Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
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 Welbrook Yuma Opco Llc during CMS and state inspections, most recent first.
A resident with chronic kidney disease and a catheter experienced episodes of red and dark red urine, along with burning and back pain, over at least two days. The resident reported that a PT noticed the urine color change and that an RN had previously flushed the catheter when the urine was red, after which it cleared, but these observations and interventions were not documented. On a later day, a CNA and an LPN initially reported not noticing abnormal urine, and only after the CNA reported dark red urine did the LPN assess the resident and confirm hematuria and symptoms. Despite staff acknowledging that such changes should be documented per facility policy, there were no progress notes reflecting the hematuria or related catheter changes in the clinical record.
A resident with hypertension and heart failure had physician orders for Amlodipine 5 mg and Lisinopril 5 mg to be held if SBP was below 120 or if HR was below 55 for Amlodipine. On one occasion, both medications were administered when the resident’s SBP was 114/64, below the ordered hold parameter, and there was no documentation explaining why they were given outside these parameters. In subsequent interviews, an RN, an LPN, and the DON all confirmed that the medications were administered contrary to the physician’s orders and not in accordance with the facility’s medication administration policy requiring verification of vital signs when necessary.
A resident with intact cognition and multiple medical conditions, including a fracture and Type 2 DM, was verbally abused by a family member during an unsupervised visit. Staff and a CNA reported hearing a brief but loud verbal argument about bills, and facility documentation later confirmed that the visitor was verbally aggressive and abusive. The DON and ED substantiated the verbal abuse allegation. Although facility policies required protection of residents during abuse investigations and trauma-informed assessment of interpersonal violence history, the resident was nonetheless subjected to verbal abuse by a visitor, resulting in a cited deficiency for failure to protect the resident from abuse.
A resident admitted with multiple medical conditions, including malignant neoplasm of the prostate, substance abuse, long-term anticoagulant use, and acute cystitis, did not have a comprehensive admission MDS completed within the required 14-day timeframe. The ARD was set and the MDS showed intact cognition, but the RN Assessment Coordinator signed completion several days past the regulatory deadline. The MDS Coordinator reported relying on a manual tracking system due to electronic system issues, managing a high volume of assessments without dedicated MDS support, and experiencing delays from interdisciplinary documentation and resident hospitalizations. The DON indicated that MDS oversight is handled corporately and acknowledged that staffing limitations and absences contribute to assessment backlogs.
A resident was admitted with a bruise and reported concerns about a neighbor, leading to an allegation of physical abuse. Although the facility notified internal leadership and later reported the incident to APS and the Ombudsman, there was no evidence that law enforcement was notified as required by policy. Staff interviews revealed uncertainty about whether police had been contacted, and the care plan was not updated promptly to address the risk. The facility did not follow its own procedures for immediate reporting of suspected abuse.
A resident experienced verbal abuse from a family member during a visit, which was witnessed by an occupational therapist. Despite the resident's fear and a history of similar incidents, the facility's investigation did not substantiate the abuse claim, and no specific interventions were implemented to prevent future occurrences. The facility's policy requires staff training to identify and report abuse, but the response to this incident was inadequate in ensuring the resident's safety.
A resident with a knee replacement developed a severe pressure ulcer due to inadequate assessment and communication by the facility's staff. Initially misidentified as a blister, the condition worsened, requiring surgical intervention. The facility failed to follow its policies on pressure ulcer prevention and communication, leading to the resident's readmission to the hospital for treatment.
Failure to Assess and Document Hematuria and Catheter Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate treatment and care in response to a resident’s change in urine color. Resident #35, admitted with acute systolic congestive heart failure, myoneural disorder, and stage 1–4 chronic kidney disease, had a care plan addressing renal insufficiency and monitoring for complications. The resident was cognitively intact with a BIMS score of 14. On one observed date, the resident’s catheter contained red-tinged urine, and the resident reported that the urine had turned red earlier that morning and that only the Physical Therapist had noticed and said he would notify the nurse. On a subsequent observation, the catheter again contained red-tinged urine. The resident reported that the day prior, an RN flushed the catheter and the urine remained clear for the rest of that day, but that the urine had again become dark red that morning and had not been addressed by staff except for the Physical Therapist who again observed the dark red urine. The resident also reported burning with urination and back pain. There was no documentation in the clinical record that the RN had observed hematuria or flushed the catheter, and no documentation by any staff noting red-tinged urine. A CNA stated she did not observe red-colored urine when emptying the catheter bag that morning, and an LPN stated she did not notice a change in urine color when she saw the resident earlier in the day. After being informed by the CNA that the urine was dark red, the LPN assessed the resident, observed dark red urine, and the resident confirmed it had been that way since the morning and that she was experiencing irritation and burning. The LPN also acknowledged having heard from the night shift nurse about hematuria, but there were no corresponding progress notes. Staff interviews, including with another LPN and the DON, confirmed that such changes should be documented in progress notes and that there was no documentation of hematuria in the resident’s record, despite a facility policy requiring nurses to record information related to changes in a resident’s condition or status.
