Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Valley Care Center during CMS and state inspections, most recent first.
Kitchen sanitation deficiencies were observed across multiple areas, including the fryer, ovens, convection oven, slicer shelf, floors, ceiling vents, and dishwasher, with heavy grease, food particles, streaking, and buildup noted on repeated observations. Outdated food items were also found in the reach-in refrigerator, including fruit cocktail and cottage cheese past their use-by or best-by dates. The same conditions remained present across repeated kitchen observations despite routine cleaning schedules being in place.
A facility survey found multiple insulin KwikPens stored on several med carts and in refrigerators without pharmacy labels. Affected residents had diabetes-related diagnoses and orders for rapid-acting and long-acting insulin, and staff interviews showed uncertainty about the missing labels, with one LPN stating pharmacy labels were discarded when medications were received.
PPE and glucometer cleaning were not performed as required during resident care. A CNA emptied a catheter bag for a resident on EBP without wearing a gown, despite signage indicating gown and glove use for catheter care, and an LPN provided care to a resident on Contact Precautions for C-diff without applying PPE first. In addition, two LPNs cleaned glucometers after blood sugar checks for two residents by wiping the devices for about 30 seconds instead of the required 2 minutes of wet contact time before air drying.
A resident with an indwelling Foley and history of UTI had a catheter bag observed full and bulging, with urine backing up into the tubing and urine on the floor after the bag broke open. On a later observation, a CNA emptied the bag multiple times but did not wear a gown despite EBP signage, and the resident’s record showed ongoing catheter-related infection concerns and prior abnormal UA/culture results.
Medication Error Rate Exceeded 5 Percent During Insulin Administration: Two insulin administrations were observed with errors involving an LPN not following manufacturer directions for insulin lispro. In one instance, the needle was primed before the needle was attached, the injection site was not allowed to dry after alcohol cleansing, and the needle was removed after 4 seconds instead of 5. In another, the needle was removed after 3 seconds instead of 5. Both residents had diabetes and moderate cognitive impairment.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was the victim of medication misappropriation by an LPN, who diverted narcotic medications for personal use. The incident was discovered after suspicious behavior was observed, a narcotic count revealed discrepancies, and tampering with a controlled substance was identified. The police and management were notified, and the facility's policy on misappropriation was referenced.
The facility did not provide or document required bed hold policy notifications to residents or their representatives during transfers to the hospital, despite residents experiencing acute medical events such as lethargy, blood-tinged urine, low oxygen saturation, and unresponsiveness. Clinical records for four residents lacked evidence of bed hold documentation at the time of discharge, and the DON confirmed that this step may be missed during emergencies.
A resident with COPD receiving nebulizer treatments did not have documented weekly replacement of nebulizer equipment or completed respiratory assessments before and after treatments, as required by physician orders and facility policy. Staff interviews and policy review confirmed these procedures should have been followed.
A resident with dementia was slapped by a CNA after the resident bit the CNA's arm during toileting assistance. The incident was witnessed by another CNA, who reported it to an RN. The resident was assessed for injuries, and the involved CNA was sent home. The facility's policy on abuse prevention was not followed, resulting in a deficiency.
The facility's kitchen was found to be unsanitary, with grease and food debris on equipment and floors, missing cleaning schedules, and staff unaware of cleaning duties. The Dietary Manager could not recall the last deep cleaning, and the evening shift was reportedly not adhering to cleaning protocols.
The facility failed to prevent the misappropriation of a resident's Oxycodone medication, with discrepancies in narcotic counts and missing medication cards linked to a QMA who did not respond to inquiries and sought legal counsel.
Kitchen sanitation and expired food storage deficiencies
Penalty
Summary
The kitchen was observed on three separate occasions with multiple sanitation concerns involving cooking equipment, floors, ceiling vents, and the dishwasher area. During the initial tour, the fryer contained yellow and brown food particles in the oil and a heavy accumulation of brown food particles on the inside shelf, both stove ovens had cream-colored food particles on the inside bottom, and the oven doors and handles were sticky with white streaks running down the front. The fryer, convection oven, stove area, slicer shelf, and floors under the equipment had visible grease, food particles, and dark brown or black buildup. Several ceiling air vents above food preparation, dishwashing, tray, and serving areas had black substance, greasy buildup, or flaking paint, and the dish machine had food particles and white streaks on its surfaces. On the second kitchen observation, the same sanitation issues remained. The fryer shelf still had a heavy accumulation of brown food particles, and the grease trap on the flat top was full of yellow and brown food particles. In the reach-in refrigerator, a container of fruit cocktail had a use-by date of 12/29/25, and two 5-pound containers of cottage cheese had best-by dates of 12/26/25 and 12/13/25. Dietary aide 2 stated the small dishes of cottage cheese on the shelf were not dipped from the outdated containers. The ceiling vent above the salad dressing and condiment shelf in dry storage was pulling loose with pieces of plaster hanging loose and was black in color, and the dishwasher had lime streaks and food particles on the clean side shelf. On the third observation, the same conditions were again present, including food particles inside the ovens, sticky and streaked oven doors, grease and food buildup around the fryer, convection oven, stove, slicer shelf, floors, and multiple ceiling vents. The vent above the salad dressing and condiment shelf remained loose with hanging plaster and black discoloration, and the dishwasher still had lime streaks down the front. Review of the facility’s cleaning schedules showed routine cleaning assignments for the stove top, grill, floors, ovens, fryer, refrigerator, and dishwasher, and the food safety policy stated food must be stored and maintained in a clean, safe, and sanitary manner, with leftovers dated properly and discarded after 72 hours unless otherwise indicated.
