Accolade Healthcare Of Savoy
ACCOLADE HEALTHCARE OF SAVOY in SAVOY, IL — inspection on September 3, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(injury/decline/room, etc.) that affect the resident.
power of attorney for an incident of elopement for one (R7) of three residents reviewed for elopement
not complete an assessment, notify R7's physician or family, and didn't follow the Facilities Missing Resident Policy for R7's elopement from the facility on 8/31/25. On 9/2/2025 at 1:10PM, V1 Administrator stated he was unaware of the situation that had occurred with R7 as it wasn't reported to V1 and V1 just initiated an investigation into the incident.
Video surveillance was viewed with V1 at this time. On 8/31/25 between 8:55 AM and 9:07 AM, R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM, V10 Licensed Practical Nurse was alerted by V18 and was observed going to get R7 in the parking lot of the church. V1 stated that no notification to the medical director, power of attorney, and green code was completed, as V1 is still investigating the failure. On 9/2/2025 at 2:35pm, V2 (Director of Nursing), stated V2 received a call around 9:15AM on 8/31/25 from V10 stating that R7 had left of the memory care unit of the facility and was next door in the church parking lot, and V2 informed V10 to chart that R7 was exit seeking. On 9/3/2025 at 9:15AM, V21 Nurse Practitioner stated that there was no communication provided from the facility about R7's elopement.
The Facilities Missing residents Policy Revised on 1/23 is to provide facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing.
This policy also documents that should an employee discover that a resident is missing from the facility, he/she should: Determine if the resident is out on an authorized leave or pass, Announce a Code green three times consecutively.
Make a thorough search of the building and premises. If the resident is not located within 15 minutes the charge nurse will report the incident to the shift supervisor who will direct additional staff to search the premises outside of the facility.
The residents attending physician will be notified.
This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated.
Contact the resident's legal representative and inform him/her of the incident.
Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
145439 09/03/2025
Accolade Healthcare of Savoy 302 West Burwash Savoy, IL 61874
one day or five pounds in a week. V21 reviewed R1's daily weights and confirmed R1's weight gain
of Lasix based on R1's [DATE] BMP. V21 confirmed the staff should have been monitoring R1's urine
eight hours without urination and staff should have straight catheterized R1 on [DATE]. V21 stated this delay in treatment could lead to complicated UTI, decreased urine output, and AKI. V21 stated if V21 was made aware of these changes in R1's condition sooner, V21 probably would have sent R1 out to the hospital sooner due to needing fluids and diuresis on top of having congestive heart failure and renal disease. V21 reviewed R1's [DATE] urine culture and stated V21 would have treated this as a UTI since R1 was symptomatic. sent her out to the hospital sooner due to needing fluids on top of having CHF.
Reviewed R1's urine culture results from facility [DATE], stated she would have treated it as a UTI since she was symptomatic. V21 stated decreased blood pressure and decreased urine output along with days without reporting could have contributed to R1's [DATE] lab results, and R1 could have been sent out sooner and may not have required dialysis. V21 stated R1 was very sick and had a lot of things going on, so it is hard to say if these failures and delay in treatment caused R1's death, it may have only prolonged things if R1 had received hospital treatment sooner. On [DATE] at 10:27AM, V20 stated V20 verbally gave R1's orders listed on [DATE] to the facility nurse. V20 stated the facility does not have a nurse manager on the weekends to remove the orders from (electronic health record software) so the orders aren't followed up on until Monday. 2.) R2's Progress Note dated [DATE], recorded by V20, documents post hospital evaluation for R2 who was hospitalized 6/13-[DATE] for congestive heart failure exacerbation, sepsis, pneumonia, orthostatic hypotension; and hospitalized 7/16-[DATE] for worsening anemia. upper gastrointestinal bleed from duodenal ulcer, weakness, and shortness of breath.
This note documents R1's weight is up 10-15 pounds, suspect fluid overload from hospital hydration and blood administration, if BMP is stable on [DATE] will consider increasing Lasix over several days if weight remains elevated, continue to monitor vitals and weight daily. R2's Progress Note dated [DATE], recorded by V30 Physician, documents the same findings as V20 noted above and to monitor weight and vital signs daily. R2's [DATE] Medication Administration Record (MAR) documents to obtain daily weights and report weight gain of three pounds in 24 hours or five pounds in one week, but there is no documentation this order was resumed after R2 readmitted from the hospital on [DATE].
