Above 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 Marquis Springfield during CMS and state inspections, most recent first.
Homelike Environment Not Maintained: A cognitively intact resident with DM2 reported a dirty-looking floor in the room, and observations found stained linoleum in multiple rooms, worn and torn hallway carpet, scratched and stained doors and casings, damaged walls and flooring, unclean lights, and damaged surfaces in common areas. The Plant Operations Manager said he was aware of needed repairs and had no comprehensive building maintenance plan, and the Administrator acknowledged significant maintenance items needed to be addressed.
Failure to complete a risk-benefit assessment for a resident with lactose intolerance. A resident with a hx of diverticulitis and an order for Lactaid continued to choose dairy foods and experienced loose stools/diarrhea after eating them. Staff knew the resident was eating dairy and having symptoms, but the RD had not completed a dietary assessment and the RNCM had not completed a Declination of Treatment related to the resident’s lactose intolerance.
A resident admitted with heart disease and cognitively intact on the admission MDS developed a bleeding left great toe injury after staff observed blood on the bed sheets. The resident said he/she did not know what happened and could not feel the feet, while staff gave conflicting accounts of whether the toe was bumped. The clinical record showed no Skin Event form or investigation was started for the new skin issue.
Failure to provide bed hold information at hospital transfer. Two cognitively intact residents were transferred to the hospital, but the record did not show that bed hold information was explained, offered, or provided to one resident, and the other resident stated no bed hold information or paperwork was given. Staff said nurses completed the Oregon Notice of Transfer or Discharge and Bed Hold form and residents were supposed to receive a copy when they left, but the documentation was incomplete and did not show when the bed hold policy was discussed.
A resident with a hx of stroke and vision loss was not provided meaningful activities aligned with a stated interest in reading. The resident was observed awake in bed without engaging in activities, the care plan had no book-related activities, and staff noted the resident often spent time in bed, appeared bored, and was sometimes irritable. The Activities Director and Administrator acknowledged that audio books were available and should have been offered.
A resident with heart disease had physician orders for daily weights and provider notification for significant weight gain, but the record showed repeated weight increases without documentation that the provider was notified. The same resident later had blood on the bed sheets and a left great toe injury, but the chart did not show a skin event, monitoring, or treatment being started for the new skin issue.
A resident with weakness and scoliosis had a history of rolling out of bed, but fall mats ordered in the care plan were repeatedly found rolled up in the corner instead of at the bedside. Another resident had meat stuck in the throat and reported ongoing swallowing problems, yet staff said the resident was not monitored or placed on alert for aspiration. In a separate event, anti-fungal powder was found on a bedside table even though staff stated meds should not be kept at the bedside without an order, assessment, and lock box.
Failure to Maintain Resident Nutrition Status: A resident with a G-tube and severe protein malnutrition had repeated missed or partial tube feedings and water flushes, delayed implementation of RD recommendations, and ongoing weight loss. Another resident with diabetes had a rapid weight loss that was not assessed or reported to the provider in a timely manner. A third resident with acute kidney failure and protein-calorie malnutrition received less protein than ordered, and staff communication about the resident’s nutritional needs was delayed.
A resident admitted with a stroke diagnosis had an initially normal PHQ-9 and BIMS, but later developed tearfulness, frustration about not going home, repeated refusals of care, irritability, withdrawal, and sexualized behaviors toward a CNA. Staff interviews described the resident as not very expressive, sometimes tearful, and seeming to struggle with depression, while the RNCM stated there was no record of a depression assessment or mental health therapy being offered. The resident later stated feeling depressed and suicidal and wanting to go home.
Medication Given Despite BP Hold Parameters: A resident with HTN had an order for Aldactone to be held when SBP was below 115 or DBP was below 70, but the MAR showed the med was administered multiple times when DBP was under 70. Staff, including a CMA, LPN, regional nurse consultant, and DNS, confirmed the doses should have been held per the order.
Insulin Open Date Not Documented: A resident with diabetes had Lispro insulin prepared by an LPN without an open date documented. Staff stated insulin should be dated when opened, but the facility could not determine when the insulin was first used because the pharmacy receipt binder did not contain a receipt for the resident’s Lispro.
