Tudor Oaks Health Center
S77 W12929 McShane Dr, Muskego, WI 53150
Tudor Oaks Health Center is a nursing home in Muskego, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionJune 16, 2025 (1 year ago)
- Health citations since January 5, 202334 (Wisconsin average 28)
- Fines in the past three years1, $117,527 in total
- CMS flagsCMS abuse icon
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CMS flags
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Fine
CMS changed the fine from June 16, 2025 from $180,810 to $117,527.
CMS update of October 8, 2026
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 5.4 to 4.3 hours per resident per day.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on December 5, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 11, 2025.
CMS has cited this home for F0600 3 times since 2025.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on August 6, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 21, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 21, 2025.
CMS has cited this home for F0609 2 times since 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 21, 2025.
CMS has cited this home for F0610 2 times since 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
July 17, 2025
Payment stoppedCMS stopped payment for new admissions from July 17, 2025, for 62 days.
Health inspection on June 16, 2025
14 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
CMS fine of $117,527 on June 16, 2025.
Show the 14 citations
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 21, 2025.
CMS has cited this home for F0689 5 times since 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 16, 2025.
CMS has cited this home for F0812 2 times since 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 10, 2025.
CMS has cited this home for F0880 2 times since 2023.
Citation F0628. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on July 3, 2025.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on July 10, 2025.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on June 19, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on June 19, 2025.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on June 19, 2025.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 16, 2025.
CMS has cited this home for F0657 2 times since 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 16, 2025.
CMS has cited this home for F0686 2 times since 2023.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on July 16, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on July 16, 2025.
CMS has cited this home for F0757 2 times since 2023.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 16, 2025.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on July 10, 2025.
Fire safety inspection on June 16, 2025
8 citationsCMS lists this as a standard inspection.
Show the 8 citations
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on July 14, 2025.
Citation E0009. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include a process for Emergency Preparedness collaboration.
CMS lists it as corrected on July 16, 2025.
Citation E0031. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on July 10, 2025.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on August 13, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 17, 2025.
CMS has cited this home for K0353 2 times since 2024.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on August 13, 2025.
Citation K0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on August 20, 2025.
CMS has cited this home for K0919 3 times since 2023.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 10, 2025.
CMS has cited this home for K0712 2 times since 2023.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Health inspection on April 23, 2025
1 citationCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
77 of 323 Wisconsin homes (24%) got a citation at the actual harm level in 2025.
Show the 1 citation
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 25, 2025.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 4 of 5.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on June 5, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 10, 2024.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of March 28, 2024
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
Fire safety inspection on March 6, 2024
11 citationsCMS lists this as a standard inspection.
Show the 11 citations
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on April 5, 2024.
Citation K0132. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
CMS lists it as corrected on April 16, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 16, 2024.
Citation K0914. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on April 5, 2024.
Citation K0918. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 16, 2024.
CMS has cited this home for K0918 2 times since 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 5, 2024.
CMS has cited this home for K0920 2 times since 2023.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on April 5, 2024.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 5, 2024.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on April 5, 2024.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on April 5, 2024.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on April 5, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
Health inspection on January 10, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 9, 2024.
Health inspection on January 5, 2023
13 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 323 Wisconsin homes (13%) got a citation at the actual harm level in 2023.
Show the 13 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 3, 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 21, 2023.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 21, 2023.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on February 21, 2023.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 21, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 21, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on February 21, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 21, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 21, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on February 21, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on February 21, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on February 21, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on February 21, 2023.
Fire safety inspection on January 5, 2023
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation K0346. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on January 27, 2023.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on January 27, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on January 27, 2023.
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on January 27, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 26, 2023.
Citation K0919. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on January 25, 2023.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 31, 2023.
Citation K0131. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for sections of health care facilities separated by fire resistive construction.
CMS lists it as corrected on January 31, 2023.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on January 27, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (414) 529-0100
- Last standard health inspection
- June 16, 2025 (1 year ago)
- Certified beds
- 50
- Residents per day, on average
- 41.6
- Ownership type
- Non profit - Church related
- Legal business name
- American Baptist Homes of the Midwest
- Chain
- American Baptist Homes of the Midwest
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (34 vs 28).
Questions
When was Tudor Oaks Health Center last inspected?
CMS lists June 16, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Tudor Oaks Health Center have?
CMS lists 34 health citations since January 5, 2023. CMS also calls these deficiencies.
Has Tudor Oaks Health Center been fined?
CMS lists 1 fine in the past three years, $117,527 in total.
What is the CMS star rating of Tudor Oaks Health Center?
Its CMS overall star rating is 2 of 5.
Is Tudor Oaks Health Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.