Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marquis Springfield during CMS and state inspections, most recent first.
A facility failed to protect residents from misappropriation of narcotic medications by an agency LPN, who documented administering medications before they were available and failed to follow standard nursing practices. Residents reported not receiving prescribed pain medications, and discrepancies in documentation and medication handling were identified, compromising resident care and safety.
The facility failed to report a suspected crime involving medication misappropriation to the State Survey Agency. An LPN was linked to discrepancies in narcotic charting, with residents receiving only Tylenol instead of prescribed oxycodone. Despite reporting to law enforcement and the Oregon State Board of Nursing, the DNS did not report to the State Survey Agency, citing insufficient evidence. The administrator and DNS later acknowledged this oversight.
A CNA failed to maintain dignity by standing while assisting residents during meals, contrary to expectations to be seated. Additionally, a resident with a neurogenic bladder had their catheter bag exposed without a privacy cover, visible from the hallway, violating privacy protocols.
The facility failed to ensure a clean and homelike environment, with significant dust accumulation in shower rooms and improper meal service in the dining room. Housekeeping and maintenance staff did not routinely clean shower room components, and meals were served on trays against protocol.
A resident with dementia and depression had their call light out of reach, despite being cognitively intact and needing assistance to move in bed. Observations showed the call light on the floor, and staff failed to ensure it was accessible. A CNA and the DNS acknowledged the oversight, confirming the expectation for call lights to be within reach.
A resident did not receive the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) after Medicare services ended, leaving them uninformed about financial responsibilities. The Social Service Director acknowledged this oversight, which placed the resident at risk for unforeseen financial liabilities.
The facility failed to assess the nutritional needs of two residents, one with diabetes and end-stage renal disease, and another with a femur fracture and lung cancer. The Admission MDS for both residents lacked comprehensive nutritional assessments, which was confirmed by the DNS.
A facility failed to implement a physician-ordered InterDry cloth for a resident with a history of stroke and dementia, leading to a risk of functional decline. Despite the order to place the cloth in the resident's right hand daily to manage contracture, observations revealed its absence. Staff acknowledged the necessity of the device, but it was not consistently used.
A resident with dysphagia was admitted with recommendations for crushed medications due to swallowing deficits. The facility failed to include these precautions in the care plan or orders, leading to an incident where the resident coughed aggressively after receiving medication in tablet form. Staff confirmed the recommendations were not reviewed or implemented.
A resident with end-stage renal disease missed a dialysis appointment due to unscheduled transportation, leading to fluid overload and inadequate monitoring. The facility also failed to maintain complete communication with the dialysis provider, with missing and incomplete documentation on several occasions.
A resident with stroke and dementia was prescribed prednisone for gout, but an LPN mistakenly administered a higher dose than prescribed. The error was discovered the next day, and the physician was notified. The resident did not experience adverse effects from the additional dose.
A facility failed to secure a dialysis contract for a resident with end-stage renal disease who required dialysis three times a week. Despite the resident receiving dialysis from an outside provider, the facility did not have a signed contract with the provider, as acknowledged by the DNS.
Misappropriation of Narcotic Medications by Staff
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property by staff, specifically involving the administration and documentation of narcotic medications. Staff 3, an agency LPN, was implicated in multiple discrepancies regarding the administration of narcotic medications to four residents. For Resident 101, Staff 3 documented administering oxycodone before it was available from the Pyxis machine, and the resident reported not receiving the medication, resulting in increased pain. Staff 3 also failed to follow standard nursing practice by not obtaining the necessary authorization for the medication and leaving the resident in pain. Resident 102, who was alert and oriented, reported not receiving oxycodone despite documentation by Staff 3 indicating it was administered. The medication was documented as given before it was available, and the resident only received Tylenol, which was ineffective for their pain. Staff 3's documentation was inconsistent with the resident's account and the timeline of medication availability, raising concerns about the accuracy and integrity of the medication administration process. For Resident 103, Staff 3 pulled a dose of Tramadol but did not administer it as the resident was sleeping. The medication was not destroyed as required, and there was no documentation of its disposal. Similarly, for Resident 104, Staff 3 documented administering oxycodone and Tylenol while the resident was reportedly asleep, and the one-to-one sitter confirmed the nurse never entered the room. These discrepancies highlight significant issues with medication management and documentation, compromising resident care and safety.
