Facility WatchInspection records for every certified US nursing home
Medical Suites at Oak Creek (The)
2700 Honadel Boulevard OAK Creek, WI 53154 (414) 435-2005
Special Focus Facility — SFF CandidateAbuse icon
CCN
525730
Certified beds
144
Ownership
For profit - Corporation
Chain
Ignite Medical Resorts
Nurse staffing
3.52
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.60 hours per resident per day
Nursing staff turnover: 66% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected December 18, 2025
3 citations · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected January 18, 2026
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected January 18, 2026
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected January 18, 2026
Inspected October 3, 2025
19 citations · from a complaint investigation · Health
D
F0554No actual harm with potential for more than minimal harm · Isolated
Allow residents to self-administer drugs if determined clinically appropriate.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0578No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0628No actual harm with potential for more than minimal harm · Isolated
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0773No actual harm with potential for more than minimal harm · Isolated
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0849No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected November 10, 2025
D
F0881No actual harm with potential for more than minimal harm · Isolated
Implement a program that monitors antibiotic use.
Deficient, Provider has date of correction · corrected November 10, 2025
E
F0550No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected November 10, 2025
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected November 10, 2025
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected November 10, 2025
F
F0814No actual harm with potential for more than minimal harm · Widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected November 10, 2025
F
F0865No actual harm with potential for more than minimal harm · Widespread
Have a plan that describes the process for conducting QAPI and QAA activities.
Deficient, Provider has date of correction · corrected November 10, 2025
G
F0697Actual harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected November 10, 2025
Inspected August 21, 2025
1 citation · from a complaint investigation · Health
D
F0554No actual harm with potential for more than minimal harm · Isolated
Allow residents to self-administer drugs if determined clinically appropriate.
Deficient, Provider has date of correction · corrected September 10, 2025
Inspected July 8, 2025
2 citations · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 4, 2025
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected August 4, 2025
Inspected June 4, 2025
2 citations · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected July 1, 2025
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected July 1, 2025
Inspected April 3, 2025
6 citations · from a complaint investigation · Health
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0625No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected April 28, 2025
D
F0770No actual harm with potential for more than minimal harm · Isolated
Provide timely, quality laboratory services/tests to meet the needs of residents.
Deficient, Provider has date of correction · corrected April 28, 2025
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected April 28, 2025
E
F0921No actual harm with potential for more than minimal harm · Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected April 28, 2025
Inspected December 4, 2024
2 citations · from a complaint investigation · Health
D
F0559No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Deficient, Provider has date of correction · corrected December 19, 2024
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected December 19, 2024
Inspected September 11, 2024
3 citations · from a complaint investigation · Health
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected October 1, 2024
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected October 1, 2024
F
F0940No actual harm with potential for more than minimal harm · Widespread
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Deficient, Provider has date of correction · corrected October 1, 2024
Inspected July 15, 2024
20 citations · from a complaint investigation · Health
D
F0585No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected August 12, 2024
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 12, 2024
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected August 12, 2024
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected October 1, 2024
D
F0679No actual harm with potential for more than minimal harm · Isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected August 12, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected August 12, 2024
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected August 12, 2024
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected August 12, 2024
D
F0804No actual harm with potential for more than minimal harm · Isolated
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected August 12, 2024
E
F0623No actual harm with potential for more than minimal harm · Pattern
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected August 12, 2024
E
F0625No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected August 12, 2024
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected August 12, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected August 12, 2024
F
F0610No actual harm with potential for more than minimal harm · Widespread
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected August 12, 2024
F
F0814No actual harm with potential for more than minimal harm · Widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected August 12, 2024
F
F0882No actual harm with potential for more than minimal harm · Widespread
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Deficient, Provider has date of correction · corrected August 12, 2024
F
F0947No actual harm with potential for more than minimal harm · Widespread
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Deficient, Provider has date of correction · corrected August 12, 2024
J
F0684Immediate jeopardy to resident health or safety · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 12, 2024
J
F0686Immediate jeopardy to resident health or safety · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected October 1, 2024
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected August 12, 2024
Inspected April 17, 2024
11 citations · from a complaint investigation · Health
D
F0554No actual harm with potential for more than minimal harm · Isolated
Allow residents to self-administer drugs if determined clinically appropriate.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0661No actual harm with potential for more than minimal harm · Isolated
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected May 2, 2024
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected May 2, 2024
J
F0678Immediate jeopardy to resident health or safety · Isolated
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Deficient, Provider has date of correction · corrected May 2, 2024
K
F0578Immediate jeopardy to resident health or safety · Pattern
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.
Deficient, Provider has date of correction · corrected May 2, 2024
Inspected September 19, 2023
4 citations · from a complaint investigation · Health
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected September 9, 2023
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected September 9, 2023
G
F0692Actual harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected September 9, 2023
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected September 9, 2023
Inspected July 27, 2023
21 citations · from a complaint investigation · Health
D
F0582No actual harm with potential for more than minimal harm · Isolated
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0645No actual harm with potential for more than minimal harm · Isolated
PASARR screening for Mental disorders or Intellectual Disabilities
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0688No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected August 22, 2023
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected August 22, 2023
E
F0607No actual harm with potential for more than minimal harm · Pattern
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected August 22, 2023
E
F0726No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected August 22, 2023
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected August 22, 2023
E
F0941No actual harm with potential for more than minimal harm · Pattern
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Deficient, Provider has date of correction · corrected August 22, 2023
E
F0944No actual harm with potential for more than minimal harm · Pattern
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Deficient, Provider has date of correction · corrected August 22, 2023
E
F0946No actual harm with potential for more than minimal harm · Pattern
Provide training in compliance and ethics.
Deficient, Provider has date of correction · corrected August 22, 2023
E
F0949No actual harm with potential for more than minimal harm · Pattern
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Deficient, Provider has date of correction · corrected August 22, 2023
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected August 22, 2023
Penalties
Date
Type
Amount
July 15, 2024
Fine
$64,527
July 15, 2024
Payment Denial · 49 days
April 17, 2024
Fine
$28,100
July 27, 2023
Fine
$94,437
July 27, 2023
Payment Denial · 15 days
Ownership transfers
Effective
Seller
Buyer
06/01/2024
IMR OAK Creek Opco LLC
OAK Creek Health and Rehabilitation Center LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.