Antihypertensive Medications Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure that antihypertensive medications were administered within the physician’s ordered parameters for one resident. The resident was admitted with hypertensive heart and chronic kidney disease with heart failure and had an MDS indicating intact cognition, with active diagnoses of hypertension and heart failure. Physician orders starting April 2, 2026, directed that Amlodipine Besylate 5 mg be given once daily for hypertension, to be held if systolic blood pressure (SBP) was less than 120 or heart rate less than 55, and that Lisinopril 5 mg be given once daily for hypertension, to be held if SBP was less than 120. Review of the April 2026 MAR showed that on April 9, 2026, both Amlodipine 5 mg and Lisinopril 5 mg were administered when the resident’s SBP was 114/64, which was below the ordered hold parameter. There was no documentation in the clinical record explaining why these medications were administered outside the ordered parameters. In interviews, the RN and LPN involved acknowledged that both medications were given when they should have been held due to the resident’s SBP of 114/64 and confirmed that this did not follow the physician’s orders. The DON also confirmed that the medications were administered out of parameters and that staff did not follow the physician’s orders. The facility’s “Administering Medications” policy dated April 2019 states that medications are to be administered safely, timely, and as prescribed, with verification of vital signs when necessary, which was not followed in this instance.
Failure to Protect Resident From Verbal Abuse by Family Visitor
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from abuse by not preventing or adequately safeguarding against verbal abuse from a family member during a visit. The resident was admitted with diagnoses including a right fibula fracture, Type 2 DM, opioid dependence, mood disturbance, anxiety, and a need for assistance with personal care, and had an admission MDS BIMS score of 13, indicating intact cognition, with no behavioral symptoms toward others noted. On the evening of January 22, 2026, staff became aware of loud yelling in the hallway that was traced to the resident’s room, where the resident and his son were engaged in a verbal argument about bills. A CNA reported hearing raised voices but no profanity, and the incident reportedly lasted less than five minutes. The resident later stated that the son became verbally abusive during the visit. The facility’s own documentation, including an incident note and a Facility Reported Incident submitted on January 27, 2026, confirmed that the son was verbally aggressive and verbally abusive toward the resident. The DON and ED both stated that the facility substantiated the allegation of verbal abuse between the visitor and the resident. Facility policies in place at the time, including “Protection of Resident’s During abuse Investigations,” directed staff not to allow unsupervised visits with a resident if the alleged perpetrator is a family member or visitor, and the “Trauma Informed Care” policy required identification of history of trauma or interpersonal violence as part of the comprehensive assessment when possible. Despite these policies, the resident experienced verbal abuse from his son during an unsupervised visit, leading to the cited deficiency for failure to protect the resident from abuse.
Late Completion of Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive Minimum Data Set (MDS) assessment within the required 14-day timeframe after admission for Resident #3. The resident was admitted with needs for assistance with personal care, malignant neoplasm of the prostate, uncomplicated substance abuse, long-term use of anticoagulants, and acute cystitis without hematuria. The admission MDS had an Assessment Reference Date (ARD) of January 6, 2026, and showed a BIMS score of 15, indicating intact cognition. However, the RN Assessment Coordinator’s signature verifying completion was dated January 28, 2026, which was six days past the latest allowable completion date of January 22, 2026, based on the established ARD. Review of the resident’s chart confirmed that the MDS was not completed within the required 14-day timeframe. During interviews, the MDS Coordinator stated she is responsible for tracking ARDs, completion dates, and submission dates for all required MDS assessments and that accurate and timely completion is essential for correct Medicare billing and identifying resident needs through Care Area Assessments. She reported relying primarily on a manual pencil-and-paper tracking system because the electronic record system does not consistently reflect accurate completion dates, and noted that she completes approximately 60 MDS assessments per week without a dedicated MDS assistant, with current support hours focused on care plan documentation rather than direct MDS completion. She also described system and staffing limitations, lack of coverage during her absences, delays in receiving required documentation from multiple departments, and challenges related to the resident’s multiple hospitalizations, which complicated interviews and determination of changes. The DON stated that MDS completion is monitored by a corporate MDS nurse rather than directly by her, and that staffing limitations and absences can affect workflow and contribute to backlog. Facility policy requires that the MDS be completed within 14 days after admission and within 14 days after a significant change or annually, which was not met for Resident #3.
