Three Oaks Health Services

Penalties

• Mar 11, 2025 — Fine ($17,345)
• Mar 4, 2024 — Fine ($14,433)

Inspection findings

1. Mar 5, 2026 Health · 7 findings
   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Apr 3, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Apr 3, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 3, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Apr 3, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Apr 3, 2026 · CMS fire safety

2. Dec 17, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jan 16, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Jan 16, 2026 · CMS health inspection

3. Mar 11, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected Apr 2, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 2, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Apr 2, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 2, 2025 · CMS health inspection

4. Dec 12, 2024 Health · 11 findings
   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jan 12, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jan 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Jan 12, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0625 Resident Rights Deficiencies

     Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

     Corrected Jan 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jan 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Jan 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 12, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jan 12, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 12, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 12, 2025 · CMS fire safety

5. Mar 4, 2024 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Feb 19, 2024 · CMS health inspection

6. Nov 1, 2023 Health · 7 findings
   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 17, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Nov 17, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Nov 17, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Nov 17, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Nov 17, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Nov 17, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BAUMANN, TROY — adp of the snf, NOT APPLICABLE, since 12/01/2016
• BAUMANN, TROY — operational/managerial control, NOT APPLICABLE, since 12/01/2016
• BAUMANN, TROY — indirect ownership interest, NOT APPLICABLE, since 12/01/2016
• BAUMANN, TROY — corporate officer, NOT APPLICABLE, since 12/01/2016
• BELONGIA, CHRISTINA — adp of the snf, NOT APPLICABLE, since 11/01/2019
• BELONGIA, CHRISTINA — operational/managerial control, NOT APPLICABLE, since 11/01/2019
• GEE, DARREN — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 06/02/2026
• GEE, DARREN — adp of the snf, NOT APPLICABLE, since 11/30/2021
• GEE, DARREN — operational/managerial control, NOT APPLICABLE, since 11/30/2021
• GREER, LAUREN — adp of the snf, NOT APPLICABLE, since 11/29/2023
• GREER, LAUREN — operational/managerial control, NOT APPLICABLE, since 11/29/2023
• HOEHN, JEFFREY — adp of the snf, NOT APPLICABLE, since 12/01/2016
• HOEHN, JEFFREY — operational/managerial control, NOT APPLICABLE, since 12/01/2016
• HOEHN, JEFFREY — corporate officer, NOT APPLICABLE, since 12/01/2016
• PATZER, COLLEEN — operational/managerial control, NOT APPLICABLE, since 02/14/2023
• PATZER, COLLEEN — adp of the snf, NOT APPLICABLE, since 02/14/2023
• PURTELL, BRIAN — adp of the snf, NOT APPLICABLE, since 06/01/2018
• PURTELL, BRIAN — operational/managerial control, NOT APPLICABLE, since 06/01/2018
• RAMNANAN, KESHNI — operational/managerial control, NOT APPLICABLE, since 03/16/2024
• RAMNANAN, KESHNI — adp of the snf, NOT APPLICABLE, since 12/21/2016
• WOLLER, KRISTIN — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• WOLLER, KRISTIN — adp of the snf, NOT APPLICABLE, since 05/01/2026
• BEVERLY ENTERPRISES - WISCONSIN INC — adp of the snf, NOT APPLICABLE, since 12/01/2016
• CIBC BANK USA — operational/managerial control, NOT APPLICABLE, since 12/31/2024
• CIBC BANK USA — 5% or greater security interest, NOT APPLICABLE, since 12/31/2024
• CLIFTONLARSONALLEN LLP — operational/managerial control, NOT APPLICABLE, since 05/22/2018
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 10/20/2025
• CONTINUUM THERAPY PARTNERS LLC — adp of the snf, NOT APPLICABLE, since 04/14/2025
• CONTINUUM THERAPY PARTNERS LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NORTH SHORE HEALTHCARE LLC — 5% or greater indirect ownership interest, 100%, since 12/01/2016
• NORTH SHORE HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 12/01/2016
• NORTH SHORE HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 04/14/2025
• NSH REHAB LLC — operational/managerial control, NOT APPLICABLE, since 03/01/2025
• NSH REHAB LLC — adp of the snf, NOT APPLICABLE, since 06/13/2025
• NSHC WISCONSIN LLC — 5% or greater direct ownership interest, 100%, since 12/01/2016
• NSHC WISCONSIN LLC — adp of the snf, NOT APPLICABLE, since 05/14/2025
• WIPFLI LLP — operational/managerial control, NOT APPLICABLE, since 02/01/2025
• WIPFLI LLP — adp of the snf, NOT APPLICABLE, since 02/01/2025