15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Sandwich, IL
2-star overall rating with 2-star inspections with $41,649 in total fines with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
515 North Main, Sandwich, IL
(815) 786-8426
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
113
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pavilion Healthcare
Operator or chain grouping
Approved since
1992-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 2 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
RN hours / resident day
0.75
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
2.96
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.65
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
2.48
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
8,598
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.75
Baseline 18.60% · Performance 20.16% · Measure score 2.75 · Achievement 2.75 · Improvement 0
Healthcare-associated infections
2.08
Baseline 9.59% · Performance 8.40% · Measure score 2.08 · Achievement 0 · Improvement 2.08
Total nurse turnover
5.66
Baseline 45.20% · Performance 40.54% · Measure score 5.66 · Achievement 5.66 · Improvement 1.79
Adjusted total nurse staffing
0
Baseline 2.41 hours · Performance 2.49 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.8% |
10.72%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 115 · Observed rate 19.13% · Lower 95% interval 9.29% |
| Discharge to community | 40.67% |
50.57%
9.9 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 33.73% · Lower 95% interval 29.76% |
| Medicare spending per beneficiary | 1.6 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 44.64% |
53.69%
9 pts worse
|
Numerator 25 · Denominator 56 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 32 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 8% |
2.29%
5.7 pts worse
|
Numerator 6 · Denominator 75 · Adjusted rate 8.52% |
| Healthcare-associated infections requiring hospitalization | 8.4% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 10.45% · Lower 95% interval 5.02% |
| Staff COVID-19 vaccination coverage | 4.07% |
8.2%
4.1 pts worse
|
Numerator 5 · Denominator 123 |
| Staff flu vaccination coverage | 9.6% |
42%
32.4 pts worse
|
Numerator 12 · Denominator 125 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 26 · Denominator 56 |
| Transfer of health information to provider | 97.06% |
95.95%
1.1 pts better
|
Numerator 33 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 33 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.3
0.6 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
89.6%
0.1 pts worse
|
93.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 88.5% · Q3 87.1% · Q4 86.6% · 4Q avg 89.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.5% |
91.6%
4.9 pts better
|
95.5%
1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.3% · Q3 1.2% · Q4 2.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 90.9% |
50.3%
40.6 pts worse
|
11.4%
79.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 92.2% · Q3 94.0% · Q4 93.8% · 4Q avg 90.9% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.5%
1.4 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 6.8% · Q4 9.6% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
18.5%
6.3 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 25.0% · Q3 25.7% · Q4 24.0% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
22.8%
7.8 pts better
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 12.3% · Q3 16.4% · Q4 15.4% · 4Q avg 15.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
17.2%
4.6 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 24.8% · Q3 23.5% · Q4 15.7% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.0%
2.2 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 10.8% · Q3 14.3% · Q4 14.3% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
21.3%
8.8 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 32.4% · Q3 30.4% · Q4 29.2% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.2%
0.2 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.3% · Q3 5.5% · Q4 4.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.0% |
68.8%
39.8 pts worse
|
81.7%
52.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.2% · Q2 30.8% · Q3 8.6% · Q4 22.0% · 4Q avg 29.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
14.0%
0.3 pts better
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 12.3% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.3%
1.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.8% |
63.0%
39.2 pts worse
|
79.7%
55.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 23.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
26.2%
8.3 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 15.8% · Expected 21.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (1 deficiency)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-13
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-12-13
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
Fire Safety
Install proper backup exit lighting.
Corrected 2024-12-13
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-13
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-13
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Not marked corrected
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-13
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-11-03
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-11-03
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-11-03
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-11-03
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-03
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-03
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-11-22
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-03
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-03
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-09-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-12
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-12
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-12
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-12
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-26
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-11-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-23
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-23
Health
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.
Corrected 2025-09-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-23
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-23
Health
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 2025-09-23
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-23
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-23
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-23
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-05
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-08-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-11
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-11
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 2024-07-05
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-23
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-23
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-23
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-23
Health
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 2023-10-23
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-10-23
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-03
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-23
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-31
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-12
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-12
Penalties and ownership
Fine · fine $41,649
Fine
Payment Denial · denial start 2023-10-25 · 9 days
9 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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