Special Focus Facility

Overview

Address
110 BELMONT RD, MADISON, WI 53714
Phone
6082497391
Certified beds
83
Avg daily residents
70 (84% of beds filled)
Ownership
For-profit LLC
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1974-11-01
Setting
Urban
Rating not available

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
Footnote 18.
— Not Available
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
Footnote 18.
— Not Available
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
Footnote 18.
— Not Available
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
Footnote 18.
— Not Available

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
3.55 3.62 3.78 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
0.58 0.63 0.62 ≥ 0.55
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
1.10 0.80 1.17
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
1.87 2.18 2.00
Licensed (RN + LPN)
Combined licensed nurse coverage.
1.67
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
0.00

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
3.23
hrs / resident / day
RN (weekend)
0.40
hrs / resident / day
Total nurse (adjusted, weekend)
3.45
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
75.6%
annual
RN turnover
76.9%
annual
Administrators departed
1
last 12 months

Resident acuity

Nursing Case-Mix Index
1.28
higher acuity than avg
Case-Mix Index Ratio
0.93
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-08-26 10 7 3 56 1 56
Cycle 2/3 (prior) 2025-03-25 69 22 56 798 1 798
Total weighted health score
241.5
lower is better

Deficiencies (103)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

1 A/B/C No actual harm — minor
92 D/E/F Actual harm — potential for minor
6 G/H/I Actual harm
4 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2025-12-15 2026-01-09
0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. D 2025-12-15 2026-01-09
0610 Respond appropriately to all alleged violations. D 2025-12-15 2026-01-09
0554 Allow residents to self-administer drugs if determined clinically appropriate. D 2025-08-26 2025-09-20
0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. D 2025-08-26 2025-09-20
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2025-08-26 2025-09-20
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2025-08-26 2025-09-20
0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. D 2025-08-26 2025-09-20
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F 2025-08-26 2025-09-20
0880 Provide and implement an infection prevention and control program. E 2025-08-26 2025-09-20
0554 Allow residents to self-administer drugs if determined clinically appropriate. D 2025-03-25 2025-04-18
0679 Provide activities to meet all resident's needs. D 2025-03-25 2025-04-14
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. J 2025-03-25 2025-04-18
0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. D 2025-03-25 2025-04-18
0711 Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. E 2025-03-25 2025-04-18
0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. D 2025-03-25 2025-04-18
0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. D 2025-03-25 2025-04-18
0730 Observe each nurse aide's job performance and give regular training. E 2025-03-25 2025-04-15
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F 2025-03-25 2025-04-15
0814 Dispose of garbage and refuse properly. F 2025-03-25 2025-04-08
0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. F 2025-03-25 2025-04-15
0880 Provide and implement an infection prevention and control program. G 2025-03-25 2025-04-18
0881 Implement a program that monitors antibiotic use. D 2025-03-25 2025-04-14
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D 2025-03-25 2025-04-18
0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. E 2025-03-25 2025-04-14
0585 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. D 2025-03-25 2025-04-14
0641 Ensure each resident receives an accurate assessment. D 2025-03-25 2025-04-18
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2025-03-25 2025-04-18
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. G 2025-03-25 2025-04-18
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2025-03-25 2025-03-25
0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. D 2025-03-25 2025-04-18
0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. K 2025-03-25 2025-04-18
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2024-11-13 2024-12-06
0557 Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. D 2024-10-10 2024-11-04
0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. E 2024-10-10 2024-11-04
0585 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. D 2024-10-10 2024-11-04
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2024-10-10 2024-11-04
0610 Respond appropriately to all alleged violations. D 2024-10-10 2024-11-04
0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. E 2024-10-10 2024-11-04
0625 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. E 2024-10-10 2024-11-04
0641 Ensure each resident receives an accurate assessment. D 2024-10-10 2024-11-04
0645 PASARR screening for Mental disorders or Intellectual Disabilities E 2024-10-10 2024-11-04
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2024-10-10 2024-11-04
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2024-10-10 2024-11-04
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2024-10-10 2024-11-04
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. E 2024-10-10 2024-11-04
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2024-10-10 2024-11-04
0687 Provide appropriate foot care. D 2024-10-10 2024-11-04
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. E 2024-10-10 2024-11-04
0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. D 2024-10-10 2024-11-04

Showing 50 most recent of 103. See the All Data CSV for the full list.

