Illinois ›Sandwich

Sandwich Living & Rehab Center

902 East Arnold Street, Sandwich, IL 60548 · De Kalb County · 63 certified beds · avg 31 residents/day · certified since Apr 20, 2009

Part of chain: LINEAGE HEALTHCARE (5 facilities, chain avg rating 1.6★)

1/5
Health inspection rating (on-site)
13
Serious findings on record
$302,370
Fines, last 3 years
2.59
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, repeated · Feb 5, 2026 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Feb 6, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Jul 3, 2024 · F-0805 · triggered by a complaint

The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.

Why it matters: Food served in the wrong texture can cause choking or lead residents to stop eating and lose weight.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jul 23, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Dec 8, 2023 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jan 3, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Dec 8, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jan 3, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 5, 2024 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Dec 27, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 5, 2024 · F-0692

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jan 31, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 24, 2024 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 10, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 25, 2024 · F-0692

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Feb 16, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 19, 2024 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Feb 13, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 19, 2024 · F-0690 · triggered by a complaint

The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.

Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Feb 13, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (57)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 15, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 4, 2026D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Feb 5, 2026▲ K · Immediate jeopardy, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 18, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 18, 2025D · Potential for harm, one-offThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Dec 5, 2024▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Dec 5, 2024▲ G · Actual harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Dec 5, 2024D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Dec 5, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 5, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Dec 5, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Dec 5, 2024D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Dec 5, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Dec 5, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Sep 24, 2024▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Sep 24, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Sep 24, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 24, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Sep 24, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 5, 2024D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Aug 5, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jul 24, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jul 10, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jul 3, 2024▲ J · Immediate jeopardy, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint
Jul 3, 2024F · Potential for harm, facility-wideThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint
Jul 3, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Jul 3, 2024E · Potential for harm, repeatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jul 3, 2024E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Jul 3, 2024E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Jul 3, 2024D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Jan 25, 2024▲ G · Actual harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jan 25, 2024F · Potential for harm, facility-wideThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Jan 25, 2024F · Potential for harm, facility-wideThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Jan 25, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jan 25, 2024F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 25, 2024D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Jan 25, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jan 25, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jan 25, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jan 25, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jan 25, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 25, 2024D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Jan 19, 2024▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Jan 19, 2024▲ G · Actual harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Dec 8, 2023▲ J · Immediate jeopardy, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Dec 8, 2023▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 8, 2023▲ G · Actual harm, one-offThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Dec 8, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Oct 6, 2023▲ G · Actual harm, one-offThe facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. · from a complaint
Oct 6, 2023▲ G · Actual harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint
Oct 6, 2023D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Oct 6, 2023D · Potential for harm, one-offThe facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · from a complaint
Oct 6, 2023D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Oct 6, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 14, 2023E · Potential for harm, repeatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Sep 14, 2023D · Potential for harm, one-offThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Sep 14, 2023D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (9 → 1).

YearCitationsSerious (G–L)Worst severity that year
2023135J ▲
2024397J ▲
202520D
202631K ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

6 fines totaling $302,370, plus 4 Medicare payment denial periods.

DateTypeAmount / length
Feb 5, 2026Fine$17,345
Feb 5, 2026Payment Denial14 days from Feb 28, 2026
Dec 5, 2024Fine$74,159
Dec 5, 2024Payment Denial35 days from Dec 27, 2024
Jul 3, 2024Fine$16,801
Jul 3, 2024Fine$35,438
Jul 3, 2024Payment Denial75 days from Jul 27, 2024
Jan 19, 2024Fine$39,998
Sep 14, 2023Fine$118,629
Sep 14, 2023Payment Denial64 days from Oct 31, 2023

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityIllinois avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)2.592.993.95bottom 43% in Illinois; bottom 5% in the U.S.
Registered Nurse hours0.550.630.69top 44% in Illinois; bottom 45% in the U.S.
Weekend total nurse staffing2.382.673.50bottom 49% in Illinois; bottom 6% in the U.S.
Weekend RN hours (not acuity-adjusted)0.890.560.48top 14% in Illinois; top 8% in the U.S.
Total nursing staff turnover (%)56.344.545.8bottom 20% in Illinois; bottom 22% in the U.S.
RN turnover (%)85.741.842.9bottom 2% in Illinois; bottom 3% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.34, RN 0.71, weekend 3.07. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5

Who owns this facility

For profit - Partnership

Owner / managerTypeRoleStakeSince
Braunstein, EphraimIndividualIndirect Ownership InterestNOT APPLICABLE12/01/2024
Diena, AharonIndividualIndirect Ownership InterestNOT APPLICABLE12/01/2024
Dommft II LLCOrganizationIndirect Ownership InterestNOT APPLICABLE12/01/2024
Marvin Mermelstein 2020 Family TrustOrganizationIndirect Ownership InterestNOT APPLICABLE12/01/2024
Petlin Holdings LLCOrganizationDirect Ownership InterestNOT APPLICABLE12/01/2024
Petlin Holdings LLCOrganizationIndirect Ownership InterestNOT APPLICABLE12/01/2024
Ahearn, MichaelIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Ahearn, MichaelIndividualADP of the SNFNOT APPLICABLE12/01/2024
Braunstein, EphraimIndividualManaging Control - Governing BodyNOT APPLICABLE12/01/2024
Braunstein, EphraimIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Braunstein, EphraimIndividualADP of the SNFNOT APPLICABLE12/01/2024
Claussen, MaryIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Claussen, MaryIndividualADP of the SNFNOT APPLICABLE12/01/2024
Diena, AharonIndividualManaging Control - Governing BodyNOT APPLICABLE12/01/2024
Diena, AharonIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Diena, AharonIndividualADP of the SNFNOT APPLICABLE12/01/2024
Johnson, RichardIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2024
Johnson, RichardIndividualADP of the SNFNOT APPLICABLE12/01/2024
Petlin Holdings LLCOrganizationOperational/Managerial ControlNOT APPLICABLE12/01/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Pavilion on Main Street, the0.7 miSandwich, IL★★★☆☆3/5
Hillside Rehab & Care Center8.3 miYorkville, IL★★☆☆☆3/5
Pearl at the Tillers13.8 miOswego, IL★★★★★4/5
Pearl of Orchard Valley14.4 miAurora, IL★☆☆☆☆1/5abuse
Prairie Crossing LVG & Rehab15.8 miShabbona, IL★★★★☆4/5
La Bella of Aurora15.8 miAurora, IL★☆☆☆☆1/5abuse
Jennings Terrace16.6 miAurora, IL★★★★☆4/5
Avantara Aurora17.4 miAurora, IL★★★★☆4/5
Asbury Gardens Nsg & Rehab17.8 miNorth Aurora, IL★★★★☆4/5
Alden Courts of Waterford18.5 miAurora, IL★★★★☆4/5

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Facility data as of CMS processing date 2026-08-01. CCN 146133.