Oregon ›Eugene

Green Valley Rehabilitation Health Center

1735 Adkins Street, Eugene, OR 97401 · Lane County · 110 certified beds · avg 121 residents/day · certified since Jul 14, 1983

Part of chain: VOLARE HEALTH (16 facilities, chain avg rating 1.8★)

1/5
Health inspection rating (on-site)
2
Serious findings on record
$53,024
Fines, last 3 years
4.73
Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

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 · Sep 13, 2024 · F-0600

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

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: Oct 29, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 13, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

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: Oct 29, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (91)

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 1, 2026E · Potential for harm, repeatedThe 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). · from a complaint
Jun 1, 2026D · Potential for harm, one-offThe facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint
Feb 2, 2026E · Potential for harm, repeatedThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Feb 2, 2026E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Feb 2, 2026D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Feb 2, 2026D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Feb 2, 2026D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential.
Feb 2, 2026D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Feb 2, 2026D · 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.
Feb 2, 2026D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Feb 2, 2026D · 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.
Feb 2, 2026D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Feb 2, 2026D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Feb 2, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Feb 2, 2026D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Feb 2, 2026D · Potential for harm, one-offThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Feb 2, 2026D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Feb 2, 2026D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Feb 2, 2026D · Potential for harm, one-offThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Jan 15, 2026F · Potential for harm, facility-wideThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Jan 15, 2026D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Jan 15, 2026D · 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
Jan 15, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 9, 2025D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
Dec 9, 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
Feb 5, 2025F · Potential for harm, facility-wideThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Feb 5, 2025D · 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. · from a complaint
Sep 13, 2024▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Sep 13, 2024▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 13, 2024F · 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. · from a complaint
Sep 13, 2024E · Potential for harm, repeatedThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Sep 13, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Sep 13, 2024E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Sep 13, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
Sep 13, 2024E · Potential for harm, repeatedThe facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials.
Sep 13, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Sep 13, 2024E · Potential for harm, repeatedThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Sep 13, 2024E · Potential for harm, repeatedThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Sep 13, 2024E · Potential for harm, repeatedThe facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign.
Sep 13, 2024E · Potential for harm, repeatedThe 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.
Sep 13, 2024D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Sep 13, 2024D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Sep 13, 2024D · 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
Sep 13, 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 13, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Sep 13, 2024D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Sep 13, 2024D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Sep 13, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Sep 13, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Sep 13, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Sep 13, 2024D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Sep 13, 2024D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Sep 13, 2024D · 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.
Sep 13, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Sep 13, 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.
Sep 13, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Sep 13, 2024D · 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.
Sep 13, 2024D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint
Sep 13, 2024D · 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.
Sep 13, 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.
Sep 13, 2024D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Feb 29, 2024E · Potential for harm, repeatedThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Feb 29, 2024E · Potential for harm, repeatedThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Nov 28, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Nov 28, 2023D · 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
Nov 28, 2023D · 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. · from a complaint
Nov 28, 2023D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint
Nov 28, 2023D · Potential for harm, one-offThe facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint
Nov 28, 2023D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
May 22, 2023F · Potential for harm, facility-wideThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
May 22, 2023F · 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, 2023E · Potential for harm, repeatedThe 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, 2023E · Potential for harm, repeatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
May 22, 2023E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
May 22, 2023E · Potential for harm, repeatedThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
May 22, 2023E · Potential for harm, repeatedThe 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, 2023D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
May 22, 2023D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
May 22, 2023D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
May 22, 2023D · Potential for harm, one-offThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
May 22, 2023D · 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, 2023D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
May 22, 2023D · 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.
May 22, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
May 22, 2023D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
May 22, 2023D · 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.
May 22, 2023D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
May 22, 2023D · 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.
May 22, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 22, 2023D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
May 22, 2023D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (34 → 17).

YearCitationsSerious (G–L)Worst severity that year
2023280F
2024362G ▲
202540F
2026230F

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)

1 fine totaling $53,024.

DateTypeAmount / length
Sep 13, 2024Fine$53,024

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

MeasureThis facilityOregon avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.735.423.95bottom 16% in Oregon; top 18% in the U.S.
Registered Nurse hours0.310.780.69bottom 3% in Oregon; bottom 11% in the U.S.
Weekend total nurse staffing4.124.853.50bottom 14% in Oregon; top 20% in the U.S.
Weekend RN hours (not acuity-adjusted)0.110.480.48bottom 1% in Oregon; bottom 2% in the U.S.
Total nursing staff turnover (%)53.247.445.8bottom 31% in Oregon; bottom 29% in the U.S.
RN turnover (%)70.051.642.9bottom 23% in Oregon; bottom 12% 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 4.32, RN 0.29, weekend 3.76. Staffing rating: 2/5.

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: 4/5 · long-stay residents: 3/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Hagler, AlexanderIndividual5% or Greater Indirect Ownership Interest—03/01/2023
Knox Healthcare Pac 12 Holdings LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Knox, DonaldIndividual5% or Greater Indirect Ownership Interest—03/01/2023
Pac 12 Holdings LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Pac 12 Opco Holdco LLCOrganization5% or Greater Direct Ownership Interest100%03/01/2023
Pac 12 Pinnacle Holdco LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Hagar, ChaimIndividualADP of the SNFNOT APPLICABLE03/01/2023
Kensington or Propco LLCOrganization5% or Greater Mortgage InterestNOT APPLICABLE03/01/2023
Kensington or Propco LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Knox, DonaldIndividualCorporate OfficerNOT APPLICABLE03/01/2023
Knox, DonaldIndividualOperational/Managerial ControlNOT APPLICABLE03/01/2023
Knox, DonaldIndividualADP of the SNFNOT APPLICABLE03/01/2023
Maheia, JasonIndividualOperational/Managerial ControlNOT APPLICABLE04/07/2025
Maheia, JasonIndividualADP of the SNFNOT APPLICABLE04/07/2025
Morris, ChristopherIndividualOperational/Managerial ControlNOT APPLICABLE08/22/2025
Morris, ChristopherIndividualADP of the SNFNOT APPLICABLE08/22/2025
Pac 12 Holdings LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Pac 12 Pinnacle Holdco LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Schwartz, EliezerIndividualOperational/Managerial ControlNOT APPLICABLE03/01/2023
Schwartz, EliezerIndividualADP of the SNFNOT APPLICABLE03/01/2023

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)

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Avamere Riverpark of Eugene2.0 miEugene, OR★★☆☆☆2/5
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Cascade Manor4.2 miEugene, OR★★★★☆4/5
Avamere Rehabilitation of Eugene4.3 miEugene, OR★☆☆☆☆1/5
Hillside Heights Rehabilitation Center4.4 miEugene, OR★★★☆☆3/5
Creekside Health and Rehabilitation of Cascadia4.5 miEugene, OR★★★★★4/5
Valley West Health Care Center5.4 miEugene, OR★★☆☆☆2/5
Avamere Rehabilitation of Junction City11.3 miJunction City, OR★★★★☆3/5
Creswell Post Acute12.1 miCreswell, OR★★☆☆☆2/5

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Facility data as of CMS processing date 2026-08-01. CCN 385156.