Cycle 1
Health 2025-02-26 · Fire 2025-02-26
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mequon, WI
Newcastle Place
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
12600 N Port Washington Rd #300, Mequon, WI
(262) 387-8850
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
2003-05-07
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.96
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.98
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.25
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.27
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.67
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
5.10
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,919
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.05% · Performance 22.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.51
Baseline 4.57% · Performance 5.59% · Measure score 7.51 · Achievement 7.51 · Improvement 0
Total nurse turnover
0
Baseline 47.83% · Performance 84.31% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
7.73
Baseline 4.77 hours · Performance 5.28 hours · Measure score 7.73 · Achievement 7.73 · Improvement 4.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.49% |
10.72%
2.8 pts worse
|
Worse than the National Rate · Eligible stays 430 · Observed rate 13.26% · Lower 95% interval 10.91% |
| Discharge to community | 70.01% |
50.57%
19.4 pts better
|
Better than the National Rate · Eligible stays 419 · Observed rate 65.16% · Lower 95% interval 65.47% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 248 · Denominator 248 |
| Falls with major injury | 0.4% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 248 |
| Discharge self-care score | 54.63% |
53.69%
0.9 pts better
|
Numerator 112 · Denominator 205 |
| Discharge mobility score | 26.34% |
50.94%
24.6 pts worse
|
Numerator 54 · Denominator 205 |
| Pressure ulcers or injuries, new or worsened | 1.61% |
2.29%
0.7 pts better
|
Numerator 4 · Denominator 248 · Adjusted rate 1.72% |
| Healthcare-associated infections requiring hospitalization | 5.59% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 241 · Observed rate 4.15% · Lower 95% interval 3.46% |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 5 · Denominator 100 |
| Staff flu vaccination coverage | 83.08% |
42%
41.1 pts better
|
Numerator 108 · Denominator 130 |
| Discharge function score | 45.37% |
56.45%
11.1 pts worse
|
Numerator 93 · Denominator 205 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 184 · Denominator 184 |
| Resident COVID-19 vaccinations up to date | 40.87% |
25.2%
15.7 pts better
|
Numerator 47 · Denominator 115 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.9%
4.9 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.3% |
16.6%
13.7 pts worse
|
19.6%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.8% |
16.7%
4.1 pts worse
|
16.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
17.3%
2.1 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
3.0%
0.8 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.5% |
25.5%
9 pts better
|
19.8%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.5% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.5%
0.4 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
86.8%
11.5 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 96.9% · Q3 98.6% · Q4 99.6% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.9% |
15.0%
5.1 pts better
|
12.0%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.9% · Observed 9.0% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.6% · Q3 1.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
82.2%
9.8 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
22.7%
3.1 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 22.6% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-13 · Fire 2023-12-13
22 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-10-27 · Fire 2022-10-27
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-12
E · Potential for more than minimal harm
2025-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-02-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-21
C · Minimal harm
2025-02-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-08
F · Potential for more than minimal harm
2023-12-13
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-12-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-01
E · Potential for more than minimal harm
2023-12-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-12-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-12-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-28
C · Minimal harm
2023-12-13
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-12-28
F · Potential for more than minimal harm
2022-10-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-27
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2022-11-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-23
D · Potential for more than minimal harm
2026-01-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-23
J · Immediate jeopardy
2025-07-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-10
F · Potential for more than minimal harm
2025-02-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-02-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-02-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-26
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-02-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-01-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-10-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-05-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-04-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-04-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-02-28
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-02-28
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-03-30
F · Potential for more than minimal harm
2023-12-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-05
F · Potential for more than minimal harm
2022-10-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-17
C · Minimal harm
2022-10-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-11-17
Penalties and ownership
What sits behind the stars
Ownership
Lifespace Communities Inc
5% Or Greater Direct Ownership Interest · Organization
Gorman, Joseph
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Jantzen, Jesse
Operational/Managerial Control · Individual
Jantzen, Jesse
Corporate Director · Individual
Jantzen, Jesse
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
Pope, Erin
Corporate Officer · Individual
Stemm, Christy
W-2 Managing Employee · Individual
Nearby options
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Milwaukee, WI
1-star overall rating with 1-star inspections with $90,921 in total fines with 27 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
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1-star overall rating with 1-star inspections with $282,090 in total fines with 25 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Bradley Estates Nursing And Rehab LLC
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $387,126 in total fines with 37 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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