Knolls West Post Acute LLC, Victorville, CA: Nursing home

Overall3★★★☆☆

Inspections3★★★☆☆

Staffing4★★★★☆

Quality2★★☆☆☆

Federal finesNoneon record

Inspection citations

18’22

11’24

17’25

5’26

Year

51 shown

Date	Severity	What inspectors found	Visit
Jul 29, 2026	D · potential	Protect each resident from the wrongful use of the resident's belongings or money.	Complaint
Jun 12, 2026	D · potential	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	Complaint
Jun 12, 2026	D · potential	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Complaint
May 7, 2026	D · potential	Let each resident or the resident's legal representative access or purchase copies of all the resident's records.	Complaint
Apr 2, 2026	D · potential	Let each resident or the resident's legal representative access or purchase copies of all the resident's records.	Complaint
May 22, 2025	D · potential	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	Routine
May 22, 2025	D · potential	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	Routine
May 22, 2025	D · potential	Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	Routine
May 22, 2025	D · potential	Ensure each resident receives an accurate assessment.	Routine
May 22, 2025	D · potential	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	Routine
May 22, 2025	D · potential	Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	Routine
May 22, 2025	D · potential	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	Routine
May 22, 2025	E · potential	Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.	Routine
May 22, 2025	D · potential	Ensure that the resident and his/her doctor meet face-to-face at all required visits.	Routine
May 22, 2025	D · potential	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	Routine
May 22, 2025	D · potential	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.	Routine
May 22, 2025	F · potential	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Routine
May 22, 2025	C · minimal	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	Routine
May 22, 2025	D · potential	Provide and implement an infection prevention and control program.	Routine
May 22, 2025	F · potential	Keep all essential equipment working safely.	Routine
Mar 26, 2025	D · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Complaint
Jan 23, 2025	D · potential	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	Complaint
Dec 30, 2024	D · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Complaint
Dec 17, 2024	D · potential	Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	Complaint
Nov 26, 2024	D · potential	Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	Complaint
Oct 3, 2024	D · potential	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Complaint
Sep 12, 2024	D · potential	Not hire anyone with a finding of abuse, neglect, exploitation, or theft.	Complaint
Jun 18, 2024	D · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Complaint
May 23, 2024	D · potential	Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	Routine
May 23, 2024	D · potential	Assure that each resident’s assessment is updated at least once every 3 months.	Routine
May 23, 2024	D · potential	Provide safe and appropriate respiratory care for a resident when needed.	Routine
May 23, 2024	D · potential	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	Routine
May 23, 2024	E · potential	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Routine
Dec 15, 2022	F · potential	Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.	Routine
Dec 15, 2022	D · potential	Assess the resident when there is a significant change in condition	Routine
Dec 15, 2022	D · potential	Ensure each resident receives an accurate assessment.	Routine
Dec 15, 2022	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Routine
Dec 15, 2022	G · harm	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	Routine
Dec 15, 2022	D · potential	Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.	Routine
Dec 15, 2022	D · potential	Provide enough food/fluids to maintain a resident's health.	Routine
Dec 15, 2022	D · potential	Provide safe, appropriate dialysis care/services for a resident who requires such services.	Routine
Dec 15, 2022	D · potential	Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	Routine
Dec 15, 2022	D · potential	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	Routine
Dec 15, 2022	E · potential	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.	Routine
Dec 15, 2022	F · potential	Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.	Routine
Dec 15, 2022	E · potential	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.	Routine
Dec 15, 2022	E · potential	Provide or get specialized rehabilitative services as required for a resident.	Routine
Dec 15, 2022	D · potential	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Routine
Dec 15, 2022	C · minimal	Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.	Routine
Dec 15, 2022	D · potential	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	Routine
Dec 15, 2022	D · potential	Provide and implement an infection prevention and control program.	Routine

Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.

Questions to ask on a visit

Knolls West Post Acute LLC
16890 Green Tree Blvd, Victorville, CA 92395 · (760) 245-5361

Visit date: ____________ Spoke with: ______________________

How many nurses and aides work each shift, including nights and weekends?
How do you handle the most recent citations on your record?
Do you accept Medi-Cal if private funds run out?
Who will be the main contact for the family?
How do you prevent falls, pressure sores and infections?

Record on file

Certification: Medicare and Medi-Cal certified skilled nursing facility
Medicare number (CCN): 555251
Certified beds: 118
Part of: David Johnson

Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.

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