Inspection Reports for Sugar Creek Alzheimer’s Special Care Center
505 E Vernon Ave, Normal, IL 61761, United States, IL, 61761
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 21, 2025, found the facility in compliance with applicable assisted living regulations and identified no deficiencies. Earlier inspections generally showed compliance, but a complaint investigation on August 7, 2025, cited a deficiency related to inadequate policies and supervision that allowed a cognitively impaired resident to elope unsupervised, resulting in police and hospital involvement. Prior reports noted no deficiencies, and no fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. Most complaint investigations were unsubstantiated, with the exception of the August 7 incident, which involved lapses in wandering prevention. The inspection history shows mostly compliance with one recent issue, indicating a generally stable regulatory status with some areas needing attention.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
0.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The visit was conducted as an original complaint investigation (IL 196750) on 08/21/2025.
Complaint Details
Original Complaint Investigation IL 196750; the establishment was found in compliance.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was conducted following a facility-reported incident involving a resident (R1) who eloped from the Alzheimer's care unit, prompting a complaint investigation into the facility's wandering and elopement prevention policies and practices.
Complaint Details
The complaint investigation was triggered by an incident on 8/2/25 where resident R1 eloped from the facility, was found by local police walking along a roadside, and was transported to the hospital. The resident alleged sexual assault, but no evidence supported this claim. The resident had a history of wandering and a moderate elopement risk score. The facility's review identified staff distraction and an unknown staff member letting the resident out of a locked unit.
Findings
The facility failed to keep a known wandering, cognitively impaired resident (R1) from leaving the establishment unsupervised, resulting in the resident walking approximately one mile across a busy avenue and requiring police intervention and hospital evaluation. The investigation revealed lapses in supervision, staff distraction, and inadequate control of exit doors despite existing policies and procedures.
Deficiencies (1)
Failure to develop and implement policies and procedures ensuring the continued safety of residents who may wander, as evidenced by a resident eloping unsupervised.
Report Facts
Elopement Risk Score: 18
Time Missing: 124
Incident Date: Aug 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Notified of elopement, reviewed camera footage, and determined an unknown staff member let resident R1 out. |
| E4 | Licensed Practical Nurse and Maintenance Director | LPN notified ED of elopement; Maintenance Director described door keypad and unlocking mechanisms. |
| E6 | Receptionist | Working front desk during elopement, confirmed distraction and inability to see resident leave. |
| E7 | Registered Nurse | Last staff member seen with resident R1 prior to elopement. |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
Original investigation of FRI IL 195030 to determine compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living and shared housing regulations during this original licensing investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
Original investigation of Complaint 2467184 / IL 177723.
Complaint Details
Investigation of Complaint 2467184 / IL 177723 resulted in compliance with applicable regulations.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
Annual licensure survey and original investigation of complaint #2466692/IL177054.
Complaint Details
Original investigation of complaint #2466692/IL177054; no deficiencies found.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
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