Medical Suites at Oak Creek: Hospice Care Gaps - WI
The resident, identified in inspection records only as Resident 127, had been readmitted to the facility with chronic obstructive pulmonary disease and dementia. A cognitive assessment conducted in August gave her a score of six out of 15, indicating severe impairment. Her care plan noted a terminal prognosis and directed staff to watch closely for signs of pain, administer medications as ordered, and call a physician immediately if breakthrough pain occurred.
Under the hospice plan of care kept in a binder at the nurses' station, a skilled nurse and a home hospice aide were each supposed to visit twice a week.
Neither did.
Inspectors reviewing the binder found no documentation of skilled nurse visits during the weeks of August 31 and September 7. During the weeks of August 24 and September 14, only a single visit was recorded each. The hospice aide had no documented visits during the week of September 7. The week before, on September 3, one aide visit appeared in the record, with nothing to show a second visit had been made.
A licensed practical nurse interviewed by inspectors on the afternoon of October 3 offered an explanation that contradicted the plan of care entirely. "The aide comes once a week and then the nurse comes once a week," she said, "unless the resident has a change in condition, we will call them, and they will come out for an extra visit to check on her."
Once a week. The plan called for twice.
The Director of Nursing, interviewed later the same day, put responsibility for tracking the visits on the unit manager, saying that person was supposed to ensure the facility received documentation from the hospice agency after each visit. She maintained the hospice staff had in fact been coming twice a week, even though the records in the binder didn't show it. The unit manager was not in the building that day and was not available to be interviewed.
When inspectors asked for a copy of the hospice contract at 5:30 that evening, the administrator said he would try to get one. By the time of the exit conference at 7:30 PM, he had not produced it. "I called to get the contract," he told inspectors, "but it is after hours, so I doubt that we will get a copy of it. I know we have a contract with them; I just cannot find ours."
A facility caring for a dying resident with severe dementia, under an arrangement requiring documented twice-weekly visits from both a nurse and an aide, could not locate the paperwork governing that arrangement on the day inspectors came to check on it.
The inspection was a complaint survey. Inspectors reviewed 30 residents total and flagged this failure for Resident 127 alone. The cited harm level was minimal harm or potential for actual harm, the lower end of the scale, though the finding noted the gaps created risk that the resident's needs would go unaddressed.
For a resident who cannot reliably report her own pain, who depends on hospice staff to monitor her condition and on facility staff to notice when those visits don't happen, the question of whether anyone was actually keeping track has no clean answer in the record. The documentation wasn't there. The contract wasn't there. The unit manager wasn't there. What was there was a care plan calling for close observation of a woman with a terminal diagnosis, and a binder at the nurses' station with weeks of blank pages where the visit records should have been.
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.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
Medical Suites at Oak Creek (The) in OAK CREEK, WI was cited for violations during a health inspection on October 3, 2025.
A cognitive assessment conducted in August gave her a score of six out of 15, indicating severe impairment.
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.