Tudor Oaks Health Center
S77 W12929 McShane Dr · Muskego, WI · 53150 · 4145290100
50 certified beds Non profit - Church related Chain: American Baptist Homes of the Midwest Part of a CCRC
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $180,810 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
- 3 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 3 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
$180,810 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
62% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 5.45 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.72 | 0.55–0.75 |
| Weekend hours / resident-day | 4.78 | ≈ weekday level |
| Nursing turnover / year | 62% | median 45% |
| Fines (3-yr window) | 1 · $180,810 |
Inspection citations (37 in the current record)
-
Potential for harm · D December 5, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 11, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 6, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 6, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 6, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected August 21, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G June 16, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 21, 2025 · Quality of Life and Care
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Potential for harm · D June 16, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected July 10, 2025 · Resident Rights
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Potential for harm · E June 16, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected July 3, 2025 · Resident Rights
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Potential for harm · D June 16, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected July 16, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 16, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 16, 2025 · Quality of Life and Care
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Potential for harm · D June 16, 2025
Provide appropriate foot care.
Corrected July 16, 2025 · Quality of Life and Care
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Potential for harm · D June 16, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected July 16, 2025 · Pharmacy Service
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Potential for harm · F June 16, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected July 16, 2025 · Nutrition and Dietary
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Potential for harm · D June 16, 2025
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 July 16, 2025 · Administration
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Potential for harm · F June 16, 2025
Provide and implement an infection prevention and control program.
Corrected July 10, 2025 · Infection Control
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Potential for harm · D June 16, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected June 19, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 16, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 19, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 16, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected June 19, 2025 · Freedom from Abuse, Neglect, and Exploitation
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No harm found · C June 16, 2025
Post nurse staffing information every day.
Corrected July 10, 2025 · Nursing and Physician Services
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Actual harm · G April 23, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 25, 2025 · Quality of Life and Care
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Potential for harm · D June 5, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 10, 2024 · Quality of Life and Care
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Potential for harm · D January 10, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 9, 2024 · Quality of Life and Care
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Potential for harm · D September 26, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected September 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 26, 2023 · found via complaint
Respond appropriately to all alleged violations.
Corrected September 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D September 26, 2023 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 29, 2023 · Quality of Life and Care
-
Actual harm · G January 5, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 3, 2023 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 16, 2025 | Fine | $180,810 |
| June 16, 2025 | Payment Denial | 62 days |
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525279 · certified since January 1, 1977. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.