Tudor Oaks Health Center: Data Analysis and Ratings
CMS Five Star Rating(2 out of 5):
S77 W12929 MCSHANE DR MUSKEGO, WI 53150
414-529-0100
Data date: May 01, 2023
The Most Important Data about Tudor Oaks Health Center
We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)
There is no indication of abuse occuring at Tudor Oaks Health Center. (CMS flags facilities where abuse has either happened or is very likely.)
CMS 5-Star Overall Rating:
(2 out of 5):
(The national average overall star rating is 3 stars.)
Current Trend: Worsening
Total Nursing Hours Spent Per Resident Per Day: 4.02
(The national average is 3.74 )
According to our analysis, Tudor Oaks Health Center is ranked #38 out of 70 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near Tudor Oaks Health Center.
What is this page all about?
Below is everything shred of information that we can find about Tudor Oaks Health Center, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.
General Data Card
These are the basic data points for the facility.
Data date: May 01, 2023
Address: S77 W12929 MCSHANE DR
MUSKEGO, WI 53150
Phone: 414-529-0100
Ranking: Tudor Oaks Health Center is ranked #13 out of 25 facilities within a 10 mile radius and #38 out of 70 facilities within a 25 mile radius.
Medicare Provider Number: 525279
Participating in Medicare Since: January 01, 1977
No. of Certified Beds: 61
No. of Residents: 44
Occupancy: 72.13 % (as of 05/21/2023 )
Amount fined in recent period: $657.80
Complaints filed: 2
Ratings History for Tudor Oaks Health Center
Review of Tudor Oaks Health Center Ratings and Inspection Scores
CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.
Ratings
| Overall Rating | 2: |
| Health Inspection Rating | 2: |
| Quality Rating | 4: |
| Staffing Rating | 3: |
Inspection Scores
| Cycle 1 Score (as of January 05, 2023) | 144 |
| Cycle 2 Score (as of November 03, 2021) | 56 |
| Cycle 3 Score (as of February 26, 2020) | 40 |
| Weighted All Cycles Score | 97 |
It has been 3 months since the most recent inspection.
What Goes Into the Nursing Home's 5-Star Rating
CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.
The rating system has five separate ratings including:
- Overall rating
- Health Inspection rating
- Staff rating
- RN Staffing rating
- Quality Measures rating
Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.
Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :
- Begin with the Health Inspection Rating
- Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
- Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
- Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
- Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.
Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)
Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.
Most Recent Nursing Home Inspections
CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for Tudor Oaks Health Center including health, fire, and inspection control inspections:
| Inspection Type | Inspection Date |
|---|---|
| Fire Safety Standard | January 04, 2023 |
| Fire Safety Standard | November 02, 2021 |
| Fire Safety Standard | February 27, 2020 |
| Health Complaint | November 03, 2021 |
| Health Complaint | September 22, 2021 |
| Health Standard | January 05, 2023 |
| Health Standard | November 03, 2021 |
| Health Standard | February 26, 2020 |
| Infection Control | September 27, 2022 |
| Infection Control | December 29, 2021 |
| Infection Control | November 16, 2020 |
| Infection Control | October 28, 2020 |
| Infection Control | June 24, 2020 |
Owner and Operator Information for Tudor Oaks Health Center
Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.
Business Entity Name:
AMERICAN BAPTIST HOMES OF THE MIDWEST
Owners:
Managers and Directors:
- RYAN ALLEN (DIRECTOR)
- ANDREA BLATNIK (OFFICER)
- ANDREA BLATNIK (MANAGING EMPLOYEE)
- ROGER DAVIDSON (DIRECTOR)
- ASHLEY FORD (DIRECTOR)
- PHILLIP HANSON (DIRECTOR)
- JEFFREY HONGSLO (DIRECTOR)
- DOROTHY JOHNSON (DIRECTOR)
- JAMES JOHNSON (DIRECTOR)
- GEORGE KILLIAN (DIRECTOR)
- CHRISTINA KOTZ (MANAGING EMPLOYEE)
- RUTH NEIMAN (DIRECTOR)
- MARSHALL PETERS (DIRECTOR)
- BRUCE VAN DER BEEK (DIRECTOR)
- STEVEN VANOSTRAM (DIRECTOR)
- STEPHANIE VAUGHN-GRAY (DIRECTOR)
- ANNE WAGONER FORD (DIRECTOR)
- BRUCE WHITAKER (DIRECTOR)
- BARBARA WOODS (DIRECTOR)
- MELISSA ZYGARLICKE (OFFICER)
Analysis of Nursing Hours Spent Per Patient
CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.
