TUDOR OAKS HEALTH CENTER: Archive Data

S77 W12929 MCSHANE DR, MUSKEGO, WI 53150 (414-529-0100)

CMS 5-Star Rating:

Data as of: September 01, 2019

This is not the most recent data for TUDOR OAKS HEALTH CENTER. For the most recent information, click here.

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: (3 out of 5):
(The national average overall star rating is 3 stars.)

Current Trend: Worsening

Total Nursing Hours Spent Per Resident Per Day: 5.25
(The national average is 3.76 )

Best Nursing Homes in WI

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: September 01, 2019

Address: S77 W12929 MCSHANE DR, MUSKEGO, WI 53150

Phone: 414-529-0100

Click for Map

Medicare Provider Number: 525279

Participating in Medicare Since: January 01, 1977

No. of Certified Beds: 61

No. of Residents: 42

Occupancy: 68.85 % (as of 09/17/2023 )

Amount fined in recent period: $11,050.00

Complaints filed: 3

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 3:
Health Inspection Rating 2:
Quality Rating 3:
Staffing Rating 4:

Inspection Scores

Cycle 1 Score (as of February 25, 2019) 52
Cycle 2 Score (as of December 06, 2017) 52
Cycle 3 Score (as of December 12, 2016) 44
Weighted All Cycles Score 51

It has been 6 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!) :

  1. Begin with the Health Inspection Rating
  2. 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".)
  3. Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
  4. Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
  5. 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:

No Inspection Information is Available

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:

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 0.96 0.96 / 0.66
Case Mix 0.35 0.38 / 0.39
Adjusted 1.04 NA / NA
Licensed Practical Nurse (LPN)
Hours 0.70 0.61 / 0.89
Case Mix 0.74 NA / NA
Adjusted 0.71 NA / NA
Certified Nursing Assistants (CNA)
Hours 3.59 2.31 / 2.22
Case Mix 2.33 NA / NA
Adjusted 3.21 NA / NA
Total Licensed Staff
Hours 1.66 1.56 / 1.54
Physical Therapist (PT)
Hours 0.07 0.07 / 0.07
Total Nursing Homes Spent per Resident on Average
Hours 5.25 3.88 / 3.76
Case Mix 3.42 3.16 / 3.17
Adjusted 4.94 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) 25.6% 20.9%
Worse
Percentage of short-stay residents who had an outpatient emergency department visit (qm522) 15.5% 11.7%
Worse
Number of hospitalizations per 1000 long-stay resident days (qm551) 2.2% 1.4%
Worse
Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) 1.0% 1.1%
Better
Percentage of long-stay residents whose need for help with daily activities has increased (qm401) 9.9% 14.1%
Better
Percentage of long-stay residents who self-report moderate to severe pain (qm402) 12.2% 9.2%
Worse
Percentage of long-stay residents who lose too much weight (qm404) 5.1% 5.2%
Better
Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) 63.5% 48.3%
Worse
Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) 0.4% 3.2%
Better
Percentage of long-stay residents with a urinary tract infection (qm407) 3.5% 3.2%
Worse
Percentage of long-stay residents who have depressive symptoms (qm408) 0.0% 4.8%
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) 11.7% 3.6%
Worse
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) 100.0% 97.1%
Better
Percentage of long-stay residents who received an antipsychotic medication (qm419) 9.7% 12.1%
Better
Percentage of short-stay residents who self-report moderate to severe pain (qm424) 19.7% 17.4%
Worse
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) 90.9% 89.4%
Better
Percentage of short-stay residents who newly received an antipsychotic medication (qm434) 2.0% 1.0%
Worse
Percentage of long-stay residents whose ability to move independently worsened (qm451) 16.4% 18.0%
Better
Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) 8.3% 15.7%
Better
Percentage of high risk long-stay residents with pressure ulcers (qm453) 8.5% 5.8%
Worse
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) 98.2% 96.3%
Better
Percentage of short-stay residents who made improvements in function (qm471) 65.4% 73.1%
Worse
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) 90.2% 86.7%
Better

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: $11,050.00, Complaints filed: 3

Deficiency Deficiency Date / Date Corrected
Install a two-hour-resistant firewall separation.
(Fire Safety)
12-07-2016 / 12-16-2016
Provide at least two remote exits on each floor or fire section of the building.
(Fire Safety)
12-07-2016 / 12-12-2016
Have properly located and lighted "Exit" signs.
(Fire Safety)
12-07-2016 / 12-08-2016
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
(Fire Safety)
12-07-2016 / 12-30-2016
Have approved installation, maintenance and testing program for fire alarm systems.
(Fire Safety)
12-07-2016 / 12-30-2016
Inspect, test, and maintain automatic sprinkler systems.
(Fire Safety)
12-07-2016 / 12-30-2016
Properly select, install, inspect, or maintain portable fire extinguishes.
(Fire Safety)
12-07-2016 / 12-30-2016
Install corridor and hallway doors that block smoke.
(Fire Safety)
12-07-2016 / 12-08-2016
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
(Fire Safety)
12-07-2016 / 12-16-2016
Have properly installed electrical wiring and gas equipment.
(Fire Safety)
12-07-2016 / 12-16-2016
Have simulated fire drills held at unexpected times.
(Fire Safety)
12-07-2016 / 12-08-2016
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
(Health)
12-12-2016 / 12-30-2016
Ensure each resident receives an accurate assessment by a qualified health professional.
(Health)
12-12-2016 / 12-13-2016
Provide care by qualified persons according to each resident's written plan of care.
(Health)
12-12-2016 / 12-30-2016
Provide necessary care and services to maintain or improve the highest well being of each resident .
(Health)
12-12-2016 / 12-22-2016
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
(Health)
12-12-2016 / 12-29-2016
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
(Health)
12-12-2016 / 12-22-2016
Develop policies and procedures for influenza and pneumococcal immunizations.
(Health)
12-12-2016 / 12-29-2016
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
(Health)
12-12-2016 / 12-29-2016
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.
(Health)
12-12-2016 / 12-28-2016
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
(Health)
08-16-2017 / 09-05-2017
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
(Health)
08-16-2017 / 09-08-2017
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
(Health)
08-16-2017 / 09-05-2017
Install an approved automatic sprinkler system.
(Fire Safety)
12-01-2017 / 12-27-2017
Inspect, test, and maintain automatic sprinkler systems.
(Fire Safety)
12-01-2017 / 12-27-2017
Have simulated fire drills held at unexpected times.
(Fire Safety)
12-01-2017 / 12-27-2017
Allow residents to self-administer drugs if determined clinically appropriate.
(Health)
12-06-2017 / 12-27-2017
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
(Health)
12-06-2017 / 12-27-2017
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
(Health)
12-06-2017 / 12-27-2017
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
(Health)
12-06-2017 / 12-27-2017
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 ne
(Health)
12-06-2017 / 12-27-2017
Ensure medication error rates are not 5 percent or greater.
(Health)
12-06-2017 / 12-27-2017
Ensure that residents are free from significant medication errors.
(Health)
12-06-2017 / 12-27-2017
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
(Health)
05-18-2018 / 05-18-2018
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
(Health)
02-25-2019 / 03-12-2019
Reasonably accommodate the needs and preferences of each resident.
(Health)
02-25-2019 / 03-12-2019
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
(Health)
02-25-2019 / 03-12-2019
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
(Health)
02-25-2019 / 03-12-2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
(Health)
02-25-2019 / 03-12-2019
Ensure services provided by the nursing facility meet professional standards of quality.
(Health)
02-25-2019 / 03-12-2019
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
(Health)
02-25-2019 / 03-12-2019
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
(Health)
02-25-2019 / 03-12-2019

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.

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 September 01, 2019.

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 September 01, 2019.