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Nursing HomeMedicaid

Knolls West Post Acute LLC

Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.

16890 Green Tree Blvd, Victorville, CA 92395118 bedsLicensed & Active
3/5
Medicare
Inspection
Quality
Staffing
Google rating
2.9/5

based on 7 Google reviews

5
4
3
2
1
Knolls West Post Acute LLC Nursing Home in Victorville, CA — Street View
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What this means for your family

This facility presents significant risks regarding medical safety and staff conduct. While some families have seen success with physical therapy, the documented instances of surgical neglect and verbal abuse are critical red flags that require immediate investigation during any facility visit.

Google Reviews

Google Reviews

7 reviews on Google
Families should exercise extreme caution, as several reviews report severe medical neglect, including unremoved surgical staples and bedsores. While some individuals have noted friendly staff members, there are recurring, serious allegations of verbal abuse, poor cleanliness, and significant understaffing.

Quality Themes

Tap a score for details
FoodN/AStaff2.0Clean1.0ActivitiesN/AMedsN/AMemoryN/AComms1.0Value1.0

Strengths

  • Friendly staff members
  • Effective skilled therapy for mobility

Concerns

  • Severe medical neglect and poor wound care
  • Chronic understaffing and slow response times (mentioned by 2 reviewers)
  • Unsanitary facility conditions
  • Unprofessional or abusive behavior by administration (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2343.02015(1)1.02018(1)1.02019(1)1.02021(1)4.32022(3)5.02025(1)

Distribution · 8 analyzed

5
2
4
2
3
1
2
0
1
3

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1I've heard wonderful things about the skilled therapy team here; how do you work with therapists to help residents regain their mobility?
  • 2With the recent changes in staffing levels, what specific steps is the facility taking to ensure residents receive timely responses to their call lights?
  • 3How does the nursing team approach wound care and monitoring to ensure every resident's medical needs are met consistently?
  • 4What is your current process for maintaining deep cleaning schedules and ensuring the resident rooms and common areas stay pristine?
  • 5How do you ensure clear and frequent communication between the administration and family members regarding a resident's daily health updates?
  • 6In the event of a medical emergency during the night, what is the protocol for notifying the family and coordinating care?

Personalized based on this facility's data


Key Review Excerpts

My mom was in there for 3 months to learn to walk again it was supposed to be skilled therapy. The staff was great and the nursed and helpers but it is really understaffed and the patients are not attended to as they should be

Rehab patient's family · 2015★★★☆☆

Worst rehabilitation facility ever. My poor aunt was sent here for rehab and this and this place is a joke. I'm literally reporting them. She had staples left in her for months after surgery, bed sores you wouldn't believe, constantly was left in her wheelchair for hours.

Rehab patient's family · 2021☆☆☆☆

I RESIDE IN KNOLLS WEST RESIDENTUAL FACILITY, IN THE TIME IVE BEEN HERE, IVE BEEN VERBALLY & MENTALLY ABUSED BY ADMINISTRATOR & HER UNDERSTAFF.

Long-term resident · 2018☆☆☆☆
Source: 7 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.46hrs
62%
Registered nurses for medical care
Total Nursing
4.63hrs
OK
All nurses + aides combined
Staff Turnover
52%
Lower is better (< 30% = good)
RN Turnover
44%
Lower is better (< 30% = good)

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
2/ 5
Better Than Avg

4

measures

Worse Than Avg

7

measures

Mixed Results

6

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility89.1%
Worse than Avg
Here
89.1%
US
12.1%
CA
7.0%
San bernardino
8.0%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility25.1%
Worse than Avg
Here
25.1%
US
15.3%
CA
10.5%
San bernardino
10.1%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility8.6%
Mixed vs Avgs
Here
8.6%
US
19.4%
CA
10.7%
San bernardino
8.3%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility19.9%
Worse than Avg
Here
19.9%
US
14.4%
CA
10.4%
San bernardino
11.0%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.6%
Better than Avg
Here
99.6%
US
93.4%
CA
98.6%
San bernardino
98.8%
🩹

Residents with pressure sores (bedsores)

↓ Lower is better
This Facility10.5%
Worse than Avg
Here
10.5%
US
4.9%
CA
4.5%
San bernardino
5.3%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility95.8%
Mixed vs Avgs
Here
95.8%
US
81.8%
CA
94.2%
San bernardino
97.3%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility85.2%
Mixed vs Avgs
Here
85.2%
US
79.7%
CA
93.2%
San bernardino
94.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.3%
Worse than Avg
Here
2.3%
US
1.6%
CA
1.5%
San bernardino
1.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

15deficiencies
Near state avg (15.4)
10 complaint-triggered

This facility shows concerning patterns with families filing complaints that triggered 11 investigations, including serious issues around resident care, accident prevention, and staff background checks. The most recurring problems involve medication management, wound care and treatment quality, and fire safety systems. While all deficiencies show correction dates, the repeated violations across multiple surveys in core care areas like treatment quality and pressure ulcer prevention suggest ongoing challenges that warrant careful evaluation during your visit.

May 22, 2025Routine
21
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0908Potential for harm · WidespreadCorrected

Environmental Deficiencies

Keep all essential equipment working safely.

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0711Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0636Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0712Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0851Minimal · WidespreadCorrected

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Mar 26, 2025Complaint
1
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Jan 23, 2025Complaint
1
0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Dec 30, 2024Complaint
1
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Dec 17, 2024Complaint
1
0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

Nov 26, 2024Complaint
1
0726Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Knolls West Post Acute LLC

Organization Type

for profit

Chain Affiliation

Chain Name

David Johnson

Chain Size

47 facilities nationwide

Chain avg rating: 3.2/5 · Rank 23 of 45

Ownership & Management

Owners

Chambers, Thomas

Owner

Johnson, David

Owner

Key personnel

Knolls West Post Acute LLCManagerMeridian Management Services LLCManagerBelanger, WilliamManagerChambers, ThomasManagerJohnson, DavidManager
Source: Medicare provider data

Contact

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References & Resources

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