Chalet Living & Rehab: Medication Errors Reach Resident - IL
The resident, identified in inspection records only as R4, has lived at the facility since April 2020 and is fully cognitively intact, scoring a perfect 15 on the Brief Interview for Mental Status assessment. Her care plan authorized her to self-administer her own medications. That authorization may be the only reason she caught what the nurse missed.
During second-shift medication pass on May 8 through May 10, a registered nurse identified in inspection records as V20 brought R4 her evening medications. On those first nights, R4 noticed the capsules looked larger than usual and that she never saw the medication container. She told V20 he had given her the wrong dose. She was prescribed 5,000 units of Vitamin D. V20 had brought her 50,000 units. He took the medications back.
Then, on May 9, V20 left Tramadol at R4's bedside along with her routine medications. R4 saw the pill in the cup but didn't recognize it. She didn't take it. Later, she looked it up online and identified it herself as Tramadol, a prescription opioid. She had never been prescribed Tramadol.
R4 brought the concern to the Assistant Director of Nursing, identified as V24, on the following Monday, May 11. V24 confirmed the pill was Tramadol. He told inspectors R4 showed him a photograph on her phone.
V20's explanation, relayed through the Director of Nursing identified as V2, was that he had become distracted while administering medications to another resident who was receiving Tramadol. He mistakenly attempted to give those medications to R4 before the error was identified and corrected. V2 told inspectors he counseled V20 and expected nurses to verify physician orders and confirm the right medication, the right patient, the right dosage, the right frequency, the right time, and the right procedure before administering anything.
V2 also told inspectors that R4 had not raised concerns about the Vitamin D dosing — only the Tramadol. That account conflicts with what R4 told inspectors directly: that she reported the wrong Vitamin D dose to V20 during the pass itself, and that V20 acknowledged the mistake and retrieved the medications.
By the time inspectors arrived, V20 was out of the country on vacation. Inspectors left messages on May 26, 27, and 28. V20 did not return any of them.
The facility produced a training sign-in sheet dated May 11 showing V20 had been educated on administering the right medications to residents at all times. The counseling and the training happened the same day R4 first reported the Tramadol error to V24.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. R4 did not take either the wrong Vitamin D dose or the Tramadol. The inspection, a complaint survey, was completed May 29.
What the record shows is a resident who had to function as her own pharmacist across three consecutive evenings. She recognized that the capsules looked wrong. She withheld an unfamiliar pill and researched it herself. She documented it with a photograph. Without that vigilance, a cognitively intact woman with obstructive sleep apnea and morbid obesity would have received ten times her prescribed Vitamin D dose and an opioid she had no business taking, administered by a nurse who said he had simply been thinking about someone else.
R4's care plan says a nurse will monitor and counsel her as necessary regarding proper medication administration. In May, it worked the other way around.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chalet Living & Rehab from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CHALET LIVING & REHAB in CHICAGO, IL was cited for violations during a health inspection on May 29, 2026.
Her care plan authorized her to self-administer her own medications.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.