Insulin KwikPens Found Without Pharmacy Labels
Penalty
Summary
The facility failed to ensure that insulin and other biologicals were properly labeled during medication storage observations. On the 300 Hall medication cart, Resident 28’s Lispro and Rezvoglar KwikPens were found without pharmacy labels in either the medication cart or the refrigerator. Resident 28 had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus with diabetic neuropathy, stage 3 chronic kidney disease, and anemia, and the record showed orders for rapid-acting lispro with meals and long-acting Rezvoglar in the morning. The resident’s MDS assessment indicated moderate cognitive impairment and that insulin had been received in the prior 7 days. On the 400 Hall medication cart, Resident 9’s Basaglar and Humalog KwikPens were observed without pharmacy labels in the cart or refrigerator, and Resident 2’s Glargine and Lispro KwikPens were also found without pharmacy labels in the cart or refrigerator. Resident 9 had diagnoses including type 2 diabetes mellitus, dementia, and schizophrenia, with orders for Basaglar at bedtime and Novolog/Humalog per sliding scale. Resident 2 had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, protein-calorie malnutrition, iron deficiency, dementia, and dysphagia, with orders for daily glargine and Humalog per sliding scale. Both residents’ MDS assessments indicated cognitive impairment and recent insulin use. On the 500 Hall medication cart, Resident 4’s Tresiba KwikPen had no pharmacy label in the cart or refrigerator, and Resident 115’s Aspart KwikPen had no pharmacy label in the cart or refrigerator. Resident 4 had diagnoses including type 2 diabetes mellitus, hyperglyceridemia, history of diabetic foot ulcer, and protein-calorie malnutrition, and the record lacked documentation of a diabetes care plan. Resident 115 had type 2 diabetes mellitus and a care plan addressing abnormal blood sugar readings, with orders for Basaglar at bedtime. On the 100 Hall medication cart, Resident 23’s Lispro KwikPen had no pharmacy label in the cart or refrigerator. Resident 23 had diagnoses including type 2 diabetes mellitus, cognitive communication deficit, and protein-calorie malnutrition, with orders for Humalog per sliding scale. Staff interviews indicated uncertainty about why labels were missing, and one LPN stated pharmacy labels were discarded upon receiving and not placed on the medications. The facility policy stated medications and biologicals with missing labels should be destroyed and reordered.
PPE and Glucometer Cleaning Failures
Penalty
Summary
The facility failed to ensure proper PPE was used during care for a resident with an indwelling catheter and wounds who was on Enhanced Barrier Precautions. During an observation, a CNA entered the resident’s room to empty a full catheter bag containing light-yellow urine and visible urine in the tubing, but only applied gloves and did not wear a gown even though the door signage indicated gown and gloves were required for EBP. The CNA emptied the bag several times until it was empty and acknowledged there was a chance of being splashed when emptying the catheter bag. The resident stated staff did not always wear gowns when performing wound treatment or emptying the catheter bag. The facility also failed to ensure PPE was applied for another resident who was on Contact Precautions and EBP for C-diff and a wound. An LPN entered the room to apply oxygen, then applied a jacket and performed hand hygiene, but did not apply PPE before providing care and only looked at the isolation signage after being in the room. The LPN stated she had not applied PPE and that the resident was in isolation for C-diff and had a wound. The resident’s record showed diagnoses including enterocolitis due to C. difficile and sepsis, with orders for Contact Precautions and care plan interventions for isolation. The facility further failed to clean glucometers according to manufacturer guidelines after blood sugar checks for two residents. After use with one resident, an LPN wiped the glucometer with a Super Sani Cloth for about 30 seconds and placed it on top of the medication cart to dry; the device was left open to the air. Another LPN performed the same type of cleaning after use with a second resident, wiping the glucometer for about 30 seconds and placing it on a paper towel on the medication cart. Both LPNs stated the glucometer required 2 minutes of wet contact time, and the manufacturer guidelines indicated hard nonporous surfaces needed 2 minutes of wet contact time before air drying.
