Three Oaks Hospice

Inspection history (47)

Records from April 2022 to October 2024.

• May 25, 2022 · Condition

  Citation L0648

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0648 (CFR 418.100) for Organizational environment. CMS recorded this at the condition level, which is the broader of the two levels used on a hospice survey. CMS recorded this citation as an immediate jeopardy finding. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0522

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0522 (CFR 418.54(a)) for Initial assessment. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0679

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0679 (CFR 418.104(b)) for Authentication. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0523

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0523 (CFR 418.54(b)) for Timeframe for completion of assessment. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0662

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0662 (CFR 418.100(g)(2)) for Training. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0781

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0781 (CFR 418.112(e)(3)) for Coordination of services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0782

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0782 (CFR 418.112(f)) for Orientation and training of staff. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0682

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0682 (CFR 418.104(e)(1)) for Discharge or transfer of care. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0900

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0900 (CFR 418.60 (d)(1)-(3)(i)-(x)) for COVID-19 Vaccination of Facility Staff. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0591

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0591 (CFR 418.64(b)(1)) for Nursing services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0713

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0713 (CFR 418.108(c)(3)) for Inpatient care provided under arrangements. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0649

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0649 (CFR 418.100) for Organization and administration of services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0672

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0672 (CFR 418.104(a)(1)) for Content. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation E0039

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag E0039 (CFR 418.113(d)(2)) for EP Testing Requirements. CMS recorded this at the standard level, which sits under a condition of participation. E tags cover the Medicare emergency preparedness requirements. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0653

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0653 (CFR 418.100(c)(2)) for Services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0796

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0796 (CFR 418.114(d)(2)) for Criminal background checks. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0774

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0774 (CFR 418.112(d)(1)) for Hospice plan of care. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0544

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0544 (CFR 418.56(b)) for Plan of care. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0596

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0596 (CFR 418.64(d)(1)) for Counseling services. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint, Recertification. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

• May 25, 2022 · Standard

  Citation L0663

  Federal surveyors cited this hospice in a survey that ended on 2022-05-25 under CMS tag L0663 (CFR 418.100(g)(3)) for Training. CMS recorded this at the standard level, which sits under a condition of participation. L tags cover the Medicare Conditions of Participation for hospices. CMS recorded the survey type as Complaint. CMS recorded the survey as conducted by a state survey agency. Source: CMS QCOR hospice statements of deficiency (as of 2026-04-09).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2022-05-25.GOV

Penalties

CMS publishes its civil money penalty and payment denial file for certified nursing homes only. No hospice appears in it, including this one. Enforcement here runs through the state licensing agency instead.

Staffing

Staffing hours are published for nursing homes and for no other kind of provider. Federal law requires Medicare- and Medicaid-certified nursing homes to file payroll-based nurse hours with CMS every quarter, and no agency collects the same return from hospices.

Ownership

For-Profit

Recent changes to this listing

Watch this facility: new record changes publish to an RSS feed any feed reader can follow. No signup.

Each line is a difference between two readings of a government file. It says what the source reported, not what the provider did.

1. Jul 23, 2026First appeared in our data

   This listing first appeared in the government file we read. That is usually when it entered the file, not the day it opened.

   Reported by CMS home health hospice (hospice)