Sandwich Living & Rehab Center
902 East Arnold Street · Sandwich, IL · 60548 · 8157868409
63 certified beds For profit - Limited Liability company Chain: Lineage Healthcare
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $74,159 in fines in the last 24 months.
- 10 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
3 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$74,159 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 3.86 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.75 | 0.55–0.75 |
| Weekend hours / resident-day | 3.25 | ≈ weekday level |
| Nursing turnover / year | 55% | median 45% |
| Fines (3-yr window) | 5 · $285,025 |
Inspection citations (77 in the current record)
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Potential for harm · D March 4, 2026 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected March 13, 2026 · Quality of Life and Care
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Potential for harm · D April 18, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 10, 2025 · Quality of Life and Care
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Potential for harm · D April 18, 2025 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected May 10, 2025 · Environmental
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Actual harm · G December 5, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 27, 2024 · Quality of Life and Care
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Actual harm · G December 5, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected January 31, 2025 · Quality of Life and Care
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Potential for harm · D December 5, 2024
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.
Corrected December 27, 2024 · Resident Rights
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Potential for harm · D December 5, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 27, 2024 · Quality of Life and Care
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Potential for harm · D December 5, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected December 27, 2024 · Quality of Life and Care
-
Potential for harm · D December 5, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 27, 2024 · Pharmacy Service
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Potential for harm · D December 5, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected December 27, 2024 · Pharmacy Service
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Potential for harm · D December 5, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected December 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · D December 5, 2024
Provide and implement an infection prevention and control program.
Corrected December 27, 2024 · Infection Control
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Actual harm · G September 24, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 10, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 24, 2024 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected October 10, 2024 · Resident Rights
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Potential for harm · D September 24, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 10, 2024 · Quality of Life and Care
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Potential for harm · D September 24, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 10, 2024 · Quality of Life and Care
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Potential for harm · D September 24, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 10, 2024 · Quality of Life and Care
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Potential for harm · D August 5, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 10, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 5, 2024 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected August 16, 2024 · Resident Assessment and Care Planning
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Potential for harm · D July 24, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 10, 2024 · Quality of Life and Care
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Potential for harm · D July 10, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 10, 2024 · Quality of Life and Care
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Immediate jeopardy · J July 3, 2024 · found via complaint
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected July 23, 2024 · Nutrition and Dietary
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Potential for harm · D July 3, 2024 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected July 23, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E July 3, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected July 23, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E July 3, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 5, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| 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 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 146133 · certified since April 20, 2009. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.