Medical Suites at Oak Creek (the)
2700 Honadel Boulevard · Oak Creek, WI · 53154 · 4144352005
144 certified beds For profit - Corporation Chain: Ignite Medical Resorts
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $64,527 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
7 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
$64,527 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
67% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.78 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.65 | 0.55–0.75 |
| Weekend hours / resident-day | 3.46 | ≈ weekday level |
| Nursing turnover / year | 67% | median 45% |
| Fines (3-yr window) | 3 · $187,064 |
Inspection citations (94 in the current record)
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Potential for harm · D December 18, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 18, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected January 18, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 18, 2026 · Pharmacy Service
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Actual harm · G October 3, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · E October 3, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected November 10, 2025 · Resident Rights
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Potential for harm · D October 3, 2025
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.
Corrected November 10, 2025 · Resident Rights
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Potential for harm · D October 3, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected November 10, 2025 · Resident Rights
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Potential for harm · D October 3, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D October 3, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D October 3, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D October 3, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D October 3, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 10, 2025 · Pharmacy Service
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Potential for harm · F October 3, 2025
Dispose of garbage and refuse properly.
Corrected November 10, 2025 · Nutrition and Dietary
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Potential for harm · F October 3, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected November 10, 2025 · Administration
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Potential for harm · D October 3, 2025
Implement a program that monitors antibiotic use.
Corrected November 10, 2025 · Infection Control
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Potential for harm · D October 3, 2025 · found via complaint
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected November 10, 2025 · Resident Rights
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Potential for harm · D October 3, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D October 3, 2025 · found via complaint
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected November 10, 2025 · Administration
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Potential for harm · E October 3, 2025 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected November 10, 2025 · Nutrition and Dietary
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Potential for harm · F October 3, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 10, 2025 · Nutrition and Dietary
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Potential for harm · D October 3, 2025 · found via complaint
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.
Corrected November 10, 2025 · Administration
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Potential for harm · D October 3, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected November 10, 2025 · Infection Control
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Potential for harm · D August 21, 2025 · found via complaint
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected September 10, 2025 · Resident Rights
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Potential for harm · D July 8, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 4, 2025 · Quality of Life and Care
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Potential for harm · D July 8, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 4, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| 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 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525730 · certified since April 8, 2020. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.