A resident admitted with diabetes and a UTI was cognitively intact, but the chart contained no documentation that the flu vaccine was offered for the current flu season. The facility policy required all residents to be offered vaccinations and for vaccination information to be recorded in the medical record, and the DNS acknowledged the resident was not offered the influenza vaccine.
Missing Bathroom Call Lights: Two residents were observed with bathrooms that did not have accessible call light cords. One resident had dementia and the other was cognitively intact; both were admitted in 11/2024. Maintenance stated staff were expected to notify him if a cord was missing, and the Administrator stated audits were done to ensure bathroom call light cords were present.
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.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a homelike environment for 1 of 1 facility reviewed for environment. Resident 74, admitted in 2015 with a diagnosis of type 2 diabetes mellitus, had an Annual MDS Assessment completed in 10/2025 that indicated a BIMS of 15, showing the resident was cognitively intact. During observation on [DATE] at 10:23 AM, several rooms on the north hall, including Resident 74's room, were seen with linoleum floors that appeared stained and dirty. On [DATE] at 9:42 AM, Resident 74 stated the floor in the room looked pretty bad and that the facility needed to do a better job caring for the floor. A facility walk-through on [DATE] at 10:00 AM found hallway carpets excessively worn, stained, or torn in 5 of 5 halls used by residents, including a divot in the hallway outside rooms [ROOM NUMBERS] that created a tripping hazard. Door and casings were significantly scratched, marred, and stained in 44 of 55 resident rooms observed. Additional findings included warped, bubbling carpet in room [ROOM NUMBER], stained linoleum in 13 of 16 rooms on the north hall, worn or chipped paint in rooms [ROOM NUMBERS], an unrepaired hole in the wall in room [ROOM NUMBER], chipped linoleum in room [ROOM NUMBER], unclean hanging lights with burnt-out bulbs in a small activity room, and damaged or dirty surfaces in the main dining room and entryway. Resident 32 later stated the carpet needed cleaning because it looked like someone bled to death on the floor. Staff 6, the Plant Operations Manager, stated he was aware of the needed repairs and had no comprehensive plan for building maintenance, and Staff 1, the Administrator, stated she was aware there were significant building maintenance items that needed to be addressed.
Failure to Complete Risk-Benefit Assessment for Lactose Intolerance
Penalty
Summary
The facility failed to provide a resident with a risk-benefit assessment related to lactose intolerance and food choices. Resident 74, admitted in 2015 with diagnoses including diverticulitis, had a clinical record entry dated 2/15/23 documenting lactose intolerance and a physician order dated 9/2024 for Lactaid. On 12/29/25, the resident stated that dairy products continued to be served with meals and that, even when taking Lactaid before each meal, loose stools still occurred after consuming dairy. Staff interviews showed that multiple staff members were aware the resident continued to eat dairy products and experienced loose stools or significant diarrhea after doing so. A CNA stated she often reminded the resident that the loose stools were related to dairy intake, and another CNA stated the resident frequently experienced loose stools when consuming dairy products. The RD stated she assumed the resident understood the consequences because Lactaid was being taken, but she had not completed a dietary assessment. The RNCM stated the resident was noncompliant with dietary recommendations but had not completed a Declination of Treatment related to lactose intolerance, and the DNS stated staff should have completed a Declination of Treatment with the resident.
Failure to Investigate New Skin Injury
Penalty
Summary
The facility failed to ensure a resident’s skin injury was investigated for one of three sampled residents reviewed for non-pressure skin injury. Resident 77 was admitted with a diagnosis of heart disease and was cognitively intact on the admission MDS. On 12/29/25, a CNA and nurse observed blood on the resident’s bed sheets, and the resident was assessed as having hit the left great toe, with the resident stating he/she was not able to feel the feet and did not know what happened. The resident later stated the toe was bleeding, while staff stated he/she bumped it on something but also stated he/she did not hit the foot on anything. The clinical record showed no investigation related to the left great toe skin injury, and staff interviews confirmed the Skin Event form and investigation were not started when the new skin issue was identified.
