CareSentinel

Compiled from official CMS federal data

Knolls West Post Acute LLC, Victorville, CA — Violations & Inspection Reports

CCN 555251 · 16890 Green Tree Blvd, Victorville, CA, 92395

Record as of Jun 2026 · Updated monthly from CMS

Does Knolls West Post Acute LLC have a federal violation or abuse history?

According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Knolls West Post Acute LLC (CCN 555251), in Victorville, CA, has federal inspection findings.

In its current inspection cycle, CMS cited the facility for 16 deficiencies; the most severe is rated F — which CMS classifies as "potential for harm," a level below actual harm (risk, but no harm confirmed). The latest standard health inspection on file is dated 2025-05-22. Earlier-cycle citations appear in the dated timeline below as historical, not current. The record also includes 2 abuse- or neglect-related citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Oct 2024). This page restates the federal record and draws no conclusion of its own.

Abuse-, fall-, and care-related findings on the federal record

  • 2 citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Oct 2024.
  • 1 citation for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Jun 2023.
  • 3 pressure-ulcer care citations (F686) — the consumer term is "bedsores"; most recent May 2025.
  • 1 nutrition and hydration citation (F692) — the consumer terms are "malnutrition" and "dehydration"; most recent Dec 2022.
  • 10 findings on file from complaint-triggered inspections.

Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.

FOR FAMILIES

What brings you to this record?

The Federal Record

Federal abuse- or neglect-related citations on record (F600-series).

Below is this facility's federal inspection record as on file with CMS.

Scope & Severity — current cycle

ANo Harm
BNo Harm
CNo Harm
DPotential
EPotential
FPotential
GActual Harm
HActual Harm
IActual Harm
JImm. Jeopardy
KImm. Jeopardy
LImm. Jeopardy

CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.

About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.

Deficiency timeline

How to read these codes ↓

Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.

2023-06-21
HISTORICAL
F689S/S G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2022-12-15
HISTORICAL
F686S/S G

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

2025-05-22
CURRENT CYCLE
F908S/S F

Keep all essential equipment working safely.

45 more citations on file — Abuse & neglect 2 · Pressure ulcers 2 · Nutrition & hydration 1 · Medication & pharmacy 5 · Resident rights 3 · Other citations 30 (expand)
2026-04-02
CURRENT CYCLE
F573S/S D

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

2025-05-22
CURRENT CYCLE
F812S/S F

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

2025-05-22
CURRENT CYCLE
F711S/S E

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

2025-05-22
CURRENT CYCLE
F644S/S D

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

2025-05-22
CURRENT CYCLE
F628S/S D

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

2025-05-22
CURRENT CYCLE
F636S/S D

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

2025-05-22
CURRENT CYCLE
F641S/S D

Ensure each resident receives an accurate assessment.

2025-05-22
CURRENT CYCLE
F550S/S D

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

2025-05-22
CURRENT CYCLE
F676S/S D

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

2025-05-22
CURRENT CYCLE
F686S/S D

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

2025-05-22
CURRENT CYCLE
F712S/S D

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

2025-05-22
CURRENT CYCLE
F755S/S D

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

2025-05-22
CURRENT CYCLE
F761S/S D

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.

2025-05-22
CURRENT CYCLE
F880S/S D

Provide and implement an infection prevention and control program.

2025-05-22
CURRENT CYCLE
F851S/S C

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

2025-03-26
HISTORICAL
F684S/S D

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

2025-01-23
HISTORICAL
F686S/S D

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

2024-12-30
HISTORICAL
F684S/S D

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

2024-12-17
HISTORICAL
F688S/S D

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.

2024-11-26
HISTORICAL
F726S/S D

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.

2024-10-03
HISTORICAL
F609S/S D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

2024-09-12
HISTORICAL
F606S/S D

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

2024-06-18
HISTORICAL
F684S/S D

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

2024-05-23
HISTORICAL
F812S/S E

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

2024-05-23
HISTORICAL
F638S/S D

Assure that each resident’s assessment is updated at least once every 3 months.

2024-05-23
HISTORICAL
F758S/S D

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.

2024-05-23
HISTORICAL
F695S/S D

Provide safe and appropriate respiratory care for a resident when needed.

2024-05-23
HISTORICAL
F636S/S D

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

2022-12-15
HISTORICAL
F563S/S F

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

2022-12-15
HISTORICAL
F801S/S F

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.

2022-12-15
HISTORICAL
F803S/S E

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.

2022-12-15
HISTORICAL
F761S/S E

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.

2022-12-15
HISTORICAL
F825S/S E

Provide or get specialized rehabilitative services as required for a resident.

2022-12-15
HISTORICAL
F692S/S D

Provide enough food/fluids to maintain a resident's health.

2022-12-15
HISTORICAL
F698S/S D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

2022-12-15
HISTORICAL
F691S/S D

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

2022-12-15
HISTORICAL
F868S/S D

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

2022-12-15
HISTORICAL
F726S/S D

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.

2022-12-15
HISTORICAL
F880S/S D

Provide and implement an infection prevention and control program.

2022-12-15
HISTORICAL
F755S/S D

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

2022-12-15
HISTORICAL
F637S/S D

Assess the resident when there is a significant change in condition

2022-12-15
HISTORICAL
F641S/S D

Ensure each resident receives an accurate assessment.

2022-12-15
HISTORICAL
F842S/S D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

2022-12-15
HISTORICAL
F656S/S D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2022-12-15
HISTORICAL
F851S/S C

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

Overall CMS star rating

This facility: 3  ·  CMS state average: 3.2

Both figures as published by CMS.

You may be reading this record for the first time.

If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.

Your federal record — tap to preview

Federal record

Knolls West Post Acute LLC — Federal Record

CMS overall 3/5 · 16 current-cycle deficiencies


Section 7 — Case Context

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SECTION 7 — CASE CONTEXT

Add what you saw at Knolls West Post Acute LLC to this record

No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.

Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.

What happened

What happened? Tap a category to see options — select all that apply. 'Other / I'm not sure' is fine.

No personal details on this step.

If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.

How to read this record

Making sense of a CMS inspection record

CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.

Three questions to ask on a tour

  • How is the home staffed on nights, weekends, and holidays?
  • What happens when a resident’s condition changes suddenly?
  • How, and how quickly, are families told about an incident?

Compare this facility on CMS’s own Care Compare →

Download the full federal record (PDF) →