The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited June 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
TUDOR OAKS HEALTH CENTER
MUSKEGO, WI · Medicare-certified · 50 beds
Needs attention
Non-profitChain member
2 of 5 overall
Tudor Oaks Health Center in Muskego, WI has an overall rating of 2 out of 5 stars, with weak health inspection results but stronger staffing and quality ratings (4 out of 5 each). It has had $180,810 in fines in the last 24 months and a recent federal penalty; reported staffing is 5.45 hours per resident per day, above the 4.1-hour federal benchmark.
Facility ratings
Health inspections
Staffing
5.448 hrs/resident/day
Quality measures
Last inspection: December 5, 2025Penalties, last 24 months: $180,810recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 5.448.
Staffing detail
- Registered nurses
- 0.72
- Licensed practical nurses
- 1.04
- Nurse aides
- 3.69
- Weekend nursing
- 4.78
Hours per resident per day.
Total staff turnover: 62%
Registered nurse turnover: 86%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
16%22.7%Worsening
Residents with a fall causing major injury
2.8%8.6%Worsening
Residents with pressure ulcers (bedsores)
5.6%3.5%Improving
Residents with a urinary tract infection
0%5.9%Worsening
Residents who lost too much weight
3.7%0%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
—30.6%—
Long-stay residents on antianxiety or sleep medication
11.1%12%Worsening
Short-stay residents newly given an antipsychotic
2.3%0%Improving
Residents with a long-term catheter
0%3.8%Worsening
Residents with new or worsening incontinence
34%34.9%Worsening
Residents with depressive symptoms
0%0%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—97.4%—
Long-stay residents given the pneumonia vaccine
100%97.1%Worsening
Short-stay residents given the seasonal flu vaccine
—86.6%—
Short-stay residents given the pneumonia vaccine
92.2%88.7%Worsening
What the inspectors found
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited January 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited June 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited June 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: F
The nursing home failed to provide the required notice or documentation about a resident’s needs, appeal rights, or bed-hold policy. Cited June 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 628 — 42 CFR §483.15(c)(2) — S/S: E
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $180,810 was recorded.
- INSPECTION
Health inspection found 14 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $180,810 in total fines · 1 payment denial.
- 62 days
Medicare/Medicaid payment denial
Jun 16, 2025
- $180,810
Federal fine
Jun 16, 2025
Operator & ownership
- Ownership
- Non profit - Church related
- Chain
- Part of AMERICAN BAPTIST HOMES OF THE MIDWEST · 6 homes · 2.3 stars avg
- Occupancy
- 43.5 residents on an average day (87% of 50 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 49 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.