Failure to Provide Bed Hold Information at Hospital Transfer
Penalty
Summary
The facility failed to ensure residents were given bed hold information for 2 of 2 sampled residents reviewed for hospitalization. The facility’s Bed Hold Policy stated staff were to complete an Oregon Notice of Transfer or Discharge and Bed Hold form with each resident transfer and ensure the resident had the paperwork when they transferred out of the facility. Resident 2 was admitted with diagnoses including a left leg infection and diabetes, and the 10/12/25 admission MDS indicated the resident was cognitively intact. The medical record showed Resident 2 transferred to the hospital, but no documentation was found showing that bed hold information was explained, offered, or given when the resident left the facility. Resident 31 was admitted with diagnoses including heart failure and respiratory failure, and the 12/4/25 admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact. A 12/17/25 Oregon Notice of Transfer or Discharge and Bed Hold form showed the resident was transferred to the hospital due to a change of condition and included bed hold policy details, but it did not show that the information was discussed with the resident. Resident 31 stated no bed hold information was discussed or paperwork provided at the time of the hospital transfer. Staff stated nurses completed the nursing portion of the form, that residents were to receive a copy when they left the facility, and that the form for Resident 31 was incomplete because it did not include when the bed hold information was discussed.
Failure to Provide Meaningful Activities for a Resident With Reading Interests
Penalty
Summary
The facility failed to provide meaningful activities designed to meet the interests of Resident 14, who was admitted with diagnoses including cerebral infarction (stroke). The resident stated a prior interest in reading and reported that the stroke took away the ability to read because of vision loss. During observations over several days, Resident 14 was seen awake and in bed without engaging in any activity. The clinical record noted, “In the past, I enjoyed reading a lot,” and a nursing note documented that the resident was unable to read after the stroke. The Activities Care Plan did not include any activities related to books. Staff reported that the resident spent most of the time in bed or listening to television, often appeared bored, and could be irritable. The Activities Director stated that a resident interested in reading should have been offered audio books, and the Administrator stated the facility had audio book options available and Resident 14 should have been offered them.
Failure to Follow Weight Monitoring and Skin Injury Orders
Penalty
Summary
The facility failed to follow physician orders for a resident admitted in 12/2025 with heart disease. The resident had an order dated 12/19/25 for daily weights and for the medical provider to be notified if there was more than a three-pound weight gain in 24 hours or a five-pound gain in one week. The weight log showed the resident weighed 272 pounds on 12/18/25, 275.8 pounds on 12/19/25, and 279.4 pounds on 12/20/25, but the clinical record did not document that the medical provider was notified of the weight gains on 12/19/25 or 12/20/25. Staff 5 verified that the provider was not notified on those dates per the physician order. The facility also failed to implement non-pressure injury interventions after a new skin issue was identified. On 12/29/25, a CNA and nurse observed blood on the resident’s bed sheets, and the resident was assessed as having hit the left great toe. The resident reported not being able to feel the feet and not knowing what happened. The record did not show that a skin event was initiated or that skin treatments and monitoring were started on the 12/2025 TAR for the toe injury. Staff 7 stated that a new skin issue required a skin event, monitoring, and treatment, and Staff 5 confirmed these actions were not initiated.
Failure to Follow Fall Precautions, Monitor After Aspiration Event, and Secure Bedside Medication
Penalty
Summary
The facility failed to ensure fall interventions remained in place for a resident with weakness and scoliosis who had a history of rolling out of bed. The resident was admitted in 11/2025, had a fall on 11/23/25 while trying to take self to the bathroom, and fall mats were added as an intervention and included in the care plan on 11/25/25. However, multiple observations from 12/29/25 through 1/5/26 showed the fall mats rolled up in the corner of the room rather than at the bedside, and the resident stated the mats were no longer being used. Staff confirmed the care plan called for fall mats at the bedside and that staff were expected to follow the care plan. The facility also failed to monitor a resident after an aspiration-related event and failed to prevent medication from being left at a bedside. One resident had a piece of meat caught in the throat, cleared it with coughing, burping, and drinking fluids, and reported ongoing problems with meat and harder vegetables getting stuck; staff documented the event and changed the diet to chopped meats with gravy, but later staff and the resident stated the resident was not monitored and had not been placed on alert for aspiration. In another instance, anti-fungal powder was observed on a resident’s bedside table, and staff stated medications were not to be kept at the bedside without an order, an assessment of the resident’s ability to self-administer, and a lock box.
