California ›Victorville

Knolls West Post Acute LLC

16890 Green Tree Blvd, Victorville, CA 92395 · San Bernardino County · 118 certified beds · avg 109 residents/day · certified since Mar 18, 1987

Part of chain: DAVID JOHNSON (48 facilities, chain avg rating 3.2★)

3/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
3.98
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Dec 15, 2022 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jan 13, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (50)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 12, 2026D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jun 12, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
May 7, 2026D · Potential for harm, one-offThe facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint
Apr 2, 2026D · Potential for harm, one-offThe facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint
May 22, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 22, 2025F · Potential for harm, facility-wideThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
May 22, 2025E · Potential for harm, repeatedThe facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit.
May 22, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 22, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
May 22, 2025D · Potential for harm, one-offThe facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
May 22, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
May 22, 2025D · Potential for harm, one-offThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
May 22, 2025D · Potential for harm, one-offThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
May 22, 2025D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
May 22, 2025D · Potential for harm, one-offThe facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule.
May 22, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 22, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 22, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 22, 2025C · Minimal risk, facility-wideThe facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Mar 26, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 23, 2025D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Dec 30, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 17, 2024D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint
Nov 26, 2024D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Oct 3, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Sep 12, 2024D · Potential for harm, one-offThe facility hired someone with an official finding of abuse, neglect, exploitation, or theft against them. Facilities are not allowed to employ people with such findings. · from a complaint
Jun 18, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 23, 2024E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 23, 2024D · Potential for harm, one-offThe facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
May 23, 2024D · Potential for harm, one-offThe facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
May 23, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 23, 2024D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Dec 15, 2022▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Dec 15, 2022F · Potential for harm, facility-wideThe facility did not honor residents' right to receive the visitors they choose, at the times they choose.
Dec 15, 2022F · Potential for harm, facility-wideThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Dec 15, 2022E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Dec 15, 2022E · Potential for harm, repeatedThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Dec 15, 2022E · Potential for harm, repeatedThe facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them.
Dec 15, 2022D · Potential for harm, one-offThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Dec 15, 2022D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Dec 15, 2022D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 15, 2022D · Potential for harm, one-offThe facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy.
Dec 15, 2022D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Dec 15, 2022D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Dec 15, 2022D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Dec 15, 2022D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Dec 15, 2022D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Dec 15, 2022D · Potential for harm, one-offThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.
Dec 15, 2022D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 15, 2022C · Minimal risk, facility-wideThe facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (5 → 15).

YearCitationsSerious (G–L)Worst severity that year
2022181G ▲
2024110E
2025170F
202640D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.984.313.95bottom 40% in California; top 40% in the U.S.
Registered Nurse hours0.400.610.69bottom 33% in California; bottom 22% in the U.S.
Weekend total nurse staffing3.773.903.50top 48% in California; top 30% in the U.S.
Weekend RN hours (not acuity-adjusted)0.490.510.48top 31% in California; top 34% in the U.S.
Total nursing staff turnover (%)53.836.745.8bottom 8% in California; bottom 28% in the U.S.
RN turnover (%)43.838.142.9bottom 37% in California; bottom 46% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.65, RN 0.47, weekend 4.40. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 2/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Chambers, ThomasIndividualDirect Ownership InterestNOT APPLICABLE10/08/2013
Johnson, DavidIndividualDirect Ownership InterestNOT APPLICABLE10/08/2013
Belanger, WilliamIndividualOperational/Managerial ControlNOT APPLICABLE07/01/2022
Belanger, WilliamIndividualADP of the SNFNOT APPLICABLE07/01/2022
Chambers, ThomasIndividualOperational/Managerial ControlNOT APPLICABLE10/08/2013
Chambers, ThomasIndividualADP of the SNFNOT APPLICABLE10/08/2013
Johnson, DavidIndividualOperational/Managerial ControlNOT APPLICABLE10/08/2013
Johnson, DavidIndividualADP of the SNFNOT APPLICABLE10/08/2013
Knolls West Post Acute LLCOrganizationOperational/Managerial ControlNOT APPLICABLE12/21/2013
Knolls West Post Acute LLCOrganizationADP of the SNFNOT APPLICABLE08/28/2025
Meridian Management Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE12/01/2013
Reddy, HariIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2023
Reddy, HariIndividualADP of the SNFNOT APPLICABLE01/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Spring Valley Post Acute LLC1.7 miVictorville, CA★★☆☆☆2/5
Desert Ridge Transitional Care Center, LP2.4 miVictorville, CA—/5
Apple Valley Care Center3.6 miApple Valley, CA★★★★★5/5
Mountains Community Hosp DP/SNF17.5 miLake Arrowhead, CA★★★★☆5/5

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Facility data as of CMS processing date 2026-08-01. CCN 555251.