This MAR documents to obtain vital signs every shift, but the last recorded vitals are on dayshift on [DATE].R2's weight log documents R2's readmission weight as 160.4 on [DATE] and 175.8 on [DATE].
There are no recorded weights after [DATE].R2's blood pressure log does not document R2's blood pressure was obtained after dayshift on [DATE] prior to R2's hospitalization on evening shift on [DATE]. On [DATE] at 10:00 AM, V25 Assistant Director of Nursing (ADON) confirmed R2 did not have daily weights resumed after [DATE] and no vital signs documented after dayshift on [DATE]. V25 stated V25 thought R2 was still in the hospital on [DATE] and therefor discontinued some of his orders. V25 stated we are pushing for the providers to enter their orders into the resident's electronic medical record (EMR) so that it requires the nurse to sign off and activate the orders. V2 and V25 confirmed physician and nurse practitioner progress notes are not consistently uploaded into the resident's EMR, these notes have to be pulled from (electronic health record software), which the floor nurses do not have access to. On [DATE] at 10:27 AM, V20 stated per facility policy, vital signs should be monitored at least twice daily, and staff should have been monitoring R2's vitals and daily weights. V2 stated R2 had a history of edema and shortness of breath with prior hospitalization. V20 stated the protocol for daily weight monitoring is to report a three-pound gain in one day or five-pound gain in one month.
145439 09/03/2025
Accolade Healthcare of Savoy 302 West Burwash Savoy, IL 61874
discover that a resident is missing from the facility, he/she should: Determine if the resident is out on
thorough search of the building and premises. If the resident is not located within 15 minutes the
the premises outside of the facility.
The residents attending physician will be notified.
This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated.
Contact the resident's legal representative and inform him/her of the incident.
Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator.
On 9/2/25 at 11:08AM, R7 was wandering around the memory care unit walking up to the doors and windows and looking outside.
On 9/2/2025 at 12:37PM, V10 Licensed Practical Nurse reenacted how R7 left the building through the door in the memory care unit. V10 stated that she had left to go to break around 8:55AM and when she returned around 9:08AM, V18 (R9's Family) had come into the facility and told V10 that V18 thought a resident was in the church parking lot. V10 stated V10 ran outside, R7 was in the church parking lot and V10 called V2 Director of Nursing to report the situation. V10 did not complete an assessment, notify the Medical Director or the Power Attorney and didn't follow the Facilities Missing Resident Policy regarding R7's elopement from the facility on 8/31/25.
On 9/2/2025 at 1:10PM, V1 Administrator stated he was unaware of the situation that had occurred with R7 as it wasn't reported to V1 and V1 just initiated an investigation into the incident.
Video surveillance was viewed with V1 at this time. On 8/31/25 at between 8:55 AM and 9:07 AM R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM V10 Licensed Practical Nurse was alerted by V18 and was observed going to get R7 in the parking lot of the church. V1 stated that no notification to the medical director, power of attorney, and green code was completed, as V1 is still investigating the failure.
R7's minimum data set documented on 7/1/25 documents R7 is cognitively impaired.
There is no documentation in R7's medical record that R7's elopement risk was reassessed after this incident or that new interventions were developed and implemented to address R7's elopement and exit seeking behavior.
The last recorded Elopement Risk Assessment in R7's medical record is dated 7/6/25 and documents R7 as low risk. R7's active care plan documents the problem area elopement/risk wandering related to Dementia was not revised after R7's elopement until 9/3/25.
On 9/2/2024 at 2:35pm, V2 Director of Nursing stated she received a call around 9:15am on 8/31/25 from V10 stating R7 had got out of the building and was next door in the church parking lot.
On 9/3/2025 at 9:10AM, V21 (Nurse Practitioner) stated that there was no communication provided to any of the Physician On Call encounters from the facility about R7's elopement. V21 stated R7 has a history of Asthma, has a shuffled gait, and is at high risk for falling. V21 stated if V21 had been notified, she would have put in an intervention for increased monitoring or one to one supervision.
145439 09/03/2025
Accolade Healthcare of Savoy 302 West Burwash Savoy, IL 61874
services of a licensed pharmacist.
four residents (R3) reviewed for accidents in the sample list of nine. On 8/27/25 at 9:30 AM, R3 was
rest. R3 stated that V3 Physical Therapy Assistant was pushing R3 in a wheelchair down to the therapy gym, R3's feet were sticking out and the wheelchair did not have foot pedals. R3 stated R3 had difficulty holding her legs up, R3's right foot went underneath of R3 causing R3's ankle to roll or twist and R3 screamed out in pain. R3 stated R3 has two broken ankle bones because of that incident.
R3's right ankle x-ray dated 8/23/25 documents R3 has severe osteopenia (low bone mineral density), R3 had Subtle linear lucencies noted through the medial and lateral malleoli suspicious for acute nondisplaced fractures and soft tissue swelling. R3's emergency room Note dated 8/22/25 at 11:09 PM documents R3 presented for ankle pain after being pushed in a wheelchair to therapy while R3's right knee was in immobilizer and without wheelchair foot pedals. R3 reported R3 was unable to hold her right leg up, her leg dropped, and her foot/ankle bent underneath the wheelchair causing significant pain, swelling, and bruising. R3's Progress Note dated 8/26/25, recorded by V29 Podiatrist, documents R3 was evaluated for right nondisplaced medial and lateral malleoli fractures, treatment options were discussed, including R3's osteopenia which may delay healing.
This note documents an order for Vitamin D3 2000 units daily. R3's August and September 2025 Medication Administration Records document as of 8/6/25 R3 receives Os-Cal Calcium plus D3 500 milligrams (mg) - 5 micrograms (200 units of vitamin D3) one tablet by mouth daily and PreserVision multivitamin with minerals two tablets by mouth twice daily. As of 9/3/25, the order for Vitamin D3 2000 units had not been transcribed or implemented. On 9/3/25 at 10:00 AM, V2 Director of Nursing stated the facility does not receive any communication of new orders or progress notes after R3's orthopedic/podiatry appointments. V2 stated these progress notes have to be obtained from (electronic health records software). V2 confirmed R3's order for Vitamin D3 2000 units ordered on 8/26/25 by V29. V2 stated R3 receives a multivitamin and Os-cal, which provides less than 2000 units of Vitamin D3 daily. V2 stated V2 will implement the order today.
145439 09/03/2025
Accolade Healthcare of Savoy 302 West Burwash Savoy, IL 61874
condition in the sample list of nine. R2's hospital discharge orders dated 7/22/24 include orders for
daily, Midodrine (treats low blood pressure)10 mg PO three times daily, and Novolog insulin per blood glucose-based sliding scale three times daily before meals. R2's July 2025 Medication Administration Record documents R2's Metoprolol, Midodrine, and Novolog insulin were stopped on 7/23/25 and R2 did not receive any doses of these medications after the morning dose on 7/23/25 prior to being hospitalized on the evening of 7/24/25.
There is no documentation in R2's medical record as to why these medications were stopped or that the physician was notified of the missed doses. On 9/3/25 at 10:00 AM, V25 Assistant Director of Nursing stated on 7/23/25, V25 thought R2 was still in the hospital and did a batch order discontinuing R2's medications. V25 stated later that day V25 resumed R2's orders, but with batch orders not all of the orders pop up if they are too close to the next scheduled dose, so not all of R2's medication orders were resumed. V25 confirmed R2's missed doses of Midodrine, Metoprolol and Novolog insulin between 7/23/25 and 7/24/25. V25 stated these medications would be considered significant with missed doses as medication errors, but there was no negative impact on R2.
145439 09/03/2025
Accolade Healthcare of Savoy 302 West Burwash Savoy, IL 61874
and no green code was completed, as V1 is still investigating the failure.
R7's medical record that R7 eloped from the facility on 8/31/25 or what steps were taken after R7's
On 9/2/2025 at 12:37PM, V10 confirmed V10 did not follow the facility's missing resident policy and did not document R7's elopement incident in R7's medical record.
On 9/2/2024 at 2:35pm, V2 (Director of Nursing) stated V2 received a call around 9:15AM on 8/31/25 from V10 stating R7 had left the building and was found next door in the church parking lot. V2 stated V2 told V10 to chart that R7 was exit seeking.
The Facilities Missing residents Policy Revised on 1/23 is to provide facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing.
Each Unit Charge Nurse, during their respective tour of duty will be aware and responsible for always knowing the location of their residents.
Nursing must report and investigate all reports of missing residents.
This policy also documents that should an employee discover that a resident is missing from the facility, he/she should: Determine if the resident is out on an authorized leave or pass, Announce a Code “green” three times consecutively.
Make a thorough search of the building and premises. If the resident is not located within 15 minutes the charge nurse will report the incident to the shift supervisor who will direct additional staff to search the premises outside of the facility.
The residents attending physician will be notified.
This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated.
Contact the resident's legal representative and inform him/her of the incident.
Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.