The Buehrle Center.

“A staff member witnessed another staff member using disrespectful language toward a resident, but this incident was not reported to the Department within 24 hours as required. The complaint was placed under a supervisor's door on January 1, 2026, but was not formally reported to the Department until January 6, 2026.”

“A staff member was witnessed using disrespectful language toward a resident, violating the requirement that residents be treated with dignity and respect.”

“A laptop on the medication cart counter was left unlocked, unattended, and accessible to residents, exposing confidential medical files.”

“Two covered plates containing eggs, a cinnamon roll, and peaches were left unlabeled and undated on the kitchen counter, violating food labeling and dating requirements.”

“The home's emergency procedures were not posted in a conspicuous and public place in the facility.”

“A prescribed as-needed medication for a resident was not available in the home at the time needed, with the medication ordered on October 7, 2025 but not received until October 9, 2025.”

“Resident assessments did not adequately document a skin tear incident sustained while parking a motorized scooter, and did not include information that a resident began using a motorized scooter for mobility inside and outside the home.”

“A resident in the Secured Care Dementia Unit (SDCU) left their room, exited the SDCU, and walked out of the main building entrance triggering alarms. Staff member A, who was seated in the hallway, did not stop the resident when they walked by. The resident was not located on the property and was found by police near a public swimming pool approximately 1 hour and 30 minutes later.”

“A resident exited an unlocked courtyard door, an alarm sounded, but staff did not investigate. The resident was later found on the ground with a pool of blood around their head. Additionally, another resident aggressively hit a second resident with a rollator walker, causing a bruise. This was a repeat violation from 4/9/2024.”

“Multiple residents were observed striking, choking, and hitting one another with objects including closed hands and canes. Incidents included resident-to-resident physical altercations in common areas and during personal interactions, indicating failure to prevent neglect, intimidation, physical abuse, or mistreatment of residents.”

“A resident was found physically attacking another resident, hitting them in the face and scratching their chest, causing injury to the victim's lip and left side of face. The incident constituted physical abuse and mistreatment of a resident.”

“A medication cart was left unattended and unlocked in the hallway near a resident's room, violating requirements that prescription medications, OTC medications, CAM and syringes be kept in a locked area or container.”

“A resident's Assessment Support Plan was not updated following an incident in which the resident attempted to strangle another resident and was placed on checks, failing to document the behavioral incident and intervention in the support plan.”

“A laptop on an unattended medication cart near a resident's room was left open with a resident's electronic Medication Administration record visible to anyone passing by, violating confidentiality requirements.”

“Medication administration records (MARs) were not properly initialed by staff to document that residents received their medications on multiple dates in August 2023. Four residents had various medications (including Trazodone, Lorazepam, Levothyroxine, Aspirin, Escitalopram, Furosemide, Potassium Chloride, and Buspirone) that were not documented as administered.”