Nursing homeActiveSpecial Focus Facility · what this means

Medical Suites at Oak Creek (The)

2700 Honadel Boulevard, Oak Creek, WI 531544144352005144 certified beds · 120 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
14
since 2023
Deficiencies
125
011312
Penalties · 3 yrs
$92,627
2 fines · 1 action
Last survey
2026-05-19
Complaint
CMS overall
stars as published by CMS
CMS overall /5
Health
Staffing
Quality
Star ratings as published by CMS · CMS’s caveats

Survey history

Source: CMS · Wisconsin Division of Quality Assurance · data as of 2026-08-01
DateKindDeficienciesOfficial recordArchived PDF
2026-05-19Complaint030CMS-2567 (Care Compare)
2026-05-07Complaint0253CMS-2567 (Care Compare)
2025-12-18Complaint030CMS-2567 (Care Compare)
2025-10-03Standard0181CMS-2567 (Care Compare)
2025-08-21Complaint010CMS-2567 (Care Compare)
2025-07-08Complaint020CMS-2567 (Care Compare)
2025-06-04Complaint020CMS-2567 (Care Compare)
2025-04-03Complaint060CMS-2567 (Care Compare)
2024-12-04Complaint020CMS-2567 (Care Compare)
2024-09-11Complaint030CMS-2567 (Care Compare)
2024-07-15Standard0173CMS-2567 (Care Compare)
2024-04-17Complaint092CMS-2567 (Care Compare)
2023-09-19Complaint022CMS-2567 (Care Compare)
2023-07-27Standard0201CMS-2567 (Care Compare)

Counts by class: paperwork · standard · harm.

Deficiencies

CMS · Wisconsin Division of Quality Assurance publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.

2026-05-19Complaint survey · 3 deficienciesOfficial report
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260519-F656
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260519-F677
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260519-F692
2026-05-07Complaint survey · 28 deficienciesOfficial report
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2026-06-05Record 525730-20260507-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2026-06-05Record 525730-20260507-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2026-06-05Record 525730-20260507-F689
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F580
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F585
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F610
F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F636
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F657
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F677
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F692
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F725
F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F745
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F755
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F759
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F760
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F761
F808Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F808
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F883
F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F941
F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Scope/severity FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F942
F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Scope/severity FStandard
Abuse & neglect
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F943
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F944
F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F945
F946Provide training in compliance and ethics.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F946
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F947
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-06-05Record 525730-20260507-F949
2025-12-18Complaint survey · 3 deficienciesOfficial report
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-18Record 525730-20251218-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-18Record 525730-20251218-F686
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-18Record 525730-20251218-F755
2025-10-03Standard survey · 19 deficienciesOfficial report
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-11-10Record 525730-20251003-F697
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F550
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F554
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F578
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F628
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F656
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F677
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F692
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F695
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F698
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F755
F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F773
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F812
F814Dispose of garbage and refuse properly.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F814
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F849
F865Have a plan that describes the process for conducting QAPI and QAA activities.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F865
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F880
F881Implement a program that monitors antibiotic use.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-10Record 525730-20251003-F881
2025-08-21Complaint survey · 1 deficiencyOfficial report
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-10Record 525730-20250821-F554
2025-07-08Complaint survey · 2 deficienciesOfficial report
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-04Record 525730-20250708-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-04Record 525730-20250708-F689
2025-06-04Complaint survey · 2 deficienciesOfficial report
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-01Record 525730-20250604-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-01Record 525730-20250604-F609
2025-04-03Complaint survey · 6 deficienciesOfficial report
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-28Record 525730-20250403-F623
F625Notify 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-28Record 525730-20250403-F625
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-28Record 525730-20250403-F757
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-28Record 525730-20250403-F759
F770Provide timely, quality laboratory services/tests to meet the needs of residents.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-28Record 525730-20250403-F770
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-04-28Record 525730-20250403-F921
2024-12-04Complaint survey · 2 deficienciesOfficial report
F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-19Record 525730-20241204-F559
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-19Record 525730-20241204-F684
2024-09-11Complaint survey · 3 deficienciesOfficial report
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-01Record 525730-20240911-F677
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-01Record 525730-20240911-F686
F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-10-01Record 525730-20240911-F940
2024-07-15Standard survey · 20 deficienciesOfficial report
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-08-12Record 525730-20240715-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-10-01Record 525730-20240715-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-08-12Record 525730-20240715-F689
F585Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F585
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F609
F610Respond appropriately to all alleged violations.Scope/severity FStandard
Abuse & neglect
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F610
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F623
F625Notify 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F625
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-01Record 525730-20240715-F677
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F679
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F755
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F756
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F758
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F761
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F804
F814Dispose of garbage and refuse properly.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F814
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F880
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F882
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-08-12Record 525730-20240715-F947
2024-04-17Complaint survey · 11 deficienciesOfficial report
F578Honor 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.Scope/severity KHarm
Dignity & rights
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-05-02Record 525730-20240417-F578
F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-05-02Record 525730-20240417-F678
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F554
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F609
F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F661
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F755
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F757
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F759
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-05-02Record 525730-20240417-F761
2023-09-19Complaint survey · 4 deficienciesOfficial report
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-09-09Record 525730-20230919-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-09-09Record 525730-20230919-F692
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-09Record 525730-20230919-F677
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-09Record 525730-20230919-F755
2023-07-27Standard survey · 21 deficienciesOfficial report
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-08-22Record 525730-20230727-F689
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F582
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F610
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F645
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F686
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F688
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F692
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F695
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F726
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F756
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F758
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F759
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F842
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F880
F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F941
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F944
F946Provide training in compliance and ethics.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F946
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 525730-20230727-F949