Failure to Timely Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to develop and/or implement policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of physical abuse involving a resident. Upon admission, the resident presented with a bruise and reported anxiety related to a neighbor who consumed alcohol. Documentation indicated that the resident attributed the bruise to this neighbor and expressed concerns about safety. Staff interviews and clinical notes confirmed that the allegation of abuse was reported internally, and the executive director was notified. However, there was no evidence that law enforcement was notified of the allegation, as required by facility policy, despite the policy mandating immediate reporting to law enforcement and other authorities. The investigation revealed that the facility reported the allegation to Adult Protective Services (APS) and the Ombudsman several days after the initial report, and the Department of Health Services (DHS) was notified via an online portal. However, review of facility documentation and the DHS complaint portal showed no evidence that the incident was reported to DHS on the date of the alleged incident. Staff interviews indicated confusion and uncertainty regarding whether law enforcement had been contacted, with some staff believing it had been done and others unable to confirm. The executive director ultimately decided not to contact law enforcement, reasoning that the incident occurred outside the facility and emergency services had already been involved. Throughout the period when the allegation was considered valid, the facility operated under the assumption that abuse had occurred, yet failed to follow its own policy requiring immediate notification of law enforcement. The care plan for the resident was not updated to reflect the risk or interventions related to the abuse allegation until several days after admission. The facility's policies clearly required immediate reporting to law enforcement and other authorities, but these procedures were not followed in this case, resulting in a deficiency related to the timely and appropriate reporting of suspected abuse.
Failure to Protect Resident from Verbal Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a visitor, specifically a family member. The incident occurred when the family member entered the resident's room and engaged in a verbally aggressive manner during a conversation about the resident's mobility. The resident expressed fear and discomfort, indicating a history of similar behavior from the family member, which had previously made the resident cry. Despite the resident's intact cognition, as indicated by a BIMS score of 15, the facility did not implement specific interventions to prevent future occurrences of verbal abuse. The incident was reported by an occupational therapist who witnessed the event and followed the mandated reporting process. The therapist attempted to de-escalate the situation by removing the resident from the room and later reported the resident's fear of the family member. The director of nursing and the executive director were informed of the incident, but the investigation concluded without substantiating the abuse claim, as the resident later downplayed the incident, possibly due to fear of retaliation or dependency on the family member for care. The facility's policy on abuse prevention requires staff training to identify and report abuse, but the investigation did not result in any specific measures to ensure the resident's safety during future visits from the family member. The lack of a clear plan to address the potential for further verbal abuse highlights a deficiency in the facility's response to the incident, as no additional interventions were documented to protect the resident from similar situations in the future.
Failure to Prevent and Properly Address Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident was free from preventable pressure-related injuries, leading to a significant deficiency. The resident, who was admitted with conditions including osteoarthritis and a left knee replacement, was at risk of altered skin integrity due to decreased mobility. Despite having a care plan in place to prevent new skin integrity issues, the resident developed a pressure sore that was initially misidentified as a blister by the nursing staff. The misidentification and inadequate assessment of the wound contributed to the worsening of the condition. The resident's condition was not accurately communicated to the healthcare provider, resulting in a delay in appropriate treatment. The nursing staff reported the injury as a blister, but upon further examination by a Nurse Practitioner, it was found to be a severe pressure injury requiring surgical intervention. The facility's failure to properly evaluate the resident's clinical condition and risk factors, implement appropriate interventions, and monitor the impact of these interventions led to the development of a stage 3 pressure ulcer. Interviews with staff revealed a lack of wound care certification and inadequate communication with the resident's surgeon. The facility's policies on pressure ulcer prevention and abuse and neglect were not effectively followed, as evidenced by the failure to report accurate findings to the physician and the lack of timely intervention. This negligence resulted in the resident being readmitted to the hospital for surgical debridement and further treatment, highlighting a significant lapse in care and communication within the facility.
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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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Nursing homes near Yuma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Yuma | 0.3 mi | — | 6 | 0 |
| Yuma Nursing Center | 0.4 mi | — | 0 | 0 |
| Haven Of Sandpointe, Llc | 0.6 mi | — | 1 | 0 |
| Haven Of Yuma | 1.2 mi | — | 0 | 0 |
| Arizona State Veteran Home - Yuma | 7.1 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.