Failure to Report Suspected Medication Misappropriation
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime to the State Survey Agency for four residents who were reviewed for misappropriation of property. The issue arose when a police department incident report indicated that the facility had reported a possible theft of narcotic medication. A complaint form submitted to the Oregon State Board of Nursing detailed a possible diversion of medications, with discrepancies noted in the charting of narcotics by an LPN. Residents reported receiving only Tylenol for pain relief instead of their prescribed oxycodone, despite being alert and oriented. An investigation linked all concerns to the LPN, and a report was filed with law enforcement. Despite these findings, the Director of Nursing Services (DNS) did not report the concerns to the State Survey Agency, believing there was insufficient evidence to prove medication diversion. The DNS acknowledged multiple documentation issues with the LPN's handling of narcotic medications, including the simultaneous administration of PRN Tylenol and PRN narcotic pain medication, which was deemed illogical. The facility's administrator and DNS later acknowledged the failure to report to the State Survey Agency.
Dignity and Privacy Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meal assistance and in maintaining privacy for a resident with a catheter. During a 30-minute observation, a CNA was seen standing or walking around the table while assisting three residents with their lunch meals, instead of being seated as expected. The CNA acknowledged the oversight and confirmed that the residents required assistance and cueing during meals. The Director of Nursing Services (DNS) also confirmed that staff are expected to sit with residents who need help with eating. Additionally, a resident with a neurogenic bladder and an indwelling catheter was observed multiple times with their catheter bag exposed and visible from the hallway, as the room door was open. The catheter bag had no privacy cover, which was against the facility's protocol. The DNS acknowledged the lack of a privacy bag or flap covering the catheter, confirming the deficiency in maintaining the resident's privacy.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in both the resident dining and shower areas. Observations revealed that five individual shower rooms had significant dust and cobweb accumulation on the heater vents, small heater units, and ceiling fans. The housekeeper, Staff 20, acknowledged the responsibility for cleaning these areas but indicated an inability to clean the accumulated dust inside the components, referring the task to the Maintenance Director, Staff 3. Staff 3 admitted to not routinely cleaning these areas unless there was a mechanical failure, indicating a lack of awareness regarding the need for regular cleaning. In the dining room, the facility's protocol for serving meals was not followed, as observed during lunch service. Residents were served meals on trays, which were not removed before serving, contrary to the facility's protocol. The Dietary Manager, Staff 8, initially stated that serving meals on trays was the standard practice since before the COVID-19 pandemic. However, upon reviewing the protocol, Staff 8 acknowledged that meals should not be served on trays, indicating a deviation from established procedures.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. Resident 25, who was admitted in November 2017 with diagnoses of dementia and depression, was found to have a BIMS score of 15, indicating cognitive intactness. On July 29, 2024, the resident expressed needing assistance to move in bed and was unaware of the call light's location. Observations from 1:08 PM to 3:09 PM on the same day revealed the call light was on the floor, out of reach. Staff entered the room at 1:18 PM and repositioned the resident but did not ensure the call light was accessible. Later, at 3:09 PM, a CNA acknowledged the call light was out of reach and confirmed that the resident required it for assistance. The Director of Nursing Services (DNS) stated on August 1, 2024, that staff were expected to ensure call lights were accessible at all times and acknowledged the oversight regarding Resident 25's call light.
Failure to Provide Financial Responsibility Information
Penalty
Summary
The facility failed to provide necessary information regarding financial responsibilities to a resident who was receiving Medicare services. Resident 14 was admitted to the facility in April 2024 and received Medicare services from late April to late June 2024. Although the resident signed the Notice of Medicare Non-Coverage (NOMNC) on June 26, 2024, there was no evidence that the resident received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), which would have informed them of their financial liability after Medicare services ended. This oversight was acknowledged by the Social Service Director on July 31, 2024, indicating that the resident did not receive the necessary information about financial responsibilities after Medicare services were discontinued while they remained in the facility.
Failure to Assess Nutritional Needs
Penalty
Summary
The facility failed to comprehensively assess the nutritional needs of two residents, placing them at risk for unmet nutritional needs and weight loss. Resident 17, admitted with diagnoses including diabetes, end-stage renal disease, and dependence on renal dialysis, had an Admission MDS Nutritional Status CAA dated 5/15/24 that did not include the resident's history, current nutritional status, or plan of care. This omission was acknowledged by Staff 2 (DNS) on 8/1/24. Similarly, Resident 42, admitted with diagnoses including a fracture of the right femur, malignant neoplasm of the lung, and type 2 diabetes, had an Admission MDS that triggered a Nutritional Status CAA for further assessment. However, there was no documentation in the resident's medical record indicating that the Nutritional Status CAA was completed, and Staff 2 (DNS) confirmed the assessment was blank on 8/1/24.
