Welbrook Yuma Opco Llc
WELBROOK YUMA OPCO LLC in YUMA, AZ — inspection on December 29, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
investigation was also documented in the five-day investigation report.
The ED stated that contacting law enforcement was dependent on the circumstances of the investigation, explaining that police are typically contacted for internal allegations, while this particular allegation occurred outside of the facility, and was considered an external allegation.
The ED stated that because emergency services transported the resident to the hospital, he determined there was no further need to contact law enforcement at that time.
The ED stated that the facility's investigation ultimately determined the resident's allegation of abuse was unsubstantiated.
The ED stated that he was notified of Resident #95's allegation of abuse on Friday, December 12, 2025, at approximately 5:30 p.m. by RN (Staff #24).
The ED stated that, according to his records, the Department of Health Services was contacted on Friday, December 12, 2025, at approximately 5:21 p.m.
The ED stated that APS and the Ombudsman were contacted on December 16, 2025, at approximately 6:30 p.m., after the investigation was completed.
The ED further clarified that law enforcement was not contacted because the incident occurred outside the facility and emergency services had already been involved on the date of the incident.
The ED declined to provide a response on the role of police in abuse allegations, due to the question being subjective.
The ED stated that he did not see documentation confirming whether the medical director or the resident's provider had been notified and said additional review would be needed to verify this.
The ED explained that APS and the Ombudsman were not contacted until December 16, 2025, because by December 15, 2025, he had concluded the incident was not an abuse situation and intended to report it as such.
The ED verbalized that from December 12 through December 15, 2025, the facility had operated under the assumption that the resident # 95 allegation of abuse was valid, and that the abuse allegation was considered active from December 12 -14, 2025. To ensure the safety for resident #95, the ED revealed a message was sent to all department managers instructing that neighbor #38 was not to have any contact with the resident.
The ED stated that he did not believe the facility policy differentiated between internal and external allegations in order to determine engagement with law enforcement.
The ED revealed receiving and taking part in abuse training as recently as of November and December 2025.
The ED stated that either he or the Director of Staff Development are responsible for conducting the training, and expect for the staff to follow the policy.
The ED stated that it was the facility's expectation that the abuse policy be followed whenever there was an allegation of abuse.The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, directed the facility to investigate and report any allegations within timeframes required by federal requirements.A policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised April 2021, revealed the administrator or the individual making the allegation immediately reports his or her suspicions to the: state licensing/certification agency, the ombudsman, the resident's representative, Adult protective services, law enforcement officials, the resident's attending physician, and the facility medical director. In addition, the policy defined immediately as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. A policy titled, Care Plans, Comprehensive Person-Centered, revised April 2021, revealed areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. A policy titled, Protection of Residents During Abuse Investigations, revised April 2021, informed the staff that if the alleged perpetrator is a resident's family member or visitor, this person (s) is not allowed unsupervised visits with the resident.
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