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Nursing HomeMedicaid Investigative

Green Valley Rehabilitation Health Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1735 Adkins Street, Eugene, OR 97401110 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.1/5

based on 112 Google reviews

5
4
3
2
1
Green Valley Rehabilitation Health Center Nursing Home in Eugene, OR — Street View
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10/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Special Focus Facility (under heightened CMS scrutiny)
  • Abuse citation on record
  • Low overall rating (2/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (40 vs median 9.0)
  • High staff turnover (57%)
  • High RN turnover (56%)

Below average in OR · Critically understaffed (RN) · Above recommended total nurse staffing · $53,024 in fines · Special Focus Facility (CMS) · Abuse citation

Source: Medicare data

What this means for your family

While the facility's therapy department is frequently praised for its effectiveness, the recent surge in negative reviews regarding neglect and poor communication is concerning. Families should exercise extreme caution and are advised to conduct unannounced visits and speak directly with current residents' families before making a decision.

Google Reviews

Google Reviews

112 reviews on Google
Green Valley Rehabilitation Health Center receives deeply polarized feedback, with many families reporting severe neglect, poor communication, and understaffing, particularly following a change in ownership. While some reviewers praise the physical and occupational therapy teams for their dedication, these positive experiences are frequently overshadowed by reports of unhygienic conditions, delayed responses to call lights, and medication errors.

Quality Themes

Tap a score for details
Food2.0Staff4.0Clean2.0Activities5.0Meds2.0Memory2.0Comms2.0ValueN/A

Strengths

  • Dedicated physical and occupational therapy teams
  • Some staff members are noted for being compassionate and kind
  • Convenient location near local amenities

Concerns

  • Severe understaffing and slow response to call lights (mentioned by 14 reviewers)
  • Poor food quality and cold meals (mentioned by 8 reviewers)
  • Inadequate hygiene and infrequent bathing/showering (mentioned by 7 reviewers)
  • Communication breakdowns and difficulty reaching staff (mentioned by 6 reviewers)
  • Medication management errors and missing personal items (mentioned by 5 reviewers)

Rating Trends

Tap a year to see what changed

234'16(3)'18(10)'20(4)'22(10)'24(10)'26(7)

Distribution · 88 analyzed

5
29
4
10
3
3
2
6
1
40

How They Respond to Reviews

50%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1We've heard wonderful things about your physical and occupational therapy teams; could you tell us more about how they work with residents to maintain mobility?
  • 2With the facility being so conveniently located near local amenities, how often do residents get opportunities to engage in outings or community activities?
  • 3How does the nursing team ensure that call lights are answered promptly and that residents' hygiene and bathing needs are met consistently throughout the day?
  • 4What specific protocols are in place to ensure medication management is accurate and that personal items are kept safe and accounted for?
  • 5Could you describe the meal service process, specifically how you ensure food stays at the proper temperature and meets nutritional needs?
  • 6How does the communication flow between the nursing staff and family members, especially if we have questions or concerns after hours?

Personalized based on this facility's data


Key Review Excerpts

My husband was a patient at Green Valley for much of August. He was given minimal care; his dietary needs were minimally met; his call button was not answered in an acceptable amount of time; he was taken off of some prescribed meds for unknown reasons.

Long-term resident's family · 2024☆☆☆☆

The best thing about my very elderly dad's visit was the terrific job the physical therapists did in getting him back to baseline that he was before his accident. That said, they are sometimes slow to answer the call light, the food doesn't look that good, and the rooms are very utilitarian.

Rehab patient's family · 2024★★★★★

My mother was here for a couple weeks, in that time, her health faded, I would walk in to seeing cnas scold her because she asked rhe same questions, due to her dementia that they diagnosed her with.

Memory care family member · 2026☆☆☆☆
Source: 112 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.34hrs
45%
Registered nurses for medical care
Total Nursing
4.85hrs
OK
All nurses + aides combined
Staff Turnover
54%
Lower is better (< 30% = good)
RN Turnover
50%
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
5/ 5
Better Than Avg

15

measures

Worse Than Avg

1

measures

Mixed Results

1

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility6.0%
Better than Avg
Here
6.0%
US
15.5%
OR
14.0%
Lane
11.9%
😔

Residents with depression symptoms

↓ Lower is better
This Facility4.2%
Better than Avg
Here
4.2%
US
12.1%
OR
4.9%
Lane
5.0%

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

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility11.8%
Better than Avg
Here
11.8%
US
19.5%
OR
12.5%
Lane
15.0%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility15.8%
Mixed vs Avgs
Here
15.8%
US
15.3%
OR
22.5%
Lane
20.7%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.3%
Better than Avg
Here
99.3%
US
93.4%
OR
95.3%
Lane
96.5%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
OR
95.2%
Lane
98.4%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility90.1%
Better than Avg
Here
90.1%
US
81.8%
OR
85.5%
Lane
87.4%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility82.2%
Better than Avg
Here
82.2%
US
79.8%
OR
81.2%
Lane
80.8%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.6%
Better than Avg
Here
0.6%
US
1.6%
OR
1.5%
Lane
1.8%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

23deficiencies
1penalties
Well above state avg (10.4)
30 complaint-triggered
$53,024 in fines

Green Valley Rehabilitation Health Center has faced significant and recurring challenges, with many families filing complaints that triggered federal investigations. The facility has persistent problems with nursing staffing shortages, medication management, and food safety that span multiple years and continue into 2025-2026. While most violations have correction dates, the pattern of repeat deficiencies in critical care areas suggests ongoing operational difficulties that families should carefully consider.

Feb 2, 2026Routine
19
0554Potential for harm · PatternCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Jan 15, 2026Complaint
4
0727Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

0585Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Dec 9, 2025Complaint
2
0557Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Feb 5, 2025Complaint
2
0725Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Sep 13, 2024Routine
22
0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0552Potential for harm · PatternCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0565Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

0680Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

0847Potential for harm · PatternCorrected

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0685Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

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.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Sep 13, 2024Complaint
14
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

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.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0585Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

0725Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0727Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

0732Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0658Potential for harm · IsolatedResolved (past non-compliance)

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0745Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

0760Potential for harm · IsolatedResolved (past non-compliance)

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Federal Penalties

Fine

Sep 13, 2024

$53,024

Ownership & Operations

Who Operates This Facility

Owner / Operator

Green Valley Rehabilitation Health Center

Organization Type

for profit

Chain Affiliation

Chain Name

Volare Health

Chain Size

16 facilities nationwide

Chain avg rating: 1.7/5 · Rank 5 of 15

Ownership & Management

Owners

Pac 12 Opco Holdco LLC

Owner · Organization

100%

Knox Healthcare Pac 12 Holdings LLC

Owner (parent company) · Organization

Pac 12 Holdings LLC

Owner (parent company) · Organization

Pac 12 Pinnacle Holdco LLC

Owner (parent company) · Organization

Hagler, Alexander

Owner (parent company)

Knox, Donald

Owner (parent company)

Key personnel

Kensington or Propco LLC5% or Greater Mortgage InterestKnox, DonaldOfficer / DirectorSmith, BrianOfficer / DirectorVolare Health LLCManagerKnox, DonaldManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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