Cycle 1
Health 2024-12-12 · Fire 2024-12-12
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Marshfield, WI
Three Oaks Health Services
2-star overall rating with 2-star inspections with $41,118 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
209 Wilderness View Drive, Marshfield, WI
(715) 389-6000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
2005-06-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,661
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.68% · Performance 21.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.87% · Performance 7.92% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.55
Baseline 37.26% · Performance 40.98% · Measure score 5.55 · Achievement 5.55 · Improvement 0
Adjusted total nurse staffing
0.78
Baseline 3.02 hours · Performance 3.3 hours · Measure score 0.78 · Achievement 0.78 · Improvement 0.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.89% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 3.23% · Lower 95% interval 5.24% |
| Discharge to community | 59.09% |
50.57%
8.5 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 54.72% · Lower 95% interval 45.71% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 34 · Denominator 34 |
| Falls with major injury | 5.88% |
0.77%
5.1 pts worse
|
Numerator 2 · Denominator 34 |
| Discharge self-care score | 34.48% |
53.69%
19.2 pts worse
|
Numerator 10 · Denominator 29 |
| Discharge mobility score | 34.48% |
50.94%
16.5 pts worse
|
Numerator 10 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.92% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 10.64% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 8.11% |
8.2%
0.1 pts worse
|
Numerator 6 · Denominator 74 |
| Staff flu vaccination coverage | 56.58% |
42%
14.6 pts better
|
Numerator 43 · Denominator 76 |
| Discharge function score | 41.38% |
56.45%
15.1 pts worse
|
Numerator 12 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
2.2
2 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.6% |
95.7%
13.1 pts worse
|
93.4%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.3% · Q2 78.2% · Q3 80.4% · Q4 83.0% · 4Q avg 82.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
95.0%
1.5 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 3.6% · Q4 3.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
5.0%
2.1 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.1% · Q3 0.0% · Q4 2.1% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
4.9%
2.3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 2.9% · Q4 2.6% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
16.6%
2.9 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 12.8% · Q3 8.3% · Q4 18.4% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
16.7%
4.5 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.1% · Q3 11.5% · Q4 3.3% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.8% |
21.1%
1.3 pts better
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
17.3%
5.3 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 21.6% · Q3 26.5% · Q4 18.9% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
2.3%
2.1 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 1.8% · Q3 5.2% · Q4 1.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
3.0%
1.2 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.9% · Q3 1.8% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.0% |
25.5%
6.5 pts worse
|
19.8%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 28.7% · Q3 32.1% · Q4 31.6% · 4Q avg 32.0% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.5%
0.8 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.1% · Q3 4.3% · Q4 3.1% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.2% |
86.8%
21.6 pts worse
|
81.7%
16.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.2% · Q2 82.0% · Q3 69.6% · Q4 42.3% · 4Q avg 65.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
15.0%
6.5 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 7.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 1.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.7% |
82.2%
21.5 pts worse
|
79.7%
19 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
22.7%
4 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 23.1% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-01 · Fire 2023-11-01
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-14 · Fire 2022-09-14
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-12
D · Potential for more than minimal harm
2024-12-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-12
D · Potential for more than minimal harm
2024-12-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-12
E · Potential for more than minimal harm
2023-11-01
K222 · Egress Deficiencies
Fire Safety
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 2023-11-17
D · Potential for more than minimal harm
2023-11-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-11-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-11-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-11-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-17
F · Potential for more than minimal harm
2022-09-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-09-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-10
C · Minimal harm
2022-09-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-10-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-17
F693 · Quality of Life and Care Deficiencies
Health
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 2026-01-16
J · Immediate jeopardy
2025-03-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-02
F · Potential for more than minimal harm
2025-03-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-11
F758 · Pharmacy Service Deficiencies
Health
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 2025-04-02
F · Potential for more than minimal harm
2024-12-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-12
F · Potential for more than minimal harm
2024-12-12
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-01-12
E · Potential for more than minimal harm
2024-12-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-12
E · Potential for more than minimal harm
2024-12-12
F625 · Resident Rights Deficiencies
Health
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 2025-01-12
D · Potential for more than minimal harm
2024-12-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-12
D · Potential for more than minimal harm
2024-12-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-12
D · Potential for more than minimal harm
2024-12-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-12
D · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-12
J · Immediate jeopardy
2024-03-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-19
D · Potential for more than minimal harm
2023-11-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-11-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
E · Potential for more than minimal harm
2022-09-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-09-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-09-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-10
Penalties and ownership
What sits behind the stars
$26,685
2025-03-11
Fine
Fine · fine $26,685
Fine
$14,433
2024-03-04
Fine
Fine · fine $14,433
Fine
Ownership
North Shore Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Baumann, Troy
5% Or Greater Direct Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Officer · Individual
Hoehn, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Officer · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nshc Wisconsin LLC
5% Or Greater Direct Ownership Interest · Organization
Nshc Wisconsin LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Norwood Health Ctr-Central
Marshfield, WI
5-star overall rating with 4-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
North Shore Healthcare At Marshfield
Marshfield, WI
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Colonial Health Services
Colby, WI
2-star overall rating with 2-star inspections with $34,140 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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