Cycle 1
Health 2025-05-22 · Fire 2025-05-22
16 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Victorville, CA
Knolls West Post Acute LLC
3-star overall rating with 3-star inspections with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
16890 Green Tree Blvd, Victorville, CA
(760) 245-5361
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1987-03-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.48
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.85
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.20
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,197
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.70
Baseline 22.68% · Performance 20.30% · Measure score 3.70 · Achievement 2.43 · Improvement 3.70
Healthcare-associated infections
4.17
Baseline 11.45% · Performance 8.44% · Measure score 4.17 · Achievement 0 · Improvement 4.17
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.27
Baseline 3.34 hours · Performance 3.44 hours · Measure score 1.27 · Achievement 1.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.58% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 329 · Observed rate 7.6% · Lower 95% interval 6.59% |
| Discharge to community | 53.3% |
50.57%
2.7 pts better
|
No Different than the National Rate · Eligible stays 366 · Observed rate 46.99% · Lower 95% interval 48.19% |
| Medicare spending per beneficiary | 1.64 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 98.93% |
95.27%
3.7 pts better
|
Numerator 369 · Denominator 373 |
| Falls with major injury | 0.27% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 373 |
| Discharge self-care score | 34.06% |
53.69%
19.6 pts worse
|
Numerator 78 · Denominator 229 |
| Discharge mobility score | 30.13% |
50.94%
20.8 pts worse
|
Numerator 69 · Denominator 229 |
| Pressure ulcers or injuries, new or worsened | 2.14% |
2.29%
0.1 pts better
|
Numerator 8 · Denominator 373 · Adjusted rate 2% |
| Healthcare-associated infections requiring hospitalization | 8.44% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 275 · Observed rate 9.45% · Lower 95% interval 6.03% |
| Staff COVID-19 vaccination coverage | 1.32% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 152 |
| Staff flu vaccination coverage | 92.11% |
42%
50.1 pts better
|
Numerator 140 · Denominator 152 |
| Discharge function score | 34.06% |
56.45%
22.4 pts worse
|
Numerator 78 · Denominator 229 |
| Transfer of health information to provider | 95.54% |
95.95%
0.4 pts worse
|
Numerator 107 · Denominator 112 |
| Transfer of health information to patient | 86.13% |
96.28%
10.2 pts worse
|
Numerator 149 · Denominator 173 |
| Resident COVID-19 vaccinations up to date | 5.08% |
25.2%
20.1 pts worse
|
Numerator 10 · Denominator 197 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.3
1.3 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 5.1 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
98.5%
0.6 pts worse
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
98.2%
3 pts worse
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
1.6%
0.5 pts worse
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 2.7% · Q4 4.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 93.5% |
6.8%
86.7 pts worse
|
11.4%
82.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 95.2% · Q3 95.4% · Q4 86.2% · 4Q avg 93.5% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
4.1%
2.4 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.2% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
13.7%
1.3 pts worse
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 13.0% · Q3 14.9% · Q4 20.9% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.0% |
14.2%
5.2 pts better
|
16.7%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 9.1% · Q3 10.5% · Q4 6.9% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.2% |
11.0%
11.2 pts worse
|
16.3%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.6% |
10.7%
9.9 pts worse
|
14.9%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 14.5% · Q3 26.5% · Q4 23.7% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.0%
1.7 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.0% · Q3 3.8% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.4% |
10.9%
5.5 pts better
|
19.8%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 1.9% · Q3 5.5% · Q4 9.2% · 4Q avg 5.4% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
4.7%
4.1 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 11.5% · Q3 7.9% · Q4 11.6% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
94.0%
3.2 pts worse
|
81.7%
9.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.7% · Q2 87.6% · Q3 96.1% · Q4 100.0% · 4Q avg 90.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
11.2%
0.8 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 10.6% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.2% · Q3 2.2% · Q4 0.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
93.2%
8 pts worse
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
23.2%
1.5 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 27.7% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
17 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-17
F · Potential for more than minimal harm
2024-05-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-05-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-05-23
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-14
F · Potential for more than minimal harm
2022-12-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-12
D · Potential for more than minimal harm
2022-12-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-12
C · Minimal harm
2022-12-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-01-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-22
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 2025-06-13
F · Potential for more than minimal harm
2025-05-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-22
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
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.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
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 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
C · Minimal harm
2025-05-22
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-17
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-03
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 2024-10-22
D · Potential for more than minimal harm
2024-09-12
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-06-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-05-23
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 2024-06-14
D · Potential for more than minimal harm
2024-05-23
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.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-05-23
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-14
G · Actual harm
2023-06-21
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 2023-07-24
D · Potential for more than minimal harm
2023-05-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-30
D · Potential for more than minimal harm
2023-03-14
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2023-03-22
G · Actual harm
2022-12-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-13
F · Potential for more than minimal harm
2022-12-15
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2023-02-13
F · Potential for more than minimal harm
2022-12-15
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-15
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-13
E · Potential for more than minimal harm
2022-12-15
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-01-13
E · Potential for more than minimal harm
2022-12-15
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-02-13
D · Potential for more than minimal harm
2022-12-15
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-15
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-15
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-15
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 2023-02-13
D · Potential for more than minimal harm
2022-12-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-02-13
D · Potential for more than minimal harm
2022-12-15
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-13
C · Minimal harm
2022-12-15
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-01-13
Penalties and ownership
What sits behind the stars
Ownership
Belanger, William
Operational/Managerial Control · Individual
Chambers, Thomas
Operational/Managerial Control · Individual
Johnson, David
Operational/Managerial Control · Individual
Knolls West Post Acute LLC
Operational/Managerial Control · Organization
Meridian Management Services LLC
Operational/Managerial Control · Organization
Reddy, Hari
Operational/Managerial Control · Individual
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5-star overall rating with 5-star inspections with $8,021 in total fines with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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