Penalties & enforcement

DateActionAmountSource
2024-07-15Civil money penalty$64,527CMS · Penalties
2024-07-15Denial of payment for new admissions
Payment denial for 49 days, from 2024-08-13
CMS · Penalties
2024-04-17Civil money penalty$28,100CMS · Penalties

Staffing

CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainer
RN hours per resident day0.62
Facility
Wisconsin
National
Wisconsin 0.99 · National 0.69
Total nurse hours per resident day3.63
Facility
Wisconsin
National
Wisconsin 4.21 · National 3.86
Weekend total nurse hours3.29
Facility
Wisconsin
National
Wisconsin 3.77 · National 3.42
Total nursing staff turnover65%
Facility
Wisconsin
National
Wisconsin 47% · National 46%
Registered nurse turnover53%
Facility
Wisconsin
National
Wisconsin 40% · National 43%

Quality measures

CMS MDS quality measures · 2025Q2-2026Q1 · definitions
MeasureFacilityWisconsinNational
Percentage of long-stay residents with pressure ulcers
lower is better
6.0%5.0%4.6%
Percentage of long-stay residents experiencing one or more falls with major injury
lower is better
4.0%3.3%3.2%
Percentage of long-stay residents who received an antipsychotic medication
lower is better
7.1%15.8%15.4%
Percentage of long-stay residents with a urinary tract infection
lower is better
1.0%2.7%1.6%
Percentage of long-stay residents who were physically restrained
lower is better
0.0%0.1%0.1%
Percentage of long-stay residents whose need for help with daily activities has increased
lower is better
21.8%16.1%13.9%
Percentage of long-stay residents who lose too much weight
lower is better
12.3%5.1%5.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication
lower is better
9.4%16.9%19.5%

Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.

Ownership

As reported to CMS (Provider Enrollment)
EntityRoleInterestSinceRegistry
Oak Creek Operations Holdings LLC
Organization
5% OR GREATER DIRECT OWNERSHIP INTEREST100%
Amdrastek, Natalie
Individual
OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Markwardt, Anne
Individual
OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Ramanujam, Sandeep
Individual
OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Amdrastek, Natalie
Individual
ADP OF THE SNFNOT APPLICABLE
Champion Care LLC
Organization
ADP OF THE SNFNOT APPLICABLE
Markwardt, Anne
Individual
ADP OF THE SNFNOT APPLICABLE
National Health Investors, Inc.
Organization
ADP OF THE SNFNOT APPLICABLE
Nhi-Reit Of Wisconsin LLC
Organization
ADP OF THE SNFNOT APPLICABLE
Ramanujam, Sandeep
Individual
ADP OF THE SNFNOT APPLICABLE
Ruvel, Menachem
Individual
ADP OF THE SNFNOT APPLICABLE
Ruvel, Menachem
Individual
CORPORATE OFFICERNOT APPLICABLE
Ruvel, Menachem
Individual
INDIRECT OWNERSHIP INTERESTNOT APPLICABLE
Weinberg, Yisroel
Individual
ADP OF THE SNFNOT APPLICABLE
Weinberg, Yisroel
Individual
INDIRECT OWNERSHIP INTERESTNOT APPLICABLE
Part of a chain
Champion Care22 facilities
View chain record

Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.

Cost context

County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Wisconsin.

No county cost figures on file for Milwaukee.

Nearby nursing homes

FacilityDistanceLast surveyDeficiencies · 3 yrs
Maple Ridge Health Services
Milwaukee
3.2 mi2025-07-010141
Autumn Lake Healthcare at Greenfield
Milwaukee
3.3 mi2026-06-242536
Greendale Park Nursing and Rehab
Greendale
4.3 mi2026-07-010596
Complete Care at Southpointe
Greenfield
4.7 mi2026-03-12171
Chi Franciscan Villa
South Milwaukee
4.4 mi2026-05-291508
Watch this facility

One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.

Sources & provenance

SectionAgency · datasetRetrieved
Facility, ratingsCMS Provider Data · Nursing Home Provider Information2026-08-01
SurveysCMS · Survey Summary2026-08-01
DeficienciesCMS · Health Deficiencies (CMS-2567 findings via Care Compare)2026-08-01
PenaltiesCMS · Penalties2026-08-01
StaffingCMS · Payroll-Based Journal (PBJ, as published Aug 2026)2026-08-01
Quality measuresCMS · MDS Quality Measures2026-08-01
OwnershipCMS · Ownership2026-08-01