Medical Suites at Oak Creek: Pain Medication Delay - WI
The resident, identified in inspection records only as R158, spoke with an inspector on October 1, 2025. "I am in pain now," she said, "but I feel better than I did yesterday after I received my pain medicine that I was supposed to be taking."
The medications were Roxicodone 5 mg, an immediate-release oxycodone used for acute pain, and Tramadol 50 mg. Both had been prescribed by the facility's own nurse practitioner, with scripts dated September 29. The pharmacy didn't receive them until September 30 at 10:30 in the morning.
What happened in between is a failure that the facility's own Director of Nursing described in detail.
The pharmacist in charge told inspectors that the facility had received hospital discharge orders for the resident but no prescriptions from the hospital physician. The scripts that eventually arrived came from the facility's nurse practitioner, not from the discharging doctor, and they didn't reach the pharmacy until a day after they were written.
The Director of Nursing, interviewed on the evening of October 3, laid out exactly what should have happened and didn't. "Pain assessments should have been completed on admission for this resident," she said. "As soon as the nurses noted that the narcotics did not come from the pharmacy, then they should have called the pharmacy to see if the scripts were there. If they were not there, then the scripts should have been signed by the provider, and the nurse fax the scripts to the pharmacy right then."
That's not what happened.
The director went further. Medical Suites at Oak Creek keeps an emergency medication supply on the premises, including Roxicodone and Tramadol. A nurse could have called the prescribing provider, obtained an order, contacted the pharmacy, and received a code to access the emergency supply. The process exists precisely for situations like this one.
Nobody used it.
The inspection was a complaint survey, meaning someone reported this to regulators before inspectors arrived. CMS rated the harm as actual, not potential, and noted that a few residents were affected. R158 is the resident named in the report.
The facility's own pain management policy, dated February 2025, calls for evaluating residents for pain upon admission and developing interventions to manage it beginning at that point. It also requires staff to notify the prescriber if pain isn't controlled. The policy was in place. The gap was in following it.
What the inspection record shows is a resident who came through a hospital discharge in pain, whose prescriptions existed on paper a day before the pharmacy received them, and who spent that interval without the medications her nurse practitioner had already decided she needed. The emergency supply that could have bridged that gap sat unused.
R158 told the inspector she was still in pain the morning after finally getting her medication. She said she felt better than the day before. That was the best available comparison she had.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 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.
The resident, identified in inspection records only as R158, spoke with an inspector on October 1, 2025.
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.