Cycle 1
Health 2025-01-08 · Fire 2025-01-08
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Yuma, AZ
Welbrook Yuma Opco LLC
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2271 South Ridgeview Drive, Yuma, AZ
(928) 256-4066
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
41
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2020-11-11
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.50
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.86
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.30
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
4.17
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.97
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.46
CMS adjusted RN staffing hours
Adjusted total hours
4.72
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,651
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.55
Baseline 20.79% · Performance 18.86% · Measure score 5.55 · Achievement 5.55 · Improvement 4.64
Healthcare-associated infections
0.83
Baseline 6.99% · Performance 7.58% · Measure score 0.83 · Achievement 0.83 · Improvement 0
Total nurse turnover
2.89
Performance 51.85% · Measure score 2.89 · Achievement 2.89 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.89
Baseline 5.26 hours · Performance 4.47 hours · Measure score 4.89 · Achievement 4.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 478 · Observed rate 9% · Lower 95% interval 7.7% |
| Discharge to community | 69.34% |
50.57%
18.8 pts better
|
Better than the National Rate · Eligible stays 447 · Observed rate 67.34% · Lower 95% interval 63.52% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.28% |
95.27%
4 pts better
|
Numerator 274 · Denominator 276 |
| Falls with major injury | 0.36% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 276 |
| Discharge self-care score | 69.23% |
53.69%
15.5 pts better
|
Numerator 135 · Denominator 195 |
| Discharge mobility score | 57.95% |
50.94%
7 pts better
|
Numerator 113 · Denominator 195 |
| Pressure ulcers or injuries, new or worsened | 2.54% |
2.29%
0.2 pts worse
|
Numerator 7 · Denominator 276 · Adjusted rate 2.78% |
| Healthcare-associated infections requiring hospitalization | 7.58% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 264 · Observed rate 7.2% · Lower 95% interval 4.8% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 119 |
| Staff flu vaccination coverage | 30.17% |
42%
11.8 pts worse
|
Numerator 35 · Denominator 116 |
| Discharge function score | 62.05% |
56.45%
5.6 pts better
|
Numerator 121 · Denominator 195 |
| Transfer of health information to provider | 99.55% |
95.95%
3.6 pts better
|
Numerator 220 · Denominator 221 |
| Transfer of health information to patient | 69.23% |
96.28%
27 pts worse
|
Numerator 36 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 6.02% |
25.2%
19.2 pts worse
|
Numerator 10 · Denominator 166 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.1%
8.7 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
10.7%
1.2 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 12.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.1%
0.4 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.3% · Q3 1.6% · Q4 2.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
87.3%
7.5 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.6% |
24.6%
7 pts worse
|
23.9%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.6% · Observed 33.8% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-22 · Fire 2023-06-22
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-07-21 · Fire 2022-07-21
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-08
D · Potential for more than minimal harm
2025-01-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-08
D · Potential for more than minimal harm
2025-01-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-08
D · Potential for more than minimal harm
2025-01-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-08
D · Potential for more than minimal harm
2025-01-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-08
D · Potential for more than minimal harm
2025-01-08
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-03-08
D · Potential for more than minimal harm
2025-01-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-08
F · Potential for more than minimal harm
2023-06-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-06-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-06-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-07
C · Minimal harm
2023-06-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-07
E · Potential for more than minimal harm
2022-07-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-07-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-07-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-22
E · Potential for more than minimal harm
2022-07-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-07-21
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-07-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-07-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-07-21
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-08-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Not marked corrected
D · Potential for more than minimal harm
2025-12-29
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 2026-02-02
D · Potential for more than minimal harm
2024-08-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-03
D · Potential for more than minimal harm
2023-06-22
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-06-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-31
E · Potential for more than minimal harm
2022-07-21
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 2022-08-28
D · Potential for more than minimal harm
2022-07-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-21
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-21
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 2022-08-28
Penalties and ownership
What sits behind the stars
Ownership
Welbrook Yuma Propco LLC
5% Or Greater Direct Ownership Interest · Organization
Rasband, Matthew
Corporate Officer · Individual
Rasband, Matthew
W-2 Managing Employee · Individual
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