Penalties (7)

Fines issued
6
last 3 years
Total fines
$413,433
Payment denials
1
Date Type Fine amount
2023-03-23 Fine $10,375
2023-12-21 Fine $14,701
2024-08-27 Fine $16,055
2023-05-04 Fine $22,122
2024-06-19 Fine $80,580
2025-03-25 Fine $269,600
2024-06-19 Payment Denial

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 8.8% Medicaid 30.6% Other 60.6%

Operating performance

Operating Margin
-8.0%
Total Margin
-6.5%
Occupancy Rate
68.7%
Cost per Resident Day
$44

Revenue & costs

Net Patient Revenue
$7.6M
Total Costs
$922K
Net Income
-$500K

Balance sheet

Total Assets
$72K
Total Liabilities
$913K
Fund Balance
-$841K

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: CHAMPION CARE

Chain ID
134
Facilities in chain
21
Legal business name
BAY AT BELMONT HEALTH AND REHABILITATION CENTER LLC
Chain-average star ratings (for peer context)
Overall
2.1
Health
2.2
Staffing
2.2
QM
2.8

Owner / manager organizations (1)

Organization Role Association
BAY AT BELMONT HOLDINGS LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 09/13/2021

Owner / manager individuals (6)

Name Role Association
RUVEL, MENACHEM 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 09/13/2021
WEINBERG, YISROEL 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 09/13/2021
RUVEL, MENACHEM OPERATIONAL/MANAGERIAL CONTROL since 01/01/2022
WEINBERG, YISROEL OPERATIONAL/MANAGERIAL CONTROL since 01/01/2022
RUVEL, MENACHEM CORPORATE DIRECTOR since 09/13/2021
WEINBERG, YISROEL CORPORATE DIRECTOR since 09/13/2021

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Special focus status
SFF
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 112 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $44 metrics.cost_per_resident_day
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 30.6% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 8.8% metrics.medicare_day_share
Cost Report Net Income ($) $-499,624 metrics.net_income
Cost Report Net Patient Revenue ($) $7,629,456 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 68.7% metrics.occupancy_rate
Cost Report Operating Margin (%) -8.0% metrics.operating_margin
Cost Report Total Assets ($) $71,733 metrics.total_assets
Cost Report Total Costs ($) $922,093 metrics.total_costs
Cost Report Total Fund Balances ($) $-841,492 metrics.fund_balance
Cost Report Total Liabilities ($) $913,225 metrics.total_liabilities
Cost Report Total Margin (%) -6.5% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 1.16888 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.99625 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.61585 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.78098 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 3.44601 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 69.9 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.80365 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.18414 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.63345 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.62124 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.19174 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.2 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.1 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 2.8 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.2 Chain Average Staffing Rating
Provider Information Chain ID 134 Chain ID
Provider Information Chain Name CHAMPION CARE Chain Name
Provider Information City/Town MADISON City/Town
Provider Information CMS Certification Number (CCN) 525074 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Dane County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1974-11-01 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote Geocoding Footnote
Provider Information Health Inspection Rating Health Inspection Rating
Provider Information Health Inspection Rating Footnote 18 Health Inspection Rating Footnote
Provider Information Latitude 43.0957 Latitude
Provider Information Legal Business Name BAY AT BELMONT HEALTH AND REHABILITATION CENTER LLC Legal Business Name
Provider Information Location 110 BELMONT RD,MADISON,WI,53714 Location
Provider Information Long-Stay QM Rating Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote 18 Long-Stay QM Rating Footnote
Provider Information Longitude -89.314 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 1 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 83 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 21 Number of Facilities in Chain
Provider Information Number of Fines 6 Number of Fines
Provider Information Number of Payment Denials 1 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.28284 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.93118 Nursing Case-Mix Index Ratio
Provider Information Overall Rating Overall Rating
Provider Information Overall Rating Footnote 18 Overall Rating Footnote
Provider Information Ownership Type For profit - Limited Liability company Ownership Type
Provider Information Physical Therapist Staffing Footnote Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 110 BELMONT RD Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name MADISON HEALTH AND REHABILITATION CENTER Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 120 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating QM Rating
Provider Information QM Rating Footnote 18 QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 56 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 3 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 7 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-08-26 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 56 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 10 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 22 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2025-03-25 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 798 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 56 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 798 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 69 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.39920 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 76.9 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.67394 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 1.09632 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 1.87232 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.00181 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.57762 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.54625 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote 18 Short-Stay QM Rating Footnote
Provider Information Special Focus Status SFF Special Focus Status
Provider Information Staffing Rating Staffing Rating
Provider Information Staffing Rating Footnote 18 Staffing Rating Footnote
Provider Information State WI State
Provider Information Telephone Number 6082497391 Telephone Number
Provider Information Total Amount of Fines in Dollars 413433.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 3.23207 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 7 Total Number of Penalties
Provider Information Total nursing staff turnover 75.6 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 241.500 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 53714 ZIP Code