident involved a resident who was not properly secured in a facility van during transport, resulting in the resident tipping backward in his wheelchair and sustaining a head abrasion. The staff member responsible for transport admitted to not securing the wheelchair correctly and stated that initial training was verbal and lacked demonstration. Documentation of training was incomplete, and the facility could not provide evidence that the staff member had been properly trained prior to the incident. Other residents were also found in unsafe positions, such as lying on the floor or between the bed and wall, without staff present or timely intervention.
Failure to Update and Implement Comprehensive Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulation. For each resident, the care plans did not include measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs as identified in their comprehensive assessments. Specifically, care plans were not updated following significant changes in condition or incidents, resulting in care plans that did not reflect the current needs or required services for the residents. One resident with vascular dementia, agitation, and a history of falls experienced multiple falls over several months. Despite documentation of these incidents in progress notes and incident reports, the resident's care plan was not updated after each fall to reflect new interventions or changes in care. Interviews with staff confirmed that interventions discussed in meetings and huddles were not consistently incorporated into the written care plan in a timely manner. Another resident with severe cognitive impairment, alcohol dependence, and a history of falls and choking incidents had multiple documented falls and a choking event. The care plan included outdated interventions, such as providing a bowl of nuts, which was not appropriate for the resident's current dietary needs. The care plan was not updated with new interventions after each incident, and staff interviews revealed a lack of awareness of the resident's current care needs. A third resident with severe cognitive impairment and exit-seeking behaviors had multiple documented elopements and attempts to leave the facility. Despite these incidents, the care plan was not updated with new approaches after each event, and staff interviews indicated uncertainty about who was responsible for updating care plans.
Failure to Provide Required Staff Training on Abuse, Neglect, and Reporting Procedures
Penalty
Summary
The facility failed to provide staff training that met minimum requirements for educating staff on abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and preventing abuse and neglect. Interviews with staff, including a nursing assistant and a registered nurse, revealed that while some education was provided, it was generally limited to addressing issues that needed correction and did not consistently cover the required topics. Staff were unclear about the content and purpose of Quality Assurance and Performance Improvement (QAPI) meetings, and there was no evidence that education on consent or comprehensive abuse prevention was included in the training. Review of in-service training records from January through July showed that none of the agendas included specific abuse training. While there were trainings on dementia, assault, de-escalation, and communication, these did not define abuse, explain its types, outline reporting procedures, or clarify who could give consent. The administrator acknowledged that the abuse training needed updating and that current education did not ensure staff understanding or practice of the required concepts.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure was observed and documented by surveyors during their review of facility practices.
Failure to Maintain Nutritional Status and Provide Adequate Mealtime Assistance
Penalty
Summary
Two residents experienced significant weight loss due to the facility's failure to maintain acceptable nutritional parameters and provide necessary assistance during meals. One resident, with severe cognitive impairment and multiple comorbidities including Parkinson's disease and dementia, lost 14.4 pounds over six months without new interventions being implemented. Despite care plan interventions such as monitoring for malnutrition and providing adaptive equipment, the resident was not observed using specialized dinnerware and continued to lose weight even while documented as consuming 76-100% of meals on most days. Staff interviews revealed inconsistent understanding of the resident's needs, and the resident was not always cued to eat as required. Another resident, with diagnoses including Alzheimer's disease, diabetes, and recent fractures, also experienced ongoing weight loss. Observations showed the resident frequently left the dining room without eating, required cueing to eat, and sometimes attempted to eat with inappropriate utensils. Although the care plan indicated the need for setup assistance and cueing, staff did not consistently provide this support, and meal intake documentation showed frequent low consumption or refusal of meals. Supplement and snack intake were also low, and there was confusion among staff regarding documentation and provision of snacks. Interviews with dietary and nursing staff highlighted gaps in communication and documentation regarding residents' nutritional intake, especially for snacks and supplemental feedings. The registered dietician acknowledged concerns about weight loss and was unsure where snack intakes were documented. The dietary manager and CNAs were unclear about procedures for residents who missed snacks or required additional assistance, contributing to the facility's failure to ensure adequate food and fluid intake to maintain residents' health.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents did not receive the behavioral health care and services necessary to address their individual needs, as required by regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehenge Of American Fork | 2.7 mi | — | 0 | 0 |
| Monument Healthcare American Fork | 3.2 mi | — | 0 | 0 |
| Cascades At Orchard Park | 4.1 mi | — | 0 | 0 |
| Stonehenge Of Orem | 4.4 mi | — | 1 | 0 |
| Orem Rehabilitation And Nursing Center | 6.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.