Mission at Alpine Rehabilitation Center
CCN: 465088 · Pleasant Grove, UT 84062 · Utah County
Overview
- Address
- 25 East Alpine Drive, Pleasant Grove, UT 84062
- Phone
- 8017853568
- Certified beds
- 52
- Avg daily residents
- 37 (72% of beds filled)
- Ownership
- Non-profit (other)
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1981-12-15
- Setting
- Urban
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 2.92 | 3.30 | 3.42 | ≥ 3.48 | Below floor |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.71 | 0.58 | 0.83 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.69 | 0.73 | 0.80 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 1.52 | 1.99 | 1.79 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.39 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.01 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Resident acuity
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-08-20 | 30 | 30 | 10 | 867 | 1 | 867 |
| Cycle 2/3 (prior) | 2023-11-30 | 7 | 7 | 2 | 68 | 1 | 68 |
Deficiencies (44)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | F | 2025-08-20 | 2025-10-20 |
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2025-08-20 | 2025-10-20 |
| 0605 | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | E | 2025-08-20 | 2025-10-20 |
| 0641 | Ensure each resident receives an accurate assessment. | D | 2025-08-20 | 2025-10-20 |
| 0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | 2025-08-20 | 2025-10-20 |
| 0728 | 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. | E | 2025-08-20 | 2025-10-20 |
| 0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | 2025-08-20 | 2025-10-20 |
| 0800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | D | 2025-08-20 | 2025-10-20 |
| 0803 | 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. | E | 2025-08-20 | 2025-10-20 |
| 0809 | 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. | E | 2025-08-20 | 2025-10-20 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | 2025-08-20 | 2025-10-20 |
| 0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | H | 2025-08-20 | 2025-10-20 |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | 2025-08-20 | 2025-10-20 |
| 0843 | 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. | F | 2025-08-20 | 2025-10-20 |
| 0865 | Have a plan that describes the process for conducting QAPI and QAA activities. | F | 2025-08-20 | 2025-10-20 |
| 0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | H | 2025-08-20 | 2025-10-20 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2025-08-20 | 2025-10-20 |
| 0881 | Implement a program that monitors antibiotic use. | D | 2025-08-20 | 2025-10-20 |
| 0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | 2025-08-20 | 2025-10-20 |
| 0944 | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | E | 2025-08-20 | 2025-10-20 |
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | K | 2025-08-20 | 2025-10-20 |
| 0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | K | 2025-08-20 | 2025-10-20 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | K | 2025-08-20 | 2025-10-20 |
| 0610 | Respond appropriately to all alleged violations. | K | 2025-08-20 | 2025-10-20 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | 2025-08-20 | 2025-10-20 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | 2025-08-20 | 2025-10-20 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K | 2025-08-20 | 2025-10-20 |
| 0692 | Provide enough food/fluids to maintain a resident's health. | D | 2025-08-20 | 2025-10-20 |
| 0740 | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D | 2025-08-20 | 2025-10-20 |
| 0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | E | 2025-08-20 | 2025-10-20 |
| 0727 | 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. | F | 2023-11-30 | 2024-01-15 |
| 0760 | Ensure that residents are free from significant medication errors. | D | 2023-11-30 | 2024-01-15 |
| 0761 | 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. | E | 2023-11-30 | 2024-01-15 |
| 0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E | 2023-11-30 | 2024-01-15 |
| 0887 | 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. | D | 2023-11-30 | 2024-01-15 |
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | E | 2023-11-30 | 2024-01-15 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | 2023-11-30 | 2024-01-15 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2022-02-16 | 2022-04-10 |
| 0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | 2022-02-16 | 2022-04-10 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | 2022-02-16 | 2022-04-10 |
| 0679 | Provide activities to meet all resident's needs. | D | 2022-02-16 | 2022-04-10 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2022-02-16 | 2022-04-10 |
| 0692 | Provide enough food/fluids to maintain a resident's health. | D | 2022-02-16 | 2022-04-10 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2022-02-16 | 2022-04-10 |
Penalties (2)
| Date | Type | Fine amount |
|---|---|---|
| 2023-11-30 | Fine | $7,443 |
| 2025-08-20 | Fine | $118,294 |
Source: CMS Nursing Home Penalties.
Financial Health (FY 2024)
Payer mix (share of resident days)
Operating performance
Revenue & costs
Balance sheet
Source: CMS SNF Cost Report (FY 2024). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: MISSION HEALTH SERVICES
- Chain ID
355- Facilities in chain
- 4
- Legal business name
- GUNNISON VALLEY HOSPITAL
Owner / manager organizations (2)
| Organization | Role | Association |
|---|---|---|
| GUNNISON VALLEY HOSPITAL | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 04/01/2017 |
| MISSION HEALTH SERVICES | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2017 |
Owner / manager individuals (8)
| Name | Role | Association |
|---|---|---|
| ELLIS, ASHLEY | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2021 |
| KEELE, EDDIE | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2023 |
| TAYLOR, JACOB | OPERATIONAL/MANAGERIAL CONTROL | since 07/16/2024 |
| WOOTTON, ZACHARY | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2024 |
| WORKMAN, DAVID | OPERATIONAL/MANAGERIAL CONTROL | since 06/01/2023 |
| ZIMBELMAN, MICHELLE | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2017 |
| BARTHOLOMEW, BRENDA | CORPORATE OFFICER | since 10/01/2021 |
| MURRAY, BRIAN | CORPORATE OFFICER | since 04/01/2017 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Special focus status
- SFF Candidate
- Abuse citation flag
- Yes — last 2 cycles
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Penalties (
nh-penalties), vintage 2026, downloaded 2026-04-14 , 16,915 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2024, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 112 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Current Ratio | 14.73 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,024 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 73.5% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 3.2% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $343,135 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $4,385,864 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 79.7% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | 5.0% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $3,588,178 | metrics.total_assets |
| Cost Report | Total Costs ($) | $227,900 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $399,874 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $3,188,304 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | 7.6% | metrics.total_margin |
| Provider Information | Abuse Icon | Y | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.80376 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 1.78569 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.82922 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.41867 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 2.63812 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 37.2 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.73167 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 1.98853 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.57672 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.29692 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 2.90588 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 2.8 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 3.3 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 4.3 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 3.3 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 355 | Chain ID |
| Provider Information | Chain Name | MISSION HEALTH SERVICES | Chain Name |
| Provider Information | City/Town | Pleasant Grove | City/Town |
| Provider Information | CMS Certification Number (CCN) | 465088 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Utah | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1981-12-15 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 1 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 40.3569 | Latitude |
| Provider Information | Legal Business Name | GUNNISON VALLEY HOSPITAL | Legal Business Name |
| Provider Information | Location | 25 East Alpine Drive,Pleasant Grove,UT,84062 | Location |
| Provider Information | Long-Stay QM Rating | 5 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -111.74 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 1 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 52 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 4 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 2 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.16795 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.84779 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 2 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Non profit - Other | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 25 East Alpine Drive | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | Mission at Alpine Rehabilitation Center | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 240 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 867 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 10 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 30 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-08-20 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 867 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 30 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 7 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2023-11-30 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 68 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 2 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 68 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 7 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.47818 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 57.1 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.39443 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.68635 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 1.52483 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.00783 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.70809 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 2.91927 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | — | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | 2 | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | SFF Candidate | Special Focus Status |
| Provider Information | Staffing Rating | 2 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | UT | State |
| Provider Information | Telephone Number | 8017853568 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 125737.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 2.25274 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 2 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 66.7 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 667.250 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 84062 | ZIP Code |