Improper Foley Drainage Management
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter drainage system for a resident with a history of UTIs. During an observation, the resident’s catheter bag was full and bulging, with urine visible traveling up the tubing toward the resident, and the floor was sticky from urine. The resident later stated the catheter bag had broken open and urine had been everywhere, and staff had mopped up the urine on the floor. When the catheter bag was observed again, it was still full and bulging, and it took multiple emptyings before it was fully drained. During that same observation, a CNA emptied the catheter bag but did not apply a gown despite signage indicating the resident was on enhanced barrier precautions and equipment to be worn during care. The resident’s record showed an indwelling catheter for urinary retention, a history of UTI, and care plan interventions including catheter care every shift, checking tubing for kinks, and enhanced barrier precautions. The record also included prior urinalysis and culture results showing abnormal findings and pseudomonas, and a later note documented catheter change after the resident complained of pain and sediment was seen in the tubing.
Medication Error Rate Exceeded 5 Percent During Insulin Administration
Penalty
Summary
The facility failed to ensure residents were free of a medication error rate greater than 5 percent, with a measured error rate of 8.33% based on 2 of 24 opportunities. During an observation of Resident 32, the LPN checked the resident’s blood glucose at 244 mg/dL and prepared 4 units of insulin Lispro. The LPN primed the insulin pen with 2 units before the needle was attached, then administered the insulin after cleaning the lower right abdomen with alcohol and not allowing it to dry. The LPN left the needle in place for only 4 seconds before retracting it, although the manufacturer required 5 seconds for Lispro insulin. Resident 32 had diagnoses including type 2 diabetes mellitus with hyperglycemia, dementia, peripheral vascular disease, and chronic kidney disease stage 3, and the MDS indicated moderate cognitive impairment. During an observation of Resident 2, an LPN checked a glucose of 249 mg/dL and prepared 4 units of Humalog Kwik Pen insulin. The LPN cleaned the abdomen with alcohol, administered the insulin, and left the needle in place for only 3 seconds before retracting it, despite the manufacturer requirement that Lispro insulin remain injected for 5 seconds. Resident 2’s record showed diagnoses including type 2 diabetes mellitus with diabetic neuropathy, dementia, alcoholic cirrhosis of the liver with ascites, chronic kidney disease stage 4, cognitive communication deficit, hypertension, and ileostomy status, and the MDS indicated moderate cognitive impairment. The facility’s insulin administration policy stated that the injection site should be cleaned with alcohol and allowed to completely dry, and that the needle should remain in the skin for 5 seconds after injection for insulin lispro.
Misappropriation of Resident Medication by Staff Member
Penalty
Summary
A facility failed to ensure that a resident was free from misappropriation of medications. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including anxiety disorder, bipolar disorder, intellectual disabilities, and dementia. The resident was non-verbal and fully dependent on staff for care. A staff member, specifically an LPN, was suspected of taking narcotic medications prescribed to the resident for personal use. The incident was discovered when a Qualified Medication Aide observed suspicious behavior from the LPN, including being found in a resident's bathroom and acting abnormally. The LPN had also signed out medication for a resident who was not present in the facility and attempted to have another staff member perform a narcotic count, which was refused. A subsequent narcotic count revealed discrepancies, including a container of liquid Ativan that had been tampered with and filled with water. The police and facility management were notified of the misappropriation. The facility's policy defined misappropriation as the deliberate misplacement or wrongful use of resident property, including missing prescription medication or diversion of controlled substances for staff use. The incident was confirmed through interviews, record reviews, and observation of the narcotic count process, which revealed the medication discrepancy and the staff member's actions leading to the deficiency.
Failure to Provide Bed Hold Policy Documentation at Hospital Transfer
Penalty
Summary
The facility failed to provide required bed hold policy documentation to residents or their representatives at the time of transfer to the hospital for four residents reviewed. Each resident had significant medical conditions, including paraplegia, neuromuscular dysfunction of the bladder, dementia, subdural hemorrhage, Parkinson's disease, chronic obstructive pulmonary disease, infection related to a joint prosthesis, cerebral infarction, and convulsions. In each case, the clinical records and progress notes documented the residents' acute changes in condition and subsequent transfers to the hospital, but lacked evidence that the bed hold policy was given to the resident or their representative at the time of discharge. Interviews and record reviews confirmed that the required bed hold notifications were not documented as provided during these transfers, even when family members were present or involved in the decision to send the resident to the hospital. The Director of Nursing acknowledged awareness of the requirement but indicated that in emergent situations, the process may not be completed. The facility's written policy requires that bed hold information be provided at the time of transfer, but this was not reflected in the clinical records for the residents reviewed.
