Facility WatchInspection records for every certified US nursing home
Sandwich Living & Rehab Center
902 East Arnold Street Sandwich, IL 60548 (815) 786-8409
CCN
146133
Certified beds
63
Ownership
For profit - Limited Liability company
Chain
Lineage Healthcare
Nurse staffing
3.09
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.60 hours per resident per day
Nursing staff turnover: 54% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected March 4, 2026
1 citation · from a complaint investigation · Health
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected March 13, 2026
Inspected April 18, 2025
2 citations · from a complaint investigation · Health
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected May 10, 2025
D
F0921No actual harm with potential for more than minimal harm · Isolated
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected May 10, 2025
Inspected December 5, 2024
9 citations · Health
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected December 27, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected December 27, 2024
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected December 27, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected December 27, 2024
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected December 27, 2024
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected December 27, 2024
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected December 27, 2024
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected December 27, 2024
G
F0692Actual harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected January 31, 2025
Inspected September 24, 2024
5 citations · from a complaint investigation · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected October 10, 2024
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected October 10, 2024
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected October 10, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected October 10, 2024
G
F0600Actual harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected October 10, 2024
Inspected August 5, 2024
2 citations · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected October 10, 2024
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected August 16, 2024
Inspected July 24, 2024
1 citation · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected October 10, 2024
Inspected July 10, 2024
1 citation · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected October 10, 2024
Inspected July 3, 2024
7 citations · from a complaint investigation · Health
D
F0602No actual harm with potential for more than minimal harm · Isolated
Protect each resident from the wrongful use of the resident's belongings or money.
Deficient, Provider has date of correction · corrected July 23, 2024
E
F0610No actual harm with potential for more than minimal harm · Pattern
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected July 23, 2024
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected September 5, 2024
E
F0921No actual harm with potential for more than minimal harm · Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected September 5, 2024
F
F0803No actual harm with potential for more than minimal harm · Widespread
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Deficient, Provider has date of correction · corrected July 23, 2024
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected July 23, 2024
J
F0805Immediate jeopardy to resident health or safety · Isolated
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Deficient, Provider has date of correction · corrected July 23, 2024
Inspected January 25, 2024
12 citations · Health
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected February 16, 2024
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected February 16, 2024
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected February 16, 2024
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected February 16, 2024
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected February 16, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected February 16, 2024
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected February 16, 2024
F
F0725No actual harm with potential for more than minimal harm · Widespread
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected February 16, 2024
F
F0727No actual harm with potential for more than minimal harm · Widespread
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Deficient, Provider has date of correction · corrected February 16, 2024
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected February 16, 2024
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected February 16, 2024
G
F0692Actual harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected February 16, 2024
Inspected January 19, 2024
2 citations · from a complaint investigation · Health
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected February 13, 2024
G
F0690Actual harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected February 13, 2024
Inspected December 8, 2023
4 citations · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected January 3, 2024
G
F0835Actual harm · Isolated
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Deficient, Provider has date of correction · corrected January 3, 2024
J
F0600Immediate jeopardy to resident health or safety · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected January 3, 2024
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected January 3, 2024
Inspected October 6, 2023
6 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected October 10, 2023
D
F0553No actual harm with potential for more than minimal harm · Isolated
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Deficient, Provider has date of correction · corrected October 10, 2023
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected October 10, 2023
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected December 8, 2023
G
F0675Actual harm · Isolated
Honor each resident's preferences, choices, values and beliefs.
Deficient, Provider has date of correction · corrected October 10, 2023
G
F0745Actual harm · Isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected October 10, 2023
Inspected September 14, 2023
3 citations · from a complaint investigation · Health
D
F0725No actual harm with potential for more than minimal harm · Isolated
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected October 6, 2023
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected October 1, 2023
E
F0580No actual harm with potential for more than minimal harm · Pattern
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected October 6, 2023
Inspected June 27, 2023
6 citations · from a complaint investigation · Health
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected August 15, 2023
D
F0691No actual harm with potential for more than minimal harm · Isolated
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected July 21, 2023
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected July 21, 2023
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected July 21, 2023
F
F0835No actual harm with potential for more than minimal harm · Widespread
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Deficient, Provider has date of correction · corrected August 15, 2023
G
F0745Actual harm · Isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected July 21, 2023
Inspected February 8, 2023
16 citations · Health
C
F0577No actual harm with potential for minimal harm · Widespread
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Deficient, Provider has date of correction · corrected February 18, 2023
D
F0561No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected February 25, 2023
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected February 18, 2023
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected February 25, 2023
D
F0604No actual harm with potential for more than minimal harm · Isolated
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Deficient, Provider has date of correction · corrected February 25, 2023
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected February 25, 2023
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected February 25, 2023
D
F0773No actual harm with potential for more than minimal harm · Isolated
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Deficient, Provider has date of correction · corrected February 25, 2023
E
F0883No actual harm with potential for more than minimal harm · Pattern
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected February 25, 2023
E
F0887No actual harm with potential for more than minimal harm · Pattern
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Deficient, Provider has date of correction · corrected February 25, 2023
F
F0606No actual harm with potential for more than minimal harm · Widespread
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Deficient, Provider has date of correction · corrected February 20, 2023
F
F0727No actual harm with potential for more than minimal harm · Widespread
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Deficient, Provider has date of correction · corrected March 1, 2023
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 5, 2023
F
F0882No actual harm with potential for more than minimal harm · Widespread
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Deficient, Provider has date of correction · corrected February 25, 2023
F
F0921No actual harm with potential for more than minimal harm · Widespread
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected March 10, 2023
F
F0943No actual harm with potential for more than minimal harm · Widespread
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Deficient, Provider has date of correction · corrected February 25, 2023
Penalties
Date
Type
Amount
February 5, 2026
Payment Denial · 14 days
December 5, 2024
Fine
$74,159
December 5, 2024
Payment Denial · 35 days
July 3, 2024
Fine
$16,801
July 3, 2024
Fine
$35,438
July 3, 2024
Payment Denial · 75 days
January 19, 2024
Fine
$39,998
September 14, 2023
Fine
$118,629
September 14, 2023
Payment Denial · 64 days
June 27, 2023
Payment Denial · 19 days
Ownership transfers
Effective
Seller
Buyer
12/01/2024
Petersen Health Business LLC
Sandwich Living & Rehab Center LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.