Medical Suites at Oak Creek (The)
2700 Honadel Boulevard, Oak Creek, WI 53154
Medical Suites at Oak Creek (The) is a nursing home in Oak Creek, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star ratingnot rated by CMS
- Last standard health inspectionOctober 3, 2025 (1 year ago)
- Health citations since July 27, 2023121 (Wisconsin average 28)
- Fines in the past three years3, $199,227 in total
- CMS flagsSpecial Focus Facility
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CMS flags
Special Focus Facility
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to not rated by CMS.
Star rating
The CMS health inspection star rating changed from 1 of 5 to not rated by CMS.
Star rating
The CMS staffing star rating changed from 2 of 5 to not rated by CMS.
Star rating
The CMS quality measures star rating changed from 2 of 5 to not rated by CMS.
Special Focus Facility
CMS now lists this home as a Special Focus Facility.
CMS update of July 29, 2026
CMS abuse icon
CMS removed its abuse icon from this home.
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Health inspection on May 19, 2026
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0656 2 times since 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0677 5 times since 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0692 4 times since 2023.
Health inspection on May 7, 2026
28 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
39 of 323 Wisconsin homes (12%) got a citation at the immediate jeopardy level in 2026.
Show the 28 citations
Citation F0684. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0684 7 times since 2023.
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0686 5 times since 2023.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0689 5 times since 2023.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on June 5, 2026.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0880 4 times since 2023.
Citation F0941. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0941 2 times since 2023.
Citation F0942. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on June 5, 2026.
Citation F0943. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on June 5, 2026.
Citation F0944. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0944 2 times since 2023.
Citation F0945. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
CMS lists it as corrected on June 5, 2026.
Citation F0946. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0946 2 times since 2023.
Citation F0947. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0947 2 times since 2024.
Citation F0949. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0949 2 times since 2023.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0610 3 times since 2023.
Citation F0760. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on June 5, 2026.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on June 5, 2026.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0585 2 times since 2024.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on June 5, 2026.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on June 5, 2026.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on June 5, 2026.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on June 5, 2026.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on June 5, 2026.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on June 5, 2026.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0755 5 times since 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0759 4 times since 2023.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on June 5, 2026.
CMS has cited this home for F0761 3 times since 2024.
Citation F0808. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
CMS lists it as corrected on June 5, 2026.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on June 5, 2026.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of February 25, 2026
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on December 18, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 18, 2026.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on January 18, 2026.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on January 18, 2026.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.2 to 3.7 hours per resident per day.
Fine
CMS changed the fine from December 14, 2022 from $44,186 to $13,000.
Health inspection on October 3, 2025
19 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
CMS fine of $106,600 on October 3, 2025.
Show the 19 citations
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on November 10, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 10, 2025.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on November 10, 2025.
CMS has cited this home for F0814 2 times since 2024.
Citation F0865. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a plan that describes the process for conducting QAPI and QAA activities.
CMS lists it as corrected on November 10, 2025.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on November 10, 2025.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on November 10, 2025.
CMS has cited this home for F0804 2 times since 2024.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on November 10, 2025.
CMS has cited this home for F0554 3 times since 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on November 10, 2025.
CMS has cited this home for F0578 2 times since 2024.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on November 10, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 10, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on November 10, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on November 10, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on November 10, 2025.
CMS has cited this home for F0695 2 times since 2023.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on November 10, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on November 10, 2025.
Citation F0773. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
CMS lists it as corrected on November 10, 2025.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
CMS lists it as corrected on November 10, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 10, 2025.
Citation F0881. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on November 10, 2025.
Health inspection on August 21, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on September 10, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Health inspection on July 8, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 4, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 4, 2025.
Health inspection on June 4, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for F0600 2 times since 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 1, 2025.
CMS has cited this home for F0609 4 times since 2023.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on April 3, 2025
6 citationsCMS lists this as a complaint inspection.
Show the 6 citations
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on April 28, 2025.
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on April 28, 2025.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on April 28, 2025.
CMS has cited this home for F0623 2 times since 2024.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 28, 2025.
CMS has cited this home for F0625 2 times since 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on April 28, 2025.
CMS has cited this home for F0757 2 times since 2024.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on April 28, 2025.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Fine
CMS changed the fine from July 15, 2024 from $99,271 to $64,526.
Health inspection on December 4, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0559. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS lists it as corrected on December 19, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 19, 2024.
CMS update of October 30, 2024
Name
CMS lists a new legal business name for this home.
Fine
CMS changed the fine from April 17, 2024 from $43,230 to $28,100.
CMS update of September 26, 2024
CMS abuse icon
CMS added its abuse icon to this home.
Fine
CMS changed the fine from July 27, 2023 from $92,723 to $94,438.
Health inspection on September 11, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0940. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
CMS lists it as corrected on October 1, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 1, 2024.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 1, 2024.
August 13, 2024
Payment stoppedCMS stopped payment for new admissions from August 13, 2024, for 49 days.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Name
CMS lists a new name for this home. It was IGNITE MEDICAL RESORT OAK CREEK.
Health inspection on July 15, 2024
20 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $64,527 on July 15, 2024.