Failure to Maintain Resident Nutrition Status
Penalty
Summary
The facility failed to maintain healthy nutrition status for 3 of 7 sampled residents reviewed for pressure ulcers, tube feeding, and nutrition. Resident 12 was admitted with diagnoses including diaphragmatic hernia without obstruction and esophageal obstruction, had a G-tube, was coded NPO, and was monitored for impaired nutrition. The hospital discharge summary and subsequent enteral feeding orders directed continuous tube feeding and water flushes, but the MAR showed multiple missed or partially administered feedings and water flushes, with documentation of NA or no total received on several dates. Resident 12’s weight declined from 117.2 pounds on 10/7/25 to 104.2 pounds on 10/17/25, and the record noted significant weight loss, severe protein malnutrition, and repeated dietitian concerns that the current interventions were not appropriate. The record showed repeated delays and gaps in implementing dietitian recommendations for Resident 12. The dietitian recommended increasing the formula after weight loss was identified, but the recommendation was returned for inaccurate calculations, resubmitted, and not approved until 10/22/25; the new order was not implemented until 10/24/25. Later orders also lacked documentation of total formula received, and the 11/2025 MAR showed the total formula received was documented only 16 out of 60 scheduled feeding opportunities. The resident continued to lose weight at points during the stay, and staff interviews confirmed awareness that the resident’s nutritional needs were not being met and that the feeding orders were not followed up in a timely manner. Resident 13 was admitted with diabetes and had a significant weight loss from 236.8 pounds on 12/4/25 to 220 pounds on 12/9/25. Staff interviews showed the weight loss was identified at different times by different staff, but the resident was not assessed and the provider was not notified in a timely manner. The RD stated nutritionally enhanced meals were recommended, while the RN RCM stated there were no recommendations from the RD and acknowledged the provider had not been notified. The DNS stated weights were reviewed daily and that significant weight loss was expected to be identified, assessed, care planned, and reported within the week, but this did not occur timely. Resident 96 was admitted with acute kidney failure and protein-calorie malnutrition. A physician order required 75 grams of protein, but the dietitian assessment documented the resident received no supplements, ate 60% of meals, and received only 42 grams of protein daily. The dietitian recommended increased calories and protein, but the assessment was incomplete and required additional information. The resident stated he or she received dialysis three times weekly and did not want breakfast before leaving. Staff interviews showed the RN was unaware the resident required additional nutritional resources, the RD did not communicate the concern until 12/29/25, and the DNS acknowledged the nutritional interventions were not implemented timely.
Failure to Address Resident Mood and Behavior Changes
Penalty
Summary
The facility failed to ensure that a resident did not develop patterns of decreased social interaction and increased withdrawn, angry, or depressive behaviors unless unavoidable. Resident 14 was admitted with diagnoses including cerebral infarction (stroke). The resident’s MDS completed in 9/2025 showed a BIMS score of 15 and a PHQ-9 score of 00, indicating the resident was cognitively intact and not depressed at that time. A 10/14/25 progress note documented that the resident was tearful, asked about therapy options after being discharged from PT for lack of progress, and expressed frustration about not being able to go home. The resident had previously been described as pleasant and cooperative, and a 10/15/25 note documented the resident declined a shower despite multiple staff attempts, with no prior declinations of care noted in the record. Subsequent progress notes documented continued changes in mood and behavior, including calling the mother believing discharge was scheduled, being tearful and upset about going home, being charted as alert for depression for 1 week, declining multiple showers or a bed bath, expressing sexualized feelings toward a female CNA, becoming irritable with staff, refusing bowel care, appearing unmotivated and avoiding eye contact, refusing to get out of bed, refusing independent exercise therapy, and later being tearful during a provider visit. On 12/29/2025, the resident stated feeling depressed and suicidal and wanting to go home, and stated staff had not been told about these feelings. During interviews, staff described the resident as not very expressive, needing frequent checks because the resident would not ask for care, and seeming to struggle with depression and sometimes being tearful. The RNCM stated there was no indication in the clinical record that the resident had been assessed for depression or offered mental health therapy, while the SSA stated therapy had been discussed and declined, but no practitioner evaluation for depression had been requested.
