Accolade Healthcare of Savoy: Wheelchair Injury Fractures - IL
That happened on August 22. Eleven days later, the doctor's order to treat the resident's bone condition still hadn't been entered into her medication record.
The incident at Accolade Healthcare of Savoy, a nursing home at 302 West Burwash, was documented during a complaint inspection completed September 3, 2025. Inspectors cited the facility for a single deficiency, but the details of what happened to the resident identified in the report as R3 trace a failure that began with a preventable injury and continued through the weeks that followed.
R3 was already fragile. Her right leg was in a splint and elevated on the wheelchair leg rest when V3, the physical therapy assistant, began pushing her down the hall toward the therapy gym. The wheelchair had no foot pedals. R3 told inspectors she had difficulty holding her legs up during the trip. Her right foot went underneath her. Her ankle rolled and twisted. She screamed in pain.
R3 went to the emergency room the same night, August 22. The ER note, timed at 11:09 PM, documents that she came in for ankle pain after being pushed in a wheelchair to therapy while her right knee was in an immobilizer and the chair had no foot pedals. She reported she was unable to hold her right leg up, that it dropped, and that her foot and ankle bent underneath the wheelchair, causing significant pain, swelling, and bruising.
X-rays showed what the fall had done. R3 had severe osteopenia, a condition that weakens bones by reducing their mineral density. The imaging found subtle linear fractures through both the medial and lateral malleoli, the bony prominences on either side of the ankle, along with soft tissue swelling.
Four days later, on August 26, a podiatrist examined R3 and documented the nondisplaced fractures. The podiatrist discussed treatment options, noting that R3's osteopenia could delay healing. The note included an order for Vitamin D3 at 2,000 units daily, a standard intervention for patients with low bone density.
Nobody entered the order.
When inspectors reviewed R3's medication administration records on September 3, eleven days after the injury and eight days after the podiatrist's order, the Vitamin D3 prescription had not been transcribed or implemented. R3 was receiving a multivitamin and a calcium supplement that together provided less than 200 units of vitamin D3 daily, a fraction of what the podiatrist had prescribed for a patient whose bones were already compromised and now broken.
The Director of Nursing, identified in the report as V2, explained the gap during an interview that morning. V2 told inspectors that the facility does not receive automatic communication of new orders or progress notes after a resident's orthopedic or podiatry appointments. Staff have to retrieve those notes manually from the electronic health records system. V2 confirmed the order had been sitting there since August 26 and confirmed R3 was not receiving the prescribed dose. V2 said the order would be implemented that day.
The inspection classified the deficiency as causing minimal harm or potential for actual harm, the lower end of the severity scale. The characterization applies to the missed medication order, not to the wheelchair accident itself, which sent R3 to the emergency room with two broken bones.
R3 told inspectors she has two broken ankle bones because of what happened in that hallway. She said it plainly, without apparent qualification. The podiatrist's notes flag that her osteopenia may delay healing. As of September 3, the treatment meant to support that healing had been waiting in a software system for more than a week, unread.
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.
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 22, 2026 · Our methodology
ACCOLADE HEALTHCARE OF SAVOY in SAVOY, IL was cited for violations during a health inspection on September 3, 2025.
Eleven days later, the doctor's order to treat the resident's bone condition still hadn't been entered into her medication record.
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.