Medical Suites at Oak Creek: Bathing Neglect Found - WI
The inspection, completed October 3, 2025, followed a complaint. What inspectors found was narrow in scope but straightforward in its facts: one certified nursing assistant, one resident, and a shower room where the water ran cold.
The CNA, identified in inspection records as CNA5, said he worked directly with the resident, referred to as R48. He acknowledged he had not offered her a shower. He said she "may have been offered a shower at some point," but then explained that the water in the shower room was cold and she may have declined because of that. He added that most residents at the facility chose bed baths instead of showers for the same reason.
Then he said he had not offered her a bed bath either.
That detail, stated plainly in his own interview, is the center of what inspectors documented. It wasn't that R48 had refused. It wasn't that she had been offered alternatives and turned them down. The offer had simply never been made.
The facility's director of nursing, interviewed the same evening, said there was "no reason" baths and showers were not getting done. She told inspectors she expected staff to offer a shower or bed bath according to each resident's schedule and stated preference. She did not offer an explanation for why CNA5 had done neither.
The facility's own written policy, revised as recently as June 2025, states residents are to be provided showers per their request or facility schedule, and offered one at minimum weekly.
CMS rated the harm level as minimal, affecting few residents. That classification matters for how the violation is categorized and what enforcement follows, but it doesn't change what CNA5 described: a resident who went without being offered basic hygiene care, in a facility where the shower room's cold water had apparently become an accepted reason not to ask.
Cold water in a shower room is a maintenance problem. It has a repair. What it is not is a reason to stop offering residents the choice altogether, or to skip the alternative entirely. CNA5's explanation moved from one justification to the next, and at the end of it, R48 still had not been offered a bath of any kind.
The director of nursing's response, that there was "no reason" this was happening, sits uncomfortably against what her own staff member said out loud to an inspector. Either she did not know the shower room had a temperature problem significant enough that most residents were avoiding it, or she knew and had not connected it to whether staff were following through on hygiene care at all. The inspection record does not resolve which.
What it does record is the gap between the policy revised four months before the inspection and the practice CNA5 described on the evening inspectors arrived. A document that says residents will be offered bathing weekly. A nursing assistant who, by his own account, had not made that offer.
R48 is identified in the record only by number. Her age, her condition, how long she had gone without being offered a bath, whether she had family who knew, whether she had asked for one herself: none of that appears in the inspection report. What appears is a CNA explaining, without apparent alarm, that he had not offered her one, and that the water was cold.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medical Suites At Oak Creek (the) from 2025-10-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
Medical Suites at Oak Creek (The) in OAK CREEK, WI was cited for neglect violations during a health inspection on October 3, 2025.
The inspection, completed October 3, 2025, followed a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.