The nursing staff of Tudor Oaks Health Center spends MORE time on average with its residents than the state average for total nursing homes spent per resident and MORE time than the national average for total nursing homes spent per resident.
| Type | Facility | State / National Avg |
|---|---|---|
| Registered Nurse (RN) | ||
| Hours | 0.64 | 0.97 / 0.65 |
| Case Mix | 0.31 | 0.37 / 0.39 |
| Adjusted | 0.79 | NA / NA |
| Licensed Practical Nurse (LPN) | ||
| Hours | 0.67 | 0.60 / 0.88 |
| Case Mix | 0.73 | NA / NA |
| Adjusted | 0.67 | NA / NA |
| Certified Nursing Assistants (CNA) | ||
| Hours | 2.71 | 2.29 / 2.21 |
| Case Mix | 2.24 | NA / NA |
| Adjusted | 2.46 | NA / NA |
| Total Licensed Staff | ||
| Hours | 1.30 | 1.56 / 1.53 |
| Physical Therapist (PT) | ||
| Hours | 0.04 | 0.07 / 0.07 |
| Total Nursing Homes Spent per Resident on Average | ||
| Hours | 4.02 | 3.85 / 3.74 |
| Case Mix | 3.28 | 3.16 / 3.16 |
| Adjusted | 3.86 | NA / NA |
Quality Measures
Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.
| Desc. | Perc. | State Avg. / Comparison |
|---|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) | 5.4% |
20.2% Better |
| Percentage of short-stay residents who had an outpatient emergency department visit (qm522) | 11.7% |
13.9% Better |
| Number of hospitalizations per 1000 long-stay resident days (qm551) | 1.6% |
1.3% Worse |
| Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) | 0.6% |
1.4% Better |
| Percentage of long-stay residents whose need for help with daily activities has increased (qm401) | 11.5% |
13.9% Better |
| Percentage of long-stay residents who lose too much weight (qm404) | 4.2% |
5.5% Better |
| Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) | 70.2% |
49.9% Worse |
| Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) | 2.2% |
3.2% Better |
| Percentage of long-stay residents with a urinary tract infection (qm407) | 3.4% |
3.2% Worse |
| Percentage of long-stay residents who have depressive symptoms (qm408) | 0.0% |
6.2% Better |
| Percentage of long-stay residents who were physically restrained (qm409) | 0.0% |
0.1% Better |
| Percentage of long-stay residents experiencing one or more falls with major injury (qm410) | 1.3% |
3.3% Better |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) | 95.5% |
95.3% Better |
| Percentage of long-stay residents who received an antipsychotic medication (qm419) | 16.1% |
14.2% Worse |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) | 79.7% |
87.3% Worse |
| Percentage of short-stay residents who newly received an antipsychotic medication (qm434) | 0.0% |
1.1% Better |
| Percentage of long-stay residents whose ability to move independently worsened (qm451) | 20.7% |
17.2% Worse |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) | 14.2% |
15.5% Better |
| Percentage of high risk long-stay residents with pressure ulcers (qm453) | 3.0% |
7.6% Better |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) | 97.5% |
95.1% Better |
| Percentage of short-stay residents who made improvements in function (qm471) | 59.5% |
76.4% Worse |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) | 75.0% |
78.9% Worse |
Tudor Oaks Health Center Violations, Complaints and Fines
These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.
