Medical Suites At Oak Creek (the)

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Review of the facility's policy Resident Self-Administration of Medication dated 04/17/25 indicated, …Each resident is offered the opportunity to self-administer medications during the routine assessment by licensed nurse and/or the facility's interdisciplinary team. Resident's [reference will be documented on the appropriate form and placed in the medical record…

Review of the facility's policy Medication Administration dated 04/09/25 indicated, …Observe resident consumption of medication…

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medical Suites at Oak Creek (the)

2700 Honadel Boulevard Oak Creek, WI 53154

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

During an interview on 10/03/25 at 5:04 PM, CNA5 stated he worked with Resident R48 but had not offered her a bath or shower. He stated she may have been offered a shower at some point, but the water in the shower room was cold and she may have declined a shower because of that. CNA5 stated most residents chose a bed bath because of the cold water in the shower, but he had not offered Resident R48 a bed bath.

During an interview on 10/03/25 at 5:38 PM, the DON stated there was no reason why baths and showers were not getting done. The DON expected staff to offer a shower or bed bath per the resident's schedule and preference.

Review of the facility's policy titled, Resident Showers, revised 06/11/25, revealed 1. Resident will be provided with showers as per request and within reasonable accommodation, or as per facility schedule protocols (at least offered weekly)…

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medical Suites at Oak Creek (the)

2700 Honadel Boulevard Oak Creek, WI 53154

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697

During an interview on 10/01/25 at 08:55 AM, Resident R158 stated, I am in pain now, but I feel better than I did yesterday after I received my pain medicine that I was supposed to be taking.

Level of Harm - Actual harm Residents Affected - Few

During an interview on 10/01/25 at 4:10 PM, the Pharmacist in Charge (PIC) stated, The first script that we received for Roxicodone 5 mg and Tramadol 50 mg for [Resident R158] was on 09/30/25 at 10:30 AM. Both scripts were dated 09/29/25 by the facility NP [nurse practitioner]. We did receive hospital discharge orders for this resident, but we did not receive any scripts from the hospital physician.

During an interview on 10/03/25 at 7:15 PM, the Director of Nursing (DON) stated, Pain assessments should have been completed on admission for this resident. 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. We have Roxicodone and Tramadol in the emergency supply here.

The nurse would have to get an order from the provider, call the pharmacy and the pharmacy will give us a code to get the medication out.

Review of the facility's policy Pain Management dated 02/05/25 indicated, The facility must ensure that pain management is provided to residents who require such services. Consistent with professional standards of practice… and the residents' goals and preferences… Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change or status occurs… the facility in collaboration with the attending physician/prescriber… and resident and/or resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual's pain beginning at admission… Facility staff will notify the practitioner, if

the resident's pain is not controlled by the current treatment regimen…

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medical Suites at Oak Creek (the)

2700 Honadel Boulevard Oak Creek, WI 53154

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview, the facility failed to obtain a physician order prior to obtaining laboratory tests for one of one resident (Resident (R)98) out of a total sample of 30 residents. This failure had the potential of obtaining unnecessary laboratory testing from residents.Findings include:Review of Resident R98's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated Resident R98 was readmitted to

the facility on [DATE REDACTED] with the diagnosis of an abdominal hematoma.

Review of Resident R98's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 06/18/25 indicated Resident R98 had a Brief Interview for Mental Status (BIMS)score of 12 out of 15, which indicated Resident R98 was moderately cognitively impaired.

During an interview on 10/02/25 at 3:49 PM, Unit Manager (UM)1 stated, the [Power of Attorney (POA)] for [Resident R98] emailed and stated that when the resident was discharged from the hospital on [DATE REDACTED], the hospital doctor wanted her [Resident R98] labs drawn. I reviewed the discharge summary, and it said on the CT [CAT] scan to follow up with abdominal CT scan if her hemoglobin was less than eight due to the CT scan in the hospital finding an abdominal hematoma. I spoke to the nurse practitioner, and she said to order a CBC [Complete Blood Count] every two weeks to monitor this. It looks like we started doing that on 08/18/25. UM1 stated Whoever orders the lab tests are responsible for putting the orders into PCC (Point Click Care).

Review of Resident R98's EMR revealed there were no physician orders for a CBC to be performed every two weeks nor were there any lab results.

On 10/02/25 at 4:20 PM, the Director of Nursing (DON) requested the laboratory results. On 10/02/25 at 6:00 PM, the DON presented the laboratory test results of CBCs that were performed every two weeks, beginning 08/18/25.

