Marquis Springfield

In the surveyor’s words

From the most serious findings on record at Marquis Springfield, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Jan 5, 2026

  Based on observation, interview and record review the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for not having a homelike environment. Findings include: 1. Resident 74 was admitted to facility in 2015 with a diagnosis of type 2 diabetes mellitus. Resident 74's Annual MDS Assessment completed in 10/2025 indicated a BIMS of 15 (cognitively intact).On [DATE] at 10:23 AM, several rooms on the north hall, including Resident 74's room, were observed to have linoleum floors that appeared stained and dirty. On [DATE] at 9:42 AM. Resident 74 stated the floor in his room looked pretty bad. She/he stated the facility needed to do a better job caring for the floor. 2. […]

• No harm, potential for more than minimal, patternF602Dec 5, 2024

  Based on interview and record review it was determined the facility failed to protect residents' rights to be free from misappropriation of property by staff for 4 of 4 sampled residents (#101, 102, 103 and 104) reviewed for misappropriation of property. Findings include: 1. Resident 101 was admitted to the facility in 2024, with diagnoses including cancer of the colon and frontal lobe of the brain. A Police Department Incident/Investigation Report dated 10/28/24, indicated the department received a report from the facility regarding possible theft of narcotic medication. On the night of 10/23/24 Staff 3 (Agency LPN) oversaw resident medications on the facility's South Hall and a resident complained to day shift staff she/he did not receive her/his narcotic pain medication and was in pain. […]

• No harm, potential for more than minimal, patternF550Aug 2, 2024

  Based on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity for 1 of 1 sampled resident (#137) reviewed for dignity, 3 of 15 residents (#s 2, 15 and 39) reviewed for assisted dining. This placed residents at risk for lack of dignity. Findings include: 1. Random observations on 7/30/24 from 12:20 PM through 12:50 PM (30 minutes) revealed Staff 19 (CNA) was in the Willamette dining room and Residents 2, 15 and 39 were all seated at the same table for lunch. Staff 19 stood or walked around the table to assist each each of the residents with their lunch meal. On 7/30/24 at 1:13 PM Staff 19 stated the three residents in the Willamette dining room needed assistance and cueing when eating their meals. […]

• No harm, potential for more than minimal, patternF584Aug 2, 2024

  Based on observation and interview it was determined the facility failed to ensure resident dining environments were homelike, and resident shower rooms were clean for 1 of 2 dining rooms and 5 of 5 shower rooms reviewed for environment. This placed residents at risk for lack of homelike environment and an unsanitary environment. Findings include: 1. Observations on 7/30/24 at 9:25 AM and 8/1/24 at 10:01 AM revealed five individual shower rooms for residents. All five shower rooms were observed to have a heater vent, a small heater unit on the wall, and a ceiling fan. […]

• No harm, potential for more than minimal, patternF759Apr 7, 2023

  Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than 5% (5 errors in 31 opportunities resulting in a 16.13% error rate) for 3 of 4 sampled residents (#s 6, 9 and 55) observed for medication administration. This placed residents at risk for medication errors. Findings include: 1. Resident 6 admitted to the facility in 2022 with diagnoses including diabetes. A review of Physician Orders revealed a 7/31/22 order for Miralax Powder (a laxative) one time a day mixed with 4 to 8 ounces (120 to 240 milliters(ml)) of fluid. On 4/6/23 at 8:11 AM Staff 21 (CMA) was observed administering medication to Resident 6 including Miralax (a bowel medication) mixed with approximately 120 ml water. […]