Cycle 1
Health 2025-06-16 · Fire 2025-06-16
19 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Muskego, WI
Tudor Oaks Health Center
1-star overall rating with 1-star inspections with 19 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
S77 W12929 Mcshane Dr, Muskego, WI
(414) 529-0100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
American Baptist Homes Of The Midwest
Operator or chain grouping
Approved since
1977-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing
LPN hours / resident day
0.83
Licensed practical nurse staffing
Aide hours / resident day
3.44
Nurse aide staffing
Weekend hours
4.59
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
95.7%
3.6 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.0%
2.4 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.2%
1.2 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.9%
2 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
16.6%
2.9 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
16.7%
3.8 pts worse
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.7% |
21.1%
3.4 pts better
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.8% |
17.3%
13.5 pts worse
|
14.9%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
3.0%
0.1 pts better
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 42.8% |
25.5%
17.3 pts worse
|
19.8%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.5%
0.9 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
86.8%
3.6 pts better
|
81.7%
8.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
15.0%
2.6 pts better
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.6% |
82.2%
4.4 pts better
|
79.7%
6.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
22.7%
8.5 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-06 · Fire 2024-03-06
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
18 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-16
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-07-10
F · Potential for more than minimal harm
2025-06-16
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-07-14
F · Potential for more than minimal harm
2025-06-16
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-06-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-08-13
F · Potential for more than minimal harm
2025-06-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-17
E · Potential for more than minimal harm
2025-06-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-13
E · Potential for more than minimal harm
2025-06-16
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-08-20
C · Minimal harm
2025-06-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-10
F · Potential for more than minimal harm
2024-03-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-06
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-04-16
F · Potential for more than minimal harm
2024-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-03-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-03-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-03-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-03-06
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-01-05
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-01-27
F · Potential for more than minimal harm
2023-01-05
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-01-27
F · Potential for more than minimal harm
2023-01-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-27
F · Potential for more than minimal harm
2023-01-05
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-01-27
F · Potential for more than minimal harm
2023-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-26
F · Potential for more than minimal harm
2023-01-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-01-25
F · Potential for more than minimal harm
2023-01-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-31
E · Potential for more than minimal harm
2023-01-05
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-01-31
D · Potential for more than minimal harm
2023-01-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-01-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-08-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-08-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-21
D · Potential for more than minimal harm
2025-08-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-21
G · Actual harm
2025-06-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-21
F · Potential for more than minimal harm
2025-06-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-16
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-06-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-06-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-06-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-16
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-16
F849 · Administration Deficiencies
Health
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.
Corrected 2025-07-16
C · Minimal harm
2025-06-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-10
G · Actual harm
2025-04-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-06-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-09
D · Potential for more than minimal harm
2023-09-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-04-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-17
G · Actual harm
2023-01-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-03
F · Potential for more than minimal harm
2023-01-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-05
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-02-21
E · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-02-21
Penalties and ownership
What sits behind the stars
Ownership
Allen, Ryan
Corporate Director · Individual
Blatnik, Andrea
Corporate Officer · Individual
Blatnik, Andrea
W-2 Managing Employee · Individual
Davidson, Roger
Corporate Director · Individual
Ford, Ashley
Corporate Director · Individual
Hanson, Phillip
Corporate Director · Individual
Johnson, Dorothy
Corporate Director · Individual
Johnson, James
Corporate Director · Individual
Johnson, Lars
Corporate Officer · Individual
Killian, George
Corporate Director · Individual
Kim, Steven
Contracted Managing Employee · Individual
Kotz, Christina
W-2 Managing Employee · Individual
Mcdonald, Anilisa
W-2 Managing Employee · Individual
Neiman, Ruth
Corporate Director · Individual
Peters, Marshall
Corporate Director · Individual
Van Der Beek, Bruce
Corporate Director · Individual
Vanostram, Steven
Corporate Director · Individual
Vaughn-Gray, Stephanie
Corporate Director · Individual
Wagoner Ford, Anne
Corporate Director · Individual
Whitaker, Bruce
Corporate Director · Individual
Nearby options
Other facilities in reach
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Muskego Health And Rehabilitation Center
Muskego, WI
2-star overall rating with 2-star inspections with 26 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Complete Care at Hales Corners
Hales Corners, WI
4-star overall rating with 4-star inspections with $17,934 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Lindengrove New Berlin
New Berlin, WI
1-star overall rating with 1-star inspections with $125,115 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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