During an interview on 10/03/25 at 3:29 PM, the DON stated, The providers are able to put orders into PCC. If they do not, then the nurse that speaks to the provider will be responsible for placing these orders

in PCC.

During a phone interview on 10/03/25 at 4:09 PM, the Nurse Practitioner (NP) stated, I don't have access to put the orders into PCC. I remember talking to [name of UM1] about having these labs performed every two weeks.

On 10/0/25 at 5:30 PM, the DON stated the facility did not have a policy on laboratory services.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medical Suites at Oak Creek (the)

2700 Honadel Boulevard Oak Creek, WI 53154

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

During an interview on 09/30/25 at 11:00 AM, Resident R124 stated the food was cold when it arrived.

Level of Harm - Minimal harm or potential for actual harm

Review of the Resident Council notes, provided by the facility, dated 08/15/25, revealed Dietary: Milk sitting out all day…Food is cold because it's not being delivered on time.

Residents Affected - Some

An observation of the lunch tray line in the kitchen on 10/02/25 at 11:21 AM, revealed the meatballs were 181 degrees Fahrenheit (F), the vegetables were 160 degrees F, and the rice was 163 degrees F. At 11:27 AM, the fruit cup was 39.4 degrees F.

During an observation on 10/02/25 at 11:36 AM, alongside the Food Service Director (FSD), a test tray was plated and placed on the cart for the 300-hall (first cart). At 11:55 AM, the cart with the test tray left the kitchen and arrived in the dining room at 11:57 AM. Staff started serving from the cart at 12:06 PM. The test tray was evaluated at 12:19 PM, alongside the DM, with around nine trays left to pass from the cart. The egg roll was 127 degrees F, the meatballs with sauce were 121.8 degrees F, the vegetables were 113 degrees F, the rice was 119 degrees F, and the fruit was 63 degrees F. The DM stated the expectation was for the cold items to be around 40 degrees F and the hot foods to be around 130 degrees F. He stated he did not know why the temperatures were so low.

During an interview on 10/02/25 at 3:00 PM, the Registered Dietitian (RD) stated the residents were complaining of cold food more often. She confirmed there was no pellet system in place.

Review of the facility's policy titled Food Preparation Guidelines reviewed 12/17/24, revealed …3.

Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. This includes but is not limited to…d. Minimizing holding time prior to meal service. 4. Foods and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include…c. Serving hot foods/ drinks hot and cold foods/ drinks cold.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medical Suites at Oak Creek (the)

2700 Honadel Boulevard Oak Creek, WI 53154

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

drinking glasses were observed. The glasses had a hard water film, along the inside of many of them. He stated they just changed to a soft water system for the dishwasher. He stated he was unaware of how to get

the hard water stains off the glasses.

1. 4. Review of the food temperature logs provided by the facility revealed a column designated for Cook-End

Temp and this column was filled out. The columns designated as Holding Temp for Temp one and Temp two were blank, throughout. Review of the records from 09/17/25- 10/02/25 for all three meals, revealed they were blank under the hot holding temperatures for Temp one and Temp two.

During an interview on 10/02/25 at 11:17 AM, the [NAME] stated he never documented the temperatures from the start of tray line. He stated he only documented the cooking temperature. He stated he would take

the tray line temperatures to make sure it was not cold, not below 140 degrees F, but did not document them.

During an interview on 10/02/25 at 3:00 PM, the Registered Dietitian (RD) stated she completed a monthly sanitation inspection. She stated she had noticed the lack of cleanliness in the kitchen and pantry on 400-hall. She stated it had been an issue that had been brought to the facility's attention. She stated the 400-hall pantry used to have a key code lock, and then the number got changed. She stated the kitchen was supposed to monitor the refrigerator in the pantry. She stated the milk gallons were supposed to be in ice for proper practice.

Review of the facility's policy titled, Food Safety Requirements, dated 03/26/25, revealed c. Refrigerated storage- foods that require refrigeration shall be refrigerated immediately…IV. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded…4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards…d. Holdingstaff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA [Food and Drug Administration] Food Code and facility policy for food temperatures as needed.

