Accolade Healthcare: Medication Order Ignored - IL
The resident, identified as R3 in the inspection report, was sitting in her room on August 27 with her right leg in a splint and elevated on a wheelchair leg rest. She told inspectors that V3 Physical Therapy Assistant was pushing her in a wheelchair down to the therapy gym when the accident happened.
"R3's feet were sticking out and the wheelchair did not have foot pedals," the inspection report states. The resident said she had difficulty holding her legs up, and her right foot went underneath her, causing her ankle to roll or twist. She screamed out in pain.
The resident now has two broken ankle bones because of the incident.
X-rays taken August 23 showed the resident has severe osteopenia, a condition of low bone mineral density that makes bones more likely to break. The imaging revealed "subtle linear lucencies noted through the medial and lateral malleoli suspicious for acute nondisplaced fractures and soft tissue swelling."
Emergency room records from August 22 at 11:09 PM document that the resident presented for ankle pain after being pushed in a wheelchair to therapy while her right knee was in an immobilizer and the wheelchair had no foot pedals. She reported being unable to hold her right leg up. Her leg dropped, and her foot and ankle bent underneath the wheelchair, causing significant pain, swelling, and bruising.
Four days later, on August 26, V29 Podiatrist evaluated the resident for the nondisplaced fractures in both ankle bones. The doctor discussed treatment options, including how the resident's osteopenia might delay healing. The podiatrist ordered Vitamin D3 2000 units daily to help the bones heal.
The facility never implemented the order.
Inspection records show that as of August 6, the resident was receiving Os-Cal Calcium plus D3 500 milligrams with 5 micrograms of vitamin D3 (200 units) once daily, plus PreserVision multivitamin with minerals twice daily. By September 3, eight days after the doctor ordered 2000 units of vitamin D3 daily, the facility still had not transcribed or implemented the new order.
V2 Director of Nursing told inspectors on September 3 at 10:00 AM that the facility does not receive any communication about new orders or progress notes after residents' orthopedic or podiatry appointments. She said these progress notes have to be obtained from the electronic health records software.
The director confirmed the resident's order for Vitamin D3 2000 units ordered on August 26 by the podiatrist. She acknowledged that the resident receives a multivitamin and Os-cal, which provides less than 2000 units of Vitamin D3 daily. She said she would implement the order that day.
The failure occurred despite federal requirements that nursing homes provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist to ensure proper medication management.
The resident's case illustrates how communication breakdowns between nursing homes and outside medical providers can leave residents without prescribed treatments. For someone with severe osteopenia and fresh fractures, the delay in receiving adequate vitamin D could affect how well the broken bones heal.
The wheelchair accident itself raises questions about proper equipment and safety protocols during physical therapy transport. The resident's right knee was already in an immobilizer, making it difficult for her to control her leg position. Using a wheelchair without foot pedals to transport her to therapy created a predictable risk that her foot could drop and get caught under the chair.
The inspection found that Accolade Healthcare of Savoy failed to transcribe physician orders for one of four residents reviewed for accidents. The facility received a citation for minimal harm or potential for actual harm affecting few residents.
The resident remains in a splint with both ankle bones fractured, dealing with the consequences of an accident that happened during what should have been routine transport to physical therapy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accolade Healthcare of Savoy from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
ACCOLADE HEALTHCARE OF SAVOY in SAVOY, IL was cited for violations during a health inspection on September 3, 2025.
She told inspectors that V3 Physical Therapy Assistant was pushing her in a wheelchair down to the therapy gym when the accident happened.
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.