Amount fined in recent period: $657.80, Complaints filed: 2
| Deficiency | Deficiency Date / Date Corrected |
|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Health) | 02-26-2020 / 03-06-2020 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 02-26-2020 / 03-06-2020 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Health) | 02-26-2020 / 03-06-2020 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Health) | 02-26-2020 / 03-06-2020 |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Health) | 02-26-2020 / 03-06-2020 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 02-26-2020 / 03-06-2020 |
| Provide properly protected cooking facilities. (Fire Safety) | 02-27-2020 / 02-28-2020 |
| Have simulated fire drills held at unexpected times. (Fire Safety) | 02-27-2020 / 02-28-2020 |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Health) | 09-22-2021 / 10-11-2021 |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. (Health) | 09-22-2021 / 10-11-2021 |
| Develop and maintain an Emergency Preparedness Program (EP). (Fire Safety) | 11-02-2021 / 11-17-2021 |
| Install an approved automatic sprinkler system. (Fire Safety) | 11-02-2021 / 11-24-2021 |
| Meet requirements for the use of electrical equipment. (Fire Safety) | 11-02-2021 / 11-24-2021 |
| Ensure proper usage of power strips and extension cords. (Fire Safety) | 11-02-2021 / 11-24-2021 |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (Health) | 11-03-2021 / 11-24-2021 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Health) | 11-03-2021 / 11-24-2021 |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Health) | 11-03-2021 / 11-04-2021 |
| Provide and implement an infection prevention and control program. (Health) | 11-03-2021 / 11-24-2021 |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (Health) | 11-03-2021 / 11-04-2021 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. (Health) | 11-03-2021 / 11-24-2021 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Health) | 11-03-2021 / 11-24-2021 |
| Meet requirements for sections of health care facilities separated by fire resistive construction. (Fire Safety) | 01-04-2023 / 01-31-2023 |
| Have properly located and lighted "Exit" signs. (Fire Safety) | 01-04-2023 / 01-27-2023 |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. (Fire Safety) | 01-04-2023 / 01-27-2023 |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. (Fire Safety) | 01-04-2023 / 01-27-2023 |
| Have simulated fire drills held at unexpected times. (Fire Safety) | 01-04-2023 / 01-27-2023 |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. (Fire Safety) | 01-04-2023 / 01-27-2023 |
| Have generator or other power source capable of supplying service within 10 seconds. (Fire Safety) | 01-04-2023 / 01-26-2023 |
| Meet requirements for the use of electrical equipment. (Fire Safety) | 01-04-2023 / 01-25-2023 |
| Ensure proper usage of power strips and extension cords. (Fire Safety) | 01-04-2023 / 01-31-2023 |
| 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. (Health) | 01-05-2023 / 02-21-2023 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 01-05-2023 / 02-21-2023 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Health) | 01-05-2023 / 02-21-2023 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. (Health) | 01-05-2023 / 02-21-2023 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Health) | 01-05-2023 / 03-03-2023 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Health) | 01-05-2023 / 02-21-2023 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Health) | 01-05-2023 / 02-21-2023 |
| Provide enough food/fluids to maintain a resident's health. (Health) | 01-05-2023 / 02-21-2023 |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Health) | 01-05-2023 / 02-21-2023 |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. (Health) | 01-05-2023 / 02-21-2023 |
| 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. (Health) | 01-05-2023 / 02-21-2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 01-05-2023 / 02-21-2023 |
| Provide and implement an infection prevention and control program. (Health) | 01-05-2023 / 02-21-2023 |
Hospitals Near Tudor Oaks Health Center
Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near Tudor Oaks Health Center.