Review of the 2022 Food Code by the U. S. Food and Drug Administration, located at https://www.fda.gov/media/184685/download?attachment, revealed on page 73: Time/ Temperature Control for Safety Food…(A) Under refrigeration that maintains the food temperature at…41 degrees F [Fahrenheit] or less…, page 75 revealed …Time/ Temperature control for safety food shall be maintained: At…(1) 135 degrees F or above…(2) At…41 degrees F or less, and page 112 revealed Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils…(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch…(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

The facility has no policy or procedure or schedule for cleaning the main kitchen including floors, walls, refrigeration units, ice machines, and equipment. In addition, the facility has no policy or procedure for checking temperatures of the food during the start of the food service, throughout and at the end of the food service.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medical Suites at Oak Creek (the)

2700 Honadel Boulevard Oak Creek, WI 53154

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to collaborate care with the hospice agency for one of one resident (Resident (R)127) reviewed for hospice services out of a total sample of 30 residents. This failure had the potential to increase the risk of resident needs not being addressed.Findings include:Review of Resident R127's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated Resident R127 readmitted to the facility on [DATE REDACTED] with diagnoses of chronic obstructive pulmonary disease and dementia.

Review of Resident R127's significant change Minimum Data Set (MDS) located under the MDS tab in the EMR, with

an Assessment Reference Date (ARD) of 08/21/25 indicated Resident R127 had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R127had severe cognitive impairment.

Review of Resident R127's Care Plan located under the Care Plan tab in the EMR dated 10/03/25 indicated Resident R127 had a …terminal prognosis and is receiving hospice services. Interventions included …Observe resident closely for signs of pain, administer pain medications as ordered and notify physician immediately if there is breakthrough pain.

Review of Resident R127's Hospice binder located at the nurses' station which contained the Hospice Plan of Care indicated Resident R127 was to receive visits from the Skilled Nurse (SN) and Home Hospice Aide (HHA) two times

a week.

Further review of the Hospice binder indicated there was no documentation for the SN during the week of 08/31/25 and 09/07/25. One visit was documented during the weeks of 08/24/25 and 09/14/25.

Continued review indicated there was no documentation of the HHA visits during the week of 09/07/25.

There was documentation of an HHA visit made on 09/03/25 but there was no further documentation indicating a second visit was made that week.

During an interview on 10/03/25 at 1:33 PM, Licensed Practical Nurse (LPN)6 stated, The aide comes once

a week and then the nurse comes once a week 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 [Resident R127].

During an interview on 10/03/25 at 5:15 PM, the Director of Nursing (DON) stated, The unit manager of the unit that the resident[Resident R127] is on is responsible for making sure the facility gets the documentation from the hospice agency of the visits that have been made. The DON stated the hospice staff came twice a week even though the supporting documentation was not available.

The DON confirmed Unit Manager (UM)1 was not in the facility and was not available for interview.

On 10/03/25 at 5:30 PM, the Administrator was notified of the need for a copy of the hospice contract for

the agency that is seeing Resident R127.

Prior to the exit conference on 10/03/25 at 7:30 PM, the Administrator stated he called to get the contract 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medical Suites at Oak Creek (the)

2700 Honadel Boulevard Oak Creek, WI 53154

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

During a Medication Administration observation on 10/02/25 at 9:53 AM, Registered Nurse (RN)1 was observed pouring a capsule of Docusate Sodium and a tablet of Aspirin into her bare hands from the bottle and then placed the pills into the medicine cup. RN1 then handed the medicine cup with the pills in it to Resident R132 to take. Resident R132 took the medicine cup from RN1 and swallowed the pills.

During an interview on 10/02/25 at 9:59 AM, RN1 was asked if she should have poured the pills from the bottle into her bare hands for Resident R132 to take. RN1 stated, Well, I sanitized my hands before I started. But I guess, since you are asking, I should not have done that.

During an interview on 10/02/25 at 11:35 AM, the IP nurse stated, They are supposed to pour the medication or pills from the bottle into the cap and then place it into the medication cup, never touching the medication.

During an interview on 10/02/25 at 12:40 PM, the DON stated, They can either pour the medication into the cup and not touch the medications with their bare hands or put gloves on and then touch the medication with their hand.

Review of the facility's policy Medication Administration dated 04/09/25 indicated, …Remove medication from source, taking care not to touch medication with bare hand… 3.During a review of the facility's infection control policies, the following policies that had not been reviewed and/or revised annually were:Antibiotic Prescribing Practices was last reviewed/revised on 05/29/24.Antibiotic Stewardship Program was last reviewed/revised on 05/29/24.Transmission-Based (Isolation) Precautions was last reviewed/revised on 06/04/24.

During an interview on 10/03/25 at 7:15 PM, the DON stated, I know the infection control policies are to be updated annually but this is done on the corporate level here and I don't have control over that.

Review of the facility's policy Antibiotic Stewardship Program dated 05/29/24 indicated, …The elements of the program and associated protocols are reviewed on an annual basis and as needed as part of the facility's review of the overall infection prevention and control program…

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet