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Nursing HomeMedicaid Investigative

Tudor Oaks Health Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

S77 W12929 Mcshane Dr, Muskego, WI 5315050 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 30 Google reviews

5
4
3
2
1

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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (19 vs median 7)
  • High staff turnover (61%)
  • High RN turnover (67%)

Bottom 25% in WI · Meets national RN staffing standard · Above recommended total nurse staffing · Worst in AMERICAN BAPTIST HOMES OF THE MIDWEST chain · No penalties on record

Source: Medicare data

What this means for your family

Tudor Oaks offers excellent physical amenities and a vibrant social calendar, making it an attractive choice for active seniors. However, families should be vigilant regarding medical oversight; ensure that any specific treatment plans are clearly documented and verified with nursing staff, as there have been reports of lapses in medication administration.

Google Reviews

Google Reviews

30 reviews on Google
Tudor Oaks generally receives high praise for its physical amenities, including the pool, wellness center, and overall cleanliness. While many residents and families report a warm, friendly environment, there are significant concerns regarding medication management, communication, and a recent shift toward group-based therapy that some find less effective than individual sessions.

Quality Themes

Tap a score for details
Food8.0Staff7.0Clean10.0Activities9.0Meds2.0Memory5.0Comms3.0ValueN/A

Strengths

  • Clean, well-maintained facility
  • Excellent amenities like pool and wellness center
  • Friendly and welcoming staff
  • Engaging activities and entertainment

Concerns

  • Inconsistent or negligent medication/treatment administration (mentioned by 2 reviewers)
  • Poor communication and responsiveness from staff (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'17(3)'19(5)'22(1)'24(1)'26(4)

Distribution · 36 analyzed

5
25
4
1
3
1
2
3
1
6

How They Respond to Reviews

53%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1I noticed you have a beautiful wellness center and pool; how are these amenities integrated into the daily activity schedule for residents?
  • 2Given the recent focus on improving clinical outcomes, what specific protocols have you implemented to ensure accuracy and consistency in medication administration?
  • 3We value clear communication; what is the standard process for families to receive timely updates regarding their loved one's health status or care plan changes?
  • 4I appreciate that you actively engage with families online; how do you utilize that feedback loop to address concerns and improve the resident experience?
  • 5With the current staffing levels, how does the team coordinate to ensure that residents receive prompt responses when they need assistance?
  • 6What steps is the leadership team taking to address the recent findings in your health inspections and improve your overall quality rating?

Personalized based on this facility's data


Key Review Excerpts

The only problem was they changed the company the contract therapy with. I went from having individual PT and OT one hour a day with each to one hour of group therapy total every other day.

Rehab patient · 2025★★★☆☆

She began to need daily breathing treatments and was doing ok until staff didn't give her her treatment. Sent her to hospital and immediately got her back to her baseline. Then the rehab center she was sent back too didn't even administer the breathing treatments until my sister and I told them she needed them.

Long-term resident's family · 2023☆☆☆☆

Staff are genuinely kind, helpful, friendly and caring. He’s very happy with the friendly staff the food at 3 meals a day.

Memory care family member · 2025★★★☆☆
Source: 30 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.72hrs
95%
Registered nurses for medical care
Total Nursing
5.45hrs
OK
All nurses + aides combined
Staff Turnover
62%
Lower is better (< 30% = good)
RN Turnover
86%
Lower is better (< 30% = good)

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
4/ 5
Better Than Avg

8

measures

Worse Than Avg

4

measures

Mixed Results

4

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility40.9%
Worse than Avg
Here
40.9%
US
19.4%
WI
25.0%
Waukesha
25.3%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility30.6%
Worse than Avg
Here
30.6%
US
14.4%
WI
16.7%
Waukesha
17.2%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
WI
5.2%
Waukesha
7.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility21.1%
Worse than Avg
Here
21.1%
US
15.4%
WI
15.9%
Waukesha
13.9%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility97.4%
Better than Avg
Here
97.4%
US
95.5%
WI
95.0%
Waukesha
90.3%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility12.6%
Mixed vs Avgs
Here
12.6%
US
19.5%
WI
16.8%
Waukesha
12.4%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility86.6%
Better than Avg
Here
86.6%
US
79.7%
WI
82.2%
Waukesha
75.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility91.8%
Better than Avg
Here
91.8%
US
81.8%
WI
86.6%
Waukesha
86.4%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.5%
Better than Avg
Here
0.5%
US
1.6%
WI
1.3%
Waukesha
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

18deficiencies
2penalties
Well above state avg (9.8)
15 complaint-triggered

This facility shows concerning patterns with families filing multiple complaints about resident abuse, neglect, and safety hazards that persist across recent surveys. The most recurring issues involve accident prevention and safety, proper reporting of abuse and neglect incidents, and building safety systems. While all deficiencies show correction dates, the repeated nature of serious complaints - particularly around protecting residents from abuse and maintaining safe environments - suggests ongoing challenges in these critical care areas that families should carefully evaluate.

Dec 5, 2025Complaint
1
0600Potential for harm · IsolatedCorrected

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.

Aug 6, 2025Complaint
3
0600Potential for harm · IsolatedCorrected

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.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Jun 16, 2025Routine
19
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0006Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

0009Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Include a process for Emergency Preparedness collaboration.

0031Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

0321Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0628Potential for harm · PatternCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0919Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0687Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate foot care.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0849Potential for harm · IsolatedCorrected

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.

0732Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

0712Minimal · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Jun 16, 2025Complaint
3
0600Potential for harm · IsolatedCorrected

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.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Apr 23, 2025Complaint
2
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0689Actual harm · IsolatedCorrected

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 5, 2024Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Federal Penalties

Fine

Jun 16, 2025

$180,810

Payment Denial

Jun 16, 2025

62-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Tudor Oaks Health Center

Organization Type

nonprofit

Chain Affiliation

Chain Name

American Baptist Homes of the Midwest

Chain Size

6 facilities nationwide

Chain avg rating: 2.3/5 · Rank 5 of 6 (Worst)

Ownership & Management

Key personnel

Kim, StevenContracted Managing EmployeeBlatnik, AndreaW-2 Managing EmployeeKotz, ChristinaW-2 Managing EmployeeMcdonald, AnilisaW-2 Managing EmployeeAllen, RyanOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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