This information is based on the most recent Hospital data. Historical data is not available.
| Hospital | 5-Star Overall Rating |
|---|---|
|
ASCENSION ST FRANCIS HOSPITAL 3237 S 16TH ST MILWAUKEE, WI 53215 |
2 |
|
FROEDTERT SOUTH INC. 6308 EIGHTH AVE KENOSHA, WI 53143 |
2 |
|
ASCENSION SE WISCONSIN HOSPITAL 5000 W CHAMBERS ST MILWAUKEE, WI 53210 |
2 |
|
ASCENSION ALL SAINTS HOSPITAL 3801 SPRING ST RACINE, WI 53405 |
3 |
|
ASCENSION COLUMBIA ST MARY'S HOSPITAL MILWAUKEE 2323 N LAKE DR MILWAUKEE, WI 53211 |
3 |
|
AURORA MEMORIAL HOSPITAL BURLINGTON 252 MCHENRY ST BURLINGTON, WI 53105 |
3 |
|
MERCY WALWORTH HOSPITAL & MEDICAL CENTER N2950 STATE ROAD 67 LAKE GENEVA, WI 53147 |
3 |
|
WEST ALLIS MEMORIAL HOSPITAL 8901 W LINCOLN AVE WEST ALLIS, WI 53227 |
3 |
|
WAUKESHA MEMORIAL HOSPITAL 725 AMERICAN AVE WAUKESHA, WI 53188 |
3 |
|
FROEDTERT MEMORIAL LUTHERAN HOSPITAL 9200 W WISCONSIN AVE MILWAUKEE, WI 53226 |
3 |
|
AURORA MEDICAL CENTER - SUMMIT 36500 AURORA DRIVE SUMMIT, WI 53066 |
4 |
|
OCONOMOWOC MEMORIAL HOSPITAL 791 E SUMMIT AVE OCONOMOWOC, WI 53066 |
4 |
|
AURORA ST LUKES MEDICAL CENTER 2900 W OKLAHOMA AVE MILWAUKEE, WI 53215 |
4 |
|
AURORA LAKELAND MEDICAL CENTER W3985 COUNTY ROAD NN ELKHORN, WI 53121 |
5 |
|
COMMUNITY MEMORIAL HOSPITAL W180 N8085 TOWN HALL RD MENOMONEE FALLS, WI 53051 |
5 |
|
AURORA MEDICAL CENTER KENOSHA 10400 75TH ST KENOSHA, WI 53142 |
5 |
|
ORTHOPAEDIC HOSPITAL OF WI 475 W RIVER WOODS PKWY GLENDALE, WI 53212 |
Not Available |
|
MIDWEST ORTHOPEDIC SPECIALTY HOSPITAL 10101 SOUTH 27TH ST 2ND FLOOR FRANKLIN, WI 53132 |
Not Available |
|
FROEDTERT COMMUNITY HOSPITAL 4805 S MOORLAND RD NEW BERLIN, WI 53151 |
Not Available |
|
ASCENSION WISCONSIN HOSP MENOMONEE FALLS CAMPUS N88W14275 MAIN STREET, SUITE 100 MENOMONEE FALLS, WI 53051 |
Not Available |
Medical Professionals Associated with Tudor Oaks Health Center
These are the doctors who are affiliated with Tudor Oaks Health Center. The data is from the most recent period. Historical data is not available.
- STEVE KIM ( INTERNAL MEDICINE - SJK GERIATRICS AND PALLIATIVE CARE INC. )
Detailed Analysis Pages:
Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.
CMS Five Star Ratings and Quality Measures for Tudor Oaks Health Center
Five different rating results plus detailed inspection numbers and quality measures for Tudor Oaks Health Center.
Covid Infections at Tudor Oaks Health Center
This report is updated weekly and shows new and historical infection levels.
Nursing Hours Analysis for Tudor Oaks Health Center
How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.
Ownership Details for Tudor Oaks Health Center
A list of all of the registered owners for Tudor Oaks Health Center. This includes direct and indirect owners and managers.
Noted Deficiencies for Tudor Oaks Health Center
A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.
Comparison Ranking of Nearby Skilled Nursing Facilities
How does Tudor Oaks Health Center compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.
Best Nursing Homes in MUSKEGO, WI
Homes that you should consider. A list ranking the best skilled nursing facilities in MUSKEGO based on their weighted inspection score as of May 01, 2023.
Worst Nursing Homes in MUSKEGO, WI
Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in MUSKEGO based on their weighted inspection score as of May 01, 2023.
Other Data Periods:
Data on Tudor Oaks Health Center is available for the following periods:
