Accolade Healthcare of Savoy: Medication Errors - IL
The medication error at Accolade Healthcare of Savoy affected a resident who had been discharged from the hospital on July 22, 2024, with orders for three essential medications: Metoprolol Succinate for heart conditions, Midodrine for low blood pressure, and Novolog insulin based on blood sugar levels.
Assistant Director of Nursing V25 discontinued all three medications on July 23, 2025, believing the resident was still hospitalized. The resident received their morning doses that day but nothing afterward.
By the evening of July 24, the resident required emergency hospitalization.
V25 told federal inspectors on September 3 that she had performed what's called a "batch order" to discontinue the resident's medications on July 23, thinking the patient remained in the hospital. She realized her mistake later that same day and tried to resume the medication orders.
But the facility's computer system created a new problem. V25 explained that when batch orders are processed too close to the next scheduled dose time, not all medication orders appear on the screen to be resumed.
The result: the resident went without heart medication, blood pressure treatment, and insulin from the evening of July 23 through July 24.
The facility's own medication administration records document the gap. The resident received no doses of Metoprolol, Midodrine, or Novolog insulin after the morning of July 23, despite being present in the facility.
No documentation exists in the resident's medical record explaining why the medications were stopped. There's also no record that any physician was notified about the missed doses.
V25 acknowledged to inspectors that missing doses of these particular medications would be considered significant medication errors. Metoprolol treats heart rhythm and blood pressure conditions. Midodrine prevents dangerous drops in blood pressure. Novolog insulin controls blood sugar spikes after meals.
The assistant nursing director told inspectors she believed there was "no negative impact" on the resident from the missed medications.
The resident was hospitalized the evening after going more than 24 hours without their prescribed heart medication, blood pressure treatment, and insulin.
Federal inspectors found the facility failed to administer medications as ordered, creating what they classified as minimal harm or potential for actual harm. The violation affected one of five residents inspectors reviewed for changes in condition.
Hospital discharge orders from July 22, 2024, were clear and specific. The resident was prescribed Metoprolol Succinate Extended Release 12.5 milligrams by mouth daily, Midodrine 10 milligrams by mouth three times daily, and Novolog insulin three times daily before meals based on blood glucose readings.
The facility's medication administration record shows these orders were active and being followed until V25's batch discontinuation order on July 23.
V25's explanation to inspectors revealed systemic problems with the facility's medication management process. The assistant nursing director made assumptions about a resident's location without verification. The computer system's batch order function created gaps when medications were resumed too close to scheduled dose times.
Most significantly, no safeguards prevented critical medications from being stopped without physician consultation or proper documentation.
The inspection was conducted as a complaint investigation on September 3, 2025. Inspectors reviewed medication records, interviewed nursing staff, and documented the sequence of events that led to the resident missing essential medications before their emergency hospitalization.
The resident's case illustrates how administrative errors in nursing homes can directly affect patient care. A simple miscommunication about hospital status led to a cardiac patient going without heart medication and a diabetic patient missing insulin doses.
V25's admission that these medications would be considered significant if missed underscores the potential seriousness of the error, regardless of her assessment that no negative impact occurred.
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 20, 2026 · Our methodology
ACCOLADE HEALTHCARE OF SAVOY in SAVOY, IL was cited for violations during a health inspection on September 3, 2025.
Assistant Director of Nursing V25 discontinued all three medications on July 23, 2025, believing the resident was still hospitalized.
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.