The most recent inspection on August 29, 2025, found the facility in overall compliance but noted a technical deficiency for not submitting a final incident report to IDPH within the required 14 days. Earlier inspections in 2025 identified multiple deficiencies related to emergency preparedness, staff training, background checks, physician assessments, and dementia-specific training, with some issues repeated from prior surveys. Complaint investigations in March and May 2025 substantiated problems with food service sanitation, environmental conditions, and compliance with staff orientation and documentation requirements. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility showed some improvement by the most recent inspection, addressing many prior issues though a few technical reporting deficiencies remained.
Deficiencies (last 1 years)
Deficiencies (over 1 years)17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
386% worse than Illinois average
Illinois average: 3.5 deficiencies/year
Deficiencies per year
86420
2025
Inspection Report Plan of CorrectionDeficiencies: 1Aug 29, 2025
Visit Reason
The survey was conducted to review compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act, specifically related to a facility reported incident IL197104.
Findings
The establishment was found to be in compliance overall, but a technical infraction was identified for failing to send the final incident report to IDPH within 14 days from the initial report. The facility took corrective steps during the survey to prevent recurrence, and no violation was imposed.
Deficiencies (1)
Description
Failure to send the final incident report to IDPH within 14 days from the initial report.
Annual Survey conducted on 5/29/2025 to assess compliance with state regulations for Bickford of Gurnee.
Findings
Multiple violations were cited including deficiencies in disaster preparedness, manager qualifications, employee orientation and training, initial health evaluations, health care worker background checks, physician assessments, and Alzheimer's and dementia program training. Several violations were repeats from the previous annual survey.
Severity Breakdown
Type 2 Violation: 4Type 3 Violation: 2
Deficiencies (7)
Description
Severity
Failed to provide orientation to residents regarding emergency/evacuation plans and failed to conduct the required minimum number of fire drills.
Type 2 Violation
Failed to notify the Department regarding a change in management/Executive Director within 10 working days after hiring.
Type 3 Violation
Failed to complete employee orientation and ongoing training within required timeframes and documentation requirements.
Type 2 Violation
Failed to complete tuberculosis skin tests for employees within required timeframes and follow policy.
Type 3 Violation
Failed to conduct health care worker background checks, fingerprint-based criminal history record checks, employment verification, internet searches, and failed to retain required documentation.
Type 2 Violation
Failed to ensure physician certification/assessment was conducted prior to admission and signed by a physician.
—
Failed to provide required dementia-specific orientation, on-the-job supervised training, and ongoing in-service education for Alzheimer's and dementia programs.
Type 2 Violation
Report Facts
Fire drills conducted: 2Residents reviewed for Disaster Preparedness: 5Employees reviewed for orientation: 9Employees reviewed for continuing training: 2Employees reviewed for TB test: 9Employees reviewed for background checks: 9Residents reviewed for Physician Assessment: 5Employees reviewed for Alzheimer's and Dementia Programs: 9Alzheimer's training hours for E5: 1.25Alzheimer's training hours for E6: 2.5
Employees Mentioned
Name
Title
Context
E1
Executive Director
Named in findings for failure to notify management change, incomplete orientation, TB testing, and background checks.
E2
Breadbasket Manager
Named in findings for incomplete background checks and employee file documentation.
E3
Health and Wellness Coordinator
Named in findings for incomplete orientation, TB testing, background checks, and Alzheimer's training.
E4
Registered Nurse
Named in findings for incomplete orientation and Alzheimer's training.
E5
Caregiver Assistant
Named in findings for incomplete orientation, TB testing, background checks, and Alzheimer's training.
E6
Caregiver Assistant
Named in findings for incomplete orientation, continuing training, background checks, and Alzheimer's training.
E7
Caregiver Assistant
Named in findings for incomplete Alzheimer's training.
E8
Certified Caregiver
Named in findings for incomplete TB testing, background checks, and Alzheimer's training.
E9
Caregiver Assistant
Named in findings for incomplete background checks and Alzheimer's training.
The inspection was conducted in response to complaint surveys at Bickford of Gurnee on 5/29/25 to identify regulatory violations.
Findings
Multiple deficiencies were identified including failure to provide resident orientation on emergency evacuation plans, failure to conduct required fire drills, failure to notify the Department of a change in Executive Director within 10 working days, failure to provide timely employee orientation and continuing training, failure to complete TB tests for employees timely, failure to conduct required background checks, failure to ensure physician certification was completed prior to resident admission, and failure to provide required dementia-specific training for employees.
Complaint Details
The visit was complaint-related as it was conducted in response to complaint surveys completed on 5/29/25. The document serves as a Statement of Correction addressing violations identified during that visit.
Deficiencies (7)
Description
Failed to provide orientation to residents or responsible parties regarding emergency evacuation plans and failed to conduct required fire drills.
Failed to notify the Department regarding a change in management/Executive Director within 10 working days after hiring.
Failed to provide timely employee orientation and continuing training hours.
Failed to complete TB tests for employees within required time frame and failed to follow TB screening policy.
Failed to show documentation of health care worker background checks, fingerprint-based criminal history checks, employment verification, and retention of criminal record requests.
Failed to ensure physician certification/assessment was completed and signed by a physician prior to resident admission.
Failed to ensure employees received required dementia-specific orientation and ongoing in-service education.
Report Facts
Fire drills completion deadline: 2025Orientation completion deadline: 2025Notification date: 2025Employee orientation completion deadline: 2025TB test administration: 4Background checks completed: 6Physician certification date: 2025Dementia training completion deadline: 2025Dementia training audit deadline: 2025
Employees Mentioned
Name
Title
Context
Abby Totero
Contact person for questions regarding the Statement of Correction
Edward Pitts
PSA
Recipient of the letter regarding the annual survey
The inspection was conducted as a complaint investigation based on multiple substantiated and unsubstantiated complaint surveys.
Findings
The facility was found to have violations related to food service sanitation, specifically staff not wearing hair nets in the kitchen, and environmental requirements, including a resident's apartment having a strong offensive odor that was not adequately addressed.
Complaint Details
The inspection was triggered by complaint investigation surveys #2476819/Il177229, #2417586/Il178277, #2418291/Il179215, and #2478876/Il180082, with three substantiated and one unsubstantiated.
Severity Breakdown
Type 3 Violation: 2
Deficiencies (2)
Description
Severity
Facility failed to ensure staff wore hair nets while in the kitchen, violating Food Service Sanitation Code.
Type 3 Violation
Facility failed to ensure a resident's apartment was free from offensive odors.
Type 3 Violation
Report Facts
Residents present: 51Sample size: 6
Employees Mentioned
Name
Title
Context
Dietary Server
E5 Dietary Server stated hair nets and gloves are required in kitchen but was observed not wearing hair net
Cook
E3 Cook stated gloves and hair net should be worn in kitchen
Caregiver
E6 Caregiver observed in kitchen without hair net
Happiness Coordinator
E7 Happiness Coordinator observed in kitchen without hair net
Dietary Manager
E9 Dietary Manager stated staff need hair covering in kitchen but facility lacks policy
Housekeeper
E10 Housekeeper reported difficulty cleaning resident R1's apartment due to clutter and odor
Health and Wellness Coordinator
E2 Health and Wellness Coordinator instructed Housekeeper to clean carpet in resident R1's apartment
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