Medical Suites at Oak Creek (the)
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 110 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Special Focus Facility (under heightened CMS scrutiny)
- Abuse citation on record
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (33 vs median 7)
- High staff turnover (73%)
- High RN turnover (65%)
Bottom 25% in WI · Below recommended RN staffing · Very high staff turnover · Worst in IGNITE MEDICAL RESORTS chain · $187,064 in fines · Special Focus Facility (CMS) · Abuse citation
What this means for your family
While the facility offers excellent physical therapy and a modern environment, the recurring reports of neglect and medication errors are deeply concerning. If you choose this facility, you must be prepared to advocate daily for your loved one, as multiple families noted that care levels dropped significantly when family members were not physically present.
Google Reviews
Google Reviews
110 reviews on Google“Medical Suites at Oak Creek presents a stark contrast between its modern, clean facility and significant, recurring failures in basic patient care. While many reviewers praise the physical therapy department and specific staff members, a large number of families report severe neglect, including patients left in soiled conditions for hours, medication errors, and a lack of responsiveness from administration. Families should be aware that while the environment is aesthetically pleasing, the quality of daily nursing and CNA support is frequently described as inconsistent or dangerously understaffed.”
Quality Themes
Tap a score for detailsStrengths
- Highly effective physical and occupational therapy
- Modern, clean, and aesthetically pleasing facility
- On-site dialysis services
- Specific, dedicated individual staff members
Concerns
- Severe understaffing leading to neglect (mentioned by 18 reviewers)
- Hygiene issues (soiled linens/diapers not changed) (mentioned by 12 reviewers)
- Medication administration errors or delays (mentioned by 7 reviewers)
- Poor communication and unresponsiveness from management (mentioned by 9 reviewers)
- Poor quality or inappropriate food (mentioned by 6 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 113 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1I noticed you have on-site dialysis, which is a great convenience; how does your clinical team coordinate that with daily nursing care to ensure residents are closely monitored?
- 2Given the feedback regarding medication management, can you walk me through the specific protocols and double-check systems you have in place to ensure medications are administered accurately and on time?
- 3I see that you are active in responding to family feedback online; how do you translate that commitment to communication into regular, proactive updates for families regarding their loved one's daily well-being?
- 4With the high volume of residents, how do you ensure that hygiene needs, such as timely assistance with linens and personal care, are consistently met throughout the day and night?
- 5Many families have praised your physical and occupational therapy programs; how are these sessions integrated into a resident's daily routine to ensure they remain active and engaged?
- 6What steps is management currently taking to improve staffing consistency and ensure that every resident receives the focused attention they need?
Personalized based on this facility's data
Key Review Excerpts
“My grandpa was walking to the bathroom without his walker, unbuckling his pants, and a CNA comes in and says, “Oh, I didn’t know he could walk.” I told her, “He’s not supposed to,” and she just walked out.”
“My dad just went back there after a hospitalization. It is horrendous. They never answer phones!! Neglect patients. I had to call oak police to do a welfare check of my dad because we couldn't get a hold of him for hours.”
“The therapy department were miracle workers. From how he looked and physically had difficulty to how he is able to independently walk with Minimàl assist.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
4
measures
9
measures
4
measures
Residents vaccinated for the flu
Residents whose bladder or bowel control got worse
Residents whose walking got worse
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents who lost too much weight
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility shows significant concern with 145 deficiencies across 15 surveys, with half triggered by family complaints about serious issues. Recurring problems include accident prevention and safety, medication management, and pressure ulcer care, with some issues persisting across multiple inspections. The high number of complaint-driven investigations indicates families have repeatedly filed reports about care quality concerns.
Dec 18, 2025Complaint3
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Oct 3, 2025Complaint8
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Administration Deficiencies
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Oct 3, 2025Routine11
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Honor 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.
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Aug 21, 2025Complaint1
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Jul 8, 2025Complaint2
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Jun 4, 2025Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Federal Penalties
Fine
Jul 15, 2024
$64,527
Payment Denial
Jul 15, 2024
49-day denial
Fine
Apr 17, 2024
$28,100
Fine
Jul 27, 2023
$94,437
Payment Denial
Jul 27, 2023
15-day denial
Ownership & Operations
Who Operates This Facility
Medical Suites at Oak Creek (the)
for profit
Chain Affiliation
Ignite Medical Resorts
25 facilities nationwide
Chain avg rating: 2.7/5 · Rank 21 of 22 (Worst)
Ownership & Management
Owners
Undisclosed
Ownership Data Not Available · Organization
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
110 reviews from families & visitors
Official Website
Visit oakcreeksuites.com
Medicare data downloads
Original nursing home datasets
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