Failure to Implement Physician-Ordered Mobility Device
Penalty
Summary
The facility failed to implement a physician-ordered mobility device for a resident, which placed the resident at risk for functional decline. The resident, admitted in October 2021, had a history of stroke and dementia, with impairments in the upper and lower extremities on one side of the body. A physician order dated January 9, 2024, required an InterDry cloth to be placed in the resident's right hand daily to manage contracture and prevent sweat and yeast buildup. However, observations from July 29 to July 31, 2024, revealed that the resident was either in a wheelchair or in bed without the prescribed skin-protecting device in the right hand. Staff members, including CNAs and LPNs, acknowledged the absence of the InterDry cloth and confirmed the necessity of its use as per the physician's order. Despite the expectation from the Director of Nursing Services and Resident Care Managers to follow the physician's order, the device was not consistently implemented.
Failure to Implement Swallowing Precautions for Resident with Dysphagia
Penalty
Summary
The facility failed to evaluate and implement necessary precautions for a resident with dysphagia, leading to a potential risk of choking. The resident, who was admitted with a history of stroke and difficulty swallowing, had a hospital speech therapy assessment indicating a need for medications to be crushed and mixed with thin liquids or puree due to swallowing deficits. However, upon admission, the facility did not include these recommendations in the resident's orders or care plan, and there was no evidence that the facility addressed the need for crushed medication. Observations and staff interviews revealed that the resident was not flagged for swallow precautions during medication administration. On one occasion, the resident was observed coughing aggressively after receiving medication in tablet form, requiring staff assistance to clear the airway. Staff confirmed that the hospital's speech therapy recommendations were not reviewed upon admission, and the resident was not assessed for safe medication swallowing after admission.
Failure to Ensure Proper Dialysis Services and Communication
Penalty
Summary
The facility failed to ensure proper dialysis services for a resident with end-stage renal disease, who was dependent on renal dialysis. The resident was admitted with a care plan indicating dialysis on specific days of the week. However, the resident missed a dialysis appointment due to transportation issues, which were not properly scheduled by the facility. This resulted in the resident experiencing fluid overload and requiring close monitoring, including daily weights and strict fluid restriction. Despite these requirements, the facility did not document the resident's weight on one of the days, indicating a lapse in monitoring. Additionally, the facility did not maintain complete communication with the dialysis provider. Several dialysis communication forms were incomplete, lacking essential information such as weight, blood pressure, and any symptoms experienced by the resident prior to dialysis. On multiple occasions, there were no communication forms completed at all, despite the resident receiving dialysis on those dates. This lack of documentation and communication with the dialysis provider further contributed to the deficiency in providing safe and appropriate dialysis care for the resident.
Medication Error: Incorrect Prednisone Dosage Administered
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically involving the administration of prednisone, a steroid medication. A resident, admitted with diagnoses including stroke and dementia, was prescribed prednisone for gout. The physician's order specified a tapering dosage, starting with 40 mg daily for five days, followed by 20 mg daily for four days. However, a medication error occurred when an LPN mistakenly administered 40 mg instead of the prescribed 20 mg on a specific day. This error was discovered the following day by another LPN, who then notified the physician and monitored the resident for any severe reactions. The error was attributed to the removal of two prednisone pills from the medication card, leading to the incorrect dosage being administered. The staff involved acknowledged the mistake and emphasized the importance of adhering to the five rights of medication administration. Despite the error, it was reported that the resident did not suffer any adverse effects from the additional dose of prednisone. The incident highlights a lapse in medication administration procedures, specifically in ensuring the correct dosage is given as per the physician's order.
Lack of Dialysis Contract for Resident
Penalty
Summary
The facility failed to have a dialysis contract in place for a resident who was dependent on renal dialysis. The resident was admitted to the facility with diagnoses including diabetes, end-stage renal disease, and dependence on renal dialysis. The care plan indicated that the resident received dialysis three times a week. However, it was acknowledged by the Director of Nursing Services (DNS) that the resident received dialysis from an outside provider, and the facility did not have a signed contract with this provider.
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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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Valley Rehabilitation Health Center | 3.4 mi | — | 25 | 0 |
| South Hills Rehabilitation Center | 4.1 mi | — | 6 | 0 |
| Creekside Health And Rehab Of Cascadia | 4.4 mi | — | 0 | 0 |
| Cascade Manor | 4.6 mi | — | 0 | 0 |
| Avamere Riverpark Of Eugene | 5.2 mi | — | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.