Medication Given Despite Blood Pressure Hold Parameters
Penalty
Summary
The facility failed to follow medication parameters for one resident who was admitted with diagnoses including hypertension. The resident had a physician order dated 12/12/25 for Aldactone 12.5 mg twice daily for fluid retention, with instructions to hold the medication if systolic blood pressure was less than 115 or diastolic blood pressure was less than 70. Review of the resident’s MAR showed Aldactone was documented as administered on multiple occasions when the diastolic blood pressure was below 70, including readings such as 124/62, 122/60, 128/68, 130/60, 128/60, 126/66, and 124/66. Staff interviews confirmed the medication was given despite the hold parameters. A CMA stated she administered Aldactone on several dates when the diastolic blood pressure was less than 70 and acknowledged it should have been held. A regional nurse consultant and an LPN also stated the medication should have been held on the dates and times identified because the resident’s blood pressure was below the ordered parameter. The DNS stated staff were expected to follow orders and hold medications when the order indicated the medication be held.
Insulin Open Date Not Documented
Penalty
Summary
The facility failed to ensure an insulin open date was documented for 1 of 1 sampled resident observed receiving insulin during medication administration. Resident 17 was admitted with a diagnosis of diabetes and had active orders for staff to administer Lispro insulin with meals. During observation, Staff 8 prepared the Lispro insulin and it did not have an open date documented. Staff 8 stated that all insulin was to be dated when first opened. Later, Staff 9 stated insulin should be dated when opened and could not determine when the Lispro was first used because the 12/2025 pharmacy receipt binder did not have a receipt for the resident’s Lispro insulin. Staff 2 also stated that all insulin was to be dated when opened and that Lispro was good for 28 days after it was opened and at room temperature.
Failure to Offer Influenza Vaccine
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility failed to ensure the influenza vaccine was offered to 1 of 5 sampled residents reviewed for vaccinations. The facility’s Vaccination of Residents policy, revised in 5/2021, stated that all residents were to be offered vaccinations that helped prevent disease and that all vaccination information was to be recorded in the resident’s medical record. Resident 13 was admitted in 11/2025 with diagnoses including diabetes and urinary tract infection, and the 11/27/25 admission MDS indicated the resident was cognitively intact. A review of the resident’s medical record found no documentation that the influenza vaccine was offered for the 2025 flu season, and the DNS acknowledged on 1/5/26 that Resident 13 was not offered the influenza vaccine for that season.
Missing Bathroom Call Lights
Penalty
Summary
The facility failed to ensure residents had accessible bathroom call lights for 2 of 3 sampled residents reviewed for accidents. Resident 38, admitted in 11/2024 with dementia, was observed on 12/29/25 at 12:42 PM with a bathroom that did not have a call light cord available for use if she fell to the ground. Resident 83, admitted in 11/2024 with a diagnosis of UTI and cognitively intact per the 11/23/25 admission MDS, was also observed on 12/29/25 at 12:42 PM with a bathroom that did not have a call light cord available for use if she fell to the ground. On 1/2/26, Maintenance staff stated that if a resident room did not have a call light cord, staff were to notify him and he would provide one, and he stated he had not been notified that Resident 38 did not have a bathroom call light cord. On 1/5/26, the Administrator stated she and the DNS completed audits to ensure residents' bathrooms had call light cords and that staff were to notify maintenance in person or through the facility online communication system if a resident needed a new call light cord.
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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What surveyors actually found near you
We read the 133 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 22 | 1 |
| Creekside Health And Rehabilitation Of Cascadia | 4.4 mi | ★★★★★ | 5 | 0 |
| Cascade Manor | 4.6 mi | ★★★★★ | 4 | 0 |
| Avamere Riverpark Of Eugene | 5.2 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.