Show the 20 citations
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 12, 2024.
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 1, 2024.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 12, 2024.
Citation F0610. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 12, 2024.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on August 12, 2024.
Citation F0882. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on August 12, 2024.
Citation F0947. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on August 12, 2024.
Citation F0623. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on August 12, 2024.
Citation F0625. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 12, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on August 12, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 12, 2024.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS lists it as corrected on August 12, 2024.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 12, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 12, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 1, 2024.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on August 12, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on August 12, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on August 12, 2024.
CMS has cited this home for F0756 2 times since 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 12, 2024.
CMS has cited this home for F0758 2 times since 2023.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on August 12, 2024.
Fire safety inspection on July 15, 2024
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on August 8, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on August 12, 2024.
CMS has cited this home for K0345 2 times since 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 12, 2024.
CMS has cited this home for K0353 3 times since 2022.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on August 12, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 12, 2024.
CMS has cited this home for K0712 3 times since 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 12, 2024.
CMS has cited this home for K0918 3 times since 2022.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on August 12, 2024.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on August 12, 2024.
Citation K0341. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on August 12, 2024.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on August 12, 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on September 11, 2024.
CMS has cited this home for K0374 2 times since 2022.
Citation K0781. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on August 12, 2024.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on August 12, 2024.
CMS has cited this home for K0920 2 times since 2023.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on August 12, 2024.
CMS update of June 26, 2024
Fine
CMS changed the fine from July 27, 2023 from $142,650 to $92,723.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Health inspection on April 17, 2024
11 citationsCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $28,100 on April 17, 2024.
Show the 11 citations
Citation F0578. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on May 2, 2024.
Citation F0678. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS lists it as corrected on May 2, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on May 2, 2024.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on May 2, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on May 2, 2024.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on May 2, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 2, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 2, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 2, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on May 2, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on May 2, 2024.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Fine
CMS changed the fine from August 15, 2022 from $112,645 to $73,219.
Fine
CMS changed the fine from December 14, 2022 from $102,075 to $44,186.
Fine
CMS changed the fine from December 14, 2022 from $67,978 to $66,349.
Health inspection on July 27, 2023
21 citationsCMS lists this as a standard inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
22 of 323 Wisconsin homes (7%) got a citation at the immediate jeopardy level in 2023.
Show the 21 citations
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 22, 2023.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on August 22, 2023.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on August 22, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 22, 2023.
Citation F0941. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on August 22, 2023.
Citation F0944. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on August 22, 2023.
Citation F0946. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on August 22, 2023.
Citation F0949. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on August 22, 2023.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on August 22, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 22, 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 22, 2023.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on August 22, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 22, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on August 22, 2023.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS lists it as corrected on August 22, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on August 22, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on August 22, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on August 22, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 22, 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on August 22, 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on August 22, 2023.
Fire safety inspection on July 27, 2023
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on August 22, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 22, 2023.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on August 29, 2023.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on August 22, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on October 13, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on August 22, 2023.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on August 22, 2023.
Citation K0345. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on August 22, 2023.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 22, 2023.
Fire safety inspection on March 30, 2022
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on April 25, 2022.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on April 25, 2022.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 25, 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 25, 2022.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 25, 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 25, 2022.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 25, 2022.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on April 25, 2022.
Citation K0911. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on April 25, 2022.
Citation K0927. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
CMS lists it as corrected on April 25, 2022.
CMS star ratings
- not rated by CMS CMS overall star rating
- not rated by CMS CMS health inspection star rating
- not rated by CMS CMS staffing star rating
- not rated by CMS CMS quality measures star rating
CMS does not give star ratings to homes in its Special Focus Facility program.
Facts from CMS
- Phone
- (414) 435-2005
- Last standard health inspection
- October 3, 2025 (1 year ago)
- Certified beds
- 144
- Residents per day, on average
- 112.1
- Ownership type
- For profit - Corporation
- Legal business name
- Oak Creek Health and Rehabilitation Center LLC
- Chain
- Champion Care
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (121 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- OAK CREEK OPERATIONS HOLDINGS LLC5% or greater direct ownership interest · 100% · since 06/01/2024
- RUVEL, MENACHEMIndirect ownership interest · not applicable · since 06/01/2024
- WEINBERG, YISROELIndirect ownership interest · not applicable · since 06/01/2024
- AMDRASTEK, NATALIEOperational/managerial control · not applicable · since 01/14/2026
- MARKWARDT, ANNEOperational/managerial control · not applicable · since 06/01/2024
Show 1 more
- RAMANUJAM, SANDEEPOperational/managerial control · not applicable · since 06/01/2024
Questions
When was Medical Suites at Oak Creek (The) last inspected?
CMS lists October 3, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Medical Suites at Oak Creek (The) have?
CMS lists 121 health citations since July 27, 2023. CMS also calls these deficiencies.
Has Medical Suites at Oak Creek (The) been fined?
CMS lists 3 fines in the past three years, $199,227 in total.
What is the CMS star rating of Medical Suites at Oak Creek (The)?
CMS does not give star ratings to homes in its Special Focus Facility program.
Is Medical Suites at Oak Creek (The) a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility.