Tudor Oaks Health Center
S77 W12929 McShane Dr, Muskego, WI 53150 · Waukesha County · 50 certified beds · avg 45 residents/day · certified since Jan 1, 1977
Part of chain: AMERICAN BAPTIST HOMES OF THE MIDWEST (6 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 16, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 21, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 23, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 25, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 5, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 3, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jun 16, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 16, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 16, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 16, 2025 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Jun 16, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Apr 23, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 5, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 26, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Sep 26, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 26, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 5, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jan 5, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 5, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jan 5, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 5, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 5, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jan 5, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 16 | 1 | G ▲ |
| 2024 | 2 | 0 | D |
| 2025 | 19 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $180,810, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jun 16, 2025 | Fine | $180,810 |
| Jun 16, 2025 | Payment Denial | 62 days from Jul 17, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.04 | 4.29 | 3.95 | bottom 47% in Wisconsin; top 38% in the U.S. |
| Registered Nurse hours | 0.61 | 1.01 | 0.69 | bottom 13% in Wisconsin; top 46% in the U.S. |
| Weekend total nurse staffing | 3.66 | 3.84 | 3.50 | top 50% in Wisconsin; top 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.43 | 0.68 | 0.48 | bottom 21% in Wisconsin; top 43% in the U.S. |
| Total nursing staff turnover (%) | 56.4 | 46.9 | 45.8 | bottom 24% in Wisconsin; bottom 22% in the U.S. |
| RN turnover (%) | 76.9 | 39.7 | 42.9 | bottom 4% in Wisconsin; bottom 7% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.34, RN 0.66, weekend 3.93. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 1/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Allen, Ryan | Individual | Corporate Director | NOT APPLICABLE | 01/01/2014 |
| Blatnik, Andrea | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2021 |
| Blatnik, Andrea | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2014 |
| Davidson, Roger | Individual | Corporate Director | NOT APPLICABLE | 08/01/2019 |
| Ford, Ashley | Individual | Corporate Director | NOT APPLICABLE | 08/01/2019 |
| Hanson, Phillip | Individual | Corporate Director | NOT APPLICABLE | 01/01/2014 |
| Johnson, Dorothy | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Johnson, James | Individual | Corporate Director | NOT APPLICABLE | 08/01/2019 |
| Johnson, Lars | Individual | Corporate Officer | NOT APPLICABLE | 06/05/2023 |
| Killian, George | Individual | Corporate Director | NOT APPLICABLE | 08/01/2019 |
| Kim, Steven | Individual | Contracted Managing Employee | NOT APPLICABLE | 01/01/2024 |
| Kotz, Christina | Individual | W-2 Managing Employee | NOT APPLICABLE | 08/01/2019 |
| McDonald, Anilisa | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/04/2019 |
| Neiman, Ruth | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Peters, Marshall | Individual | Corporate Director | NOT APPLICABLE | 01/01/2014 |
| Van Der Beek, Bruce | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Vanostram, Steven | Individual | Corporate Director | NOT APPLICABLE | 01/01/2014 |
| Vaughn-Gray, Stephanie | Individual | Corporate Director | NOT APPLICABLE | 08/01/2019 |
| Wagoner Ford, Anne | Individual | Corporate Director | NOT APPLICABLE | 08/01/2019 |
| Whitaker, Bruce | Individual | Corporate Director | NOT APPLICABLE | 01/01/2014 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Muskego Health and Rehabilitation Center | 0.0 mi | Muskego, WI | ★★☆☆☆ | 2/5 | |
| Complete Care at Hales Corners | 6.1 mi | Hales Corners, WI | ★★★☆☆ | 3/5 | |
| Lindengrove New Berlin | 7.1 mi | New Berlin, WI | ★☆☆☆☆ | 1/5 | |
| Clement Manor Health Care Center | 7.4 mi | Greenfield, WI | ★☆☆☆☆ | 1/5 | |
| Greendale Park Nursing and Rehab | 8.2 mi | Greendale, WI | ★☆☆☆☆ | 1/5 | |
| Maplewood Center | 8.6 mi | West Allis, WI | ★☆☆☆☆ | 1/5 | |
| Medical Suites at Oak Creek (the) | 8.8 mi | Oak Creek, WI | —/5 | SFF | |
| Complete Care at Southpointe | 9.0 mi | Greenfield, WI | ★★★☆☆ | 2/5 | |
| Maple Ridge Health Services | 9.4 mi | Milwaukee, WI | ★★☆☆☆ | 3/5 | |
| Autumn Lake Healthcare at Greenfield | 9.5 mi | Milwaukee, WI | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525279.