Failure to Document Nebulizer Equipment Maintenance and Respiratory Assessments
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident diagnosed with chronic obstructive pulmonary disease who was receiving nebulizer treatments. Specifically, the clinical record review revealed that there was no documentation of weekly replacement of the nebulizer equipment for the months of December and January, despite physician orders and facility policy requiring this maintenance. Additionally, the resident's record lacked evidence of completed respiratory assessments before and after nebulizer administration in January. Interviews with staff confirmed that respiratory assessments should be conducted prior to and after nebulizer treatments to ensure effectiveness, and that nebulizer equipment should be changed weekly. The facility's own policy, as provided by the Director of Nursing, also outlined these requirements. These deficiencies were identified through observation, interview, and record review for one of three residents reviewed for respiratory care.
Failure to Prevent Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse involving a resident diagnosed with dementia. On the night of the incident, a CNA was assisting the resident with toileting needs when the resident bit the CNA's arm. In response, the CNA reflexively slapped the resident's face. This incident was witnessed by another CNA, who reported it to an RN. The RN and the witnessing CNA then removed the resident from the dining room and assessed her for any injuries or distress, finding none. The CNA involved in the incident was instructed to clock out and leave the facility. The incident was documented in an incident report and corroborated by written statements from the involved staff. The facility's policy on abuse prevention, which prohibits physical abuse such as slapping, was not adhered to in this case. The incident was reported to the Executive Director, and the involved CNA admitted to the action, describing it as a reflex. The facility's failure to prevent this incident of abuse constitutes a deficiency in protecting residents from abuse.
Deficient Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen, as observed during a survey. The deep fryer had a buildup of grease and a brown-black substance on the fryer baskets and the top and sides of the fryer. The gas stove knobs were covered in grease and food debris, and a cart beside the stove had a sheet pan with greasy food buildup on the utensils. The employee sink had a black substance in the bowl and on the front and sides, while the kitchen floor was greasy, slippery, and littered with grime, food debris, and trash. Additionally, a large bowl with a dried, crusty brown substance and a container with a dried yellow substance were found near the dishwasher. The refrigerator door handle was missing, and the doors had food debris and smudges. Stainless steel tables were also dirty with dark brown spots, food debris, and grease. Interviews with the dietary staff revealed a lack of awareness and adherence to cleaning schedules. The Assistant Dietary Manager was unable to locate the cleaning schedules, and dietary aides were unsure about the contents and duration of the substances found in the kitchen. The Dietary Manager indicated that the kitchen should be cleaned daily, with deep cleaning weekly, but could not recall the last deep cleaning. The cleaning policy required a posted cleaning schedule, which was not found, and the dietary staff reported that the evening shift was not cleaning as required. The Dietary Manager acknowledged the use of a cleaning service for stove hoods but was unsure of the last cleaning date, and the floor was supposed to be mopped multiple times a day, especially after meals.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to ensure the misappropriation of resident property did not occur for Resident D, who had diagnoses including depression, anxiety, and pain. The physician's order indicated Resident D was to receive Oxycodone 5 mg, one half of a tablet twice a day and every 4 hours as needed for pain. An internal facility incident report indicated that Resident D was missing one card with 22.5 tablets of Oxycodone and one narcotic count sheet. The discrepancy was identified on the Memory Care Unit, and the missing medication was last administered by QMA 9 according to the medication administration record (MAR). The Shift Change Controlled Substance Inventory Sheets showed inconsistencies and alterations in the narcotic count. On 4/22/24, the inventory sheet initially documented 22 cards and 25 narcotic count sheets, which were later altered to 21 cards and 24 sheets. Interviews with LPN 7 and LPN 6 revealed that QMA 9 was involved in the narcotic count during the shifts when the discrepancies occurred. The Director of Nursing (DON) attempted to contact QMA 9, who did not respond and later indicated through legal counsel that she would not speak without legal representation. Further investigation by the Unit Manager and LPN 8 revealed that staff were using the wrong page of the narcotic count sheets for Resident D's Oxycodone, and the correct page and corresponding medication card were missing. The DON noted that QMA 9 had been administering more as-needed narcotic medications than usual. The facility's policy on misappropriation of resident property, which includes missing prescription medications, was provided but not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Woods Health Campus | 0.2 mi | ★★★★★ | 7 | 0 |
| Lincoln Hills Of New Albany | 1.4 mi | ★★★★★ | 12 | 0 |
| Villages At Historic Silvercrest The | 2 mi | ★★★★★ | 4 | 0 |
| Rolling Hills Healthcare Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Wedgewood Healthcare Center | 2.8 mi | ★★★★★ | 12 | 0 |
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