Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allegria Village during CMS and state inspections, most recent first.
An LPN withheld three ordered medications for a resident with COPD, dementia, CAD, and atrial fibrillation based on nursing judgment and a BP of 109/58, even though there were no physician hold parameters or orders to do so and the physician was not notified. The resident also had a Tiotropium inhaler order that was not transcribed to the MAR, resulting in missed doses for three days.
Medication administration errors exceeded the allowed rate, with 9 errors in 34 opportunities. An LPN withheld several ordered meds for one resident without a provider order or parameters and failed to notify the physician, while also marking other meds as not given because they were allegedly unavailable without checking the cart, med room, or back-up box. A second resident also missed ordered Aspirin, Metformin, and Losartan because the LPN said they were missing, and the DON later confirmed the meds should have been given.
A resident who spoke Arabic and did not speak English was not provided an effective communication method on admission. Staff and the RR reported that the initial communication board was not useful, Arabic-speaking interpreters were not consistently used, and the SW completed the BIMS without interviewing the resident because of the language barrier. The resident had COPD, unspecified dementia, atrial fibrillation, and HF, and the admission communication assessment incorrectly documented no barriers and verbal communication as the method.
A resident with COPD and dementia missed three consecutive doses of a prescribed Tiotropium inhaler because the order was not transcribed onto the MAR. The RN who completed the admission orders confirmed the inhaler was missed, and the DON confirmed the resident did not receive the doses.
The facility failed to provide meals at a safe and appetizing temperature for residents eating in their rooms. Residents reported cold and unappealing food, confirmed by a test tray showing below-standard temperatures. The heating system to maintain food temperature had been broken for two years, and no policy was provided when requested.
The facility failed to maintain a sanitary and functional environment, affecting all 69 residents. Observations revealed heavily soiled carpeting, broken kitchen equipment, and non-functional hand washing sinks. Interviews with residents and staff indicated a lack of responsibility and cleaning rotation for carpets. The Administrator acknowledged the issues but did not provide a timeline for addressing them.
A resident in a LTC facility experienced dissatisfaction and a tripping hazard due to a missing floor covering near their bed. Despite the resident's concerns and the facility's awareness, the issue was not addressed. Interviews with staff confirmed the hazard, and the facility's maintenance policy was not followed.
A resident with muscle weakness and seizures was not assisted with toilet transfers as required, leading to unmet care needs and dissatisfaction. Despite needing moderate assistance, a CNA instructed the resident to urinate on themselves, and documentation of care was inconsistent. Staff interviews confirmed the resident's need for assistance, which was not provided according to facility policy.
The facility failed to ensure that three residents received pneumococcal and influenza vaccinations and the necessary education. Two residents with dementia and other conditions lacked documentation for pneumococcal vaccines, while another resident with hypertensive heart disease lacked documentation for the influenza vaccine. The DON confirmed that these residents should have been educated and offered the vaccines, as required by the facility's policy.
The facility failed to ensure that two residents were provided with COVID-19 vaccinations and education, potentially leading to the spread of COVID-19. The Infection Preventionist reported no documentation of immunization or refusal for these residents, who were admitted with dementia and other conditions. The DON confirmed that both residents should have been educated and offered the vaccine, as required by the facility's Vaccine Policy and Procedure.
A resident with impaired cognition was left unsupervised during an outside appointment, leading to an elopement incident. The resident, diagnosed with aphasia following a cerebral infarction and a BIMS score indicating cognitive impairment, was unattended for several hours and found walking along an expressway. The facility's policy lacked specific interventions for escorting such residents, and staff interviews confirmed the need for supervision.
The facility failed to provide scheduled showers for two residents, resulting in unmet hygiene needs. Despite having scheduled shower days, there was no documentation of showers or bed baths for the entire month for both residents. Staff interviews confirmed that showers should be documented in the POC system, but no such documentation was found.
The facility failed to properly assess a resident on anti-coagulant therapy after an unwitnessed fall, including not obtaining vital signs and not completing neurological checks. The resident later called 911, was hospitalized for a brain bleed, and subsequently died. Interviews and records confirmed that required assessments were not performed, despite facility policies mandating them.
The facility failed to inform the family of a resident's fall. The resident, who had no cognitive impairment, reported hitting his head but the family was not notified. The family only learned of the incident when the resident was in the ER with a brain bleed. Facility guidelines require family notification, which was not followed.
Medication orders were withheld without parameters and one inhaler order was not transcribed
Penalty
Summary
The facility failed to follow standards of practice for medication administration for one resident, who had diagnoses including COPD, dementia, coronary artery disease with stable angina, and atrial fibrillation. During observation of medication pass, an LPN withheld three ordered medications—Isosorbide Mononitrate ER 30 mg, Metoprolol Succinate ER 50 mg, and Amiodarone 100 mg—because the resident's blood pressure was 109/58, even though there were no physician orders or blood pressure parameters authorizing the medications to be held. The LPN stated it was their nursing judgment and did not notify the physician that the medications were withheld. The resident's medication reconciliation also showed that a physician's order for Tiotropium 2.5 mcg/ACT inhaler, 2 inhalations daily, was not transcribed onto the MAR. As a result, the medication was not administered for three consecutive days. The DON confirmed there were no parameters for holding the withheld medications and acknowledged that the Tiotropium order had been missed and not placed on the MAR.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with survey observation showing 9 errors in 34 opportunities for a 26.47% medication error rate. During observation of medication administration for one resident with COPD, dementia, coronary artery disease with stable angina, and atrial fibrillation, an LPN withheld three ordered medications without any physician order or blood pressure parameter: Isosorbide Mononitrate ER 30 mg, Metoprolol Succinate ER 50 mg, and Amiodarone 100 mg. The LPN stated it was her nursing judgment and did not notify the physician. The same resident also did not receive Vitamin B-12, Omega-3 1000 mg, and Ferrous Sulfate 325 mg because the LPN said they were not available, but there was no attempt to search the cart, medication room, or back-up box, and no notification to the nurse unit manager, pharmacy, or physician. The medications were marked as not given on the MAR. During observation of another resident with A-fib and type 2 diabetes, the LPN did not administer Aspirin 81 mg, Metformin HCL 500 mg, and Losartan Potassium 100 mg, stating the medications were missing from the cart. There was no attempt to locate the ordered medications. Review of the resident records confirmed the medications were ordered. The DON stated there were no parameters for the withheld medications and that they should have been given, and the nurse unit manager later found Aspirin, Omega-3, and Ferrous Sulfate in the medication cart and obtained Metformin and Losartan from the medication room back-up box. The facility policy stated medications are to be administered as prescribed and that a temporary medication hold may be ordered by the attending physician.
Failure to Establish Effective Communication for an Arabic-Speaking Resident
Penalty
Summary
The facility failed to ensure an effective means of communication was established in a timely manner for a resident who spoke Arabic and did not speak English. On 9/22/25, the resident’s RR stated that the resident understood and spoke Arabic, that he was present only during the day, and that no method had been provided for communicating with the resident when he was away. The RR also stated that the facility should have had Arabic-speaking staff available to interpret for the resident at other times. A Patient Advocate confirmed that a communication board should have been provided on arrival, and noted that Arabic-speaking staff were available to interpret. The resident was admitted on 9/19/25 with diagnoses including COPD, unspecified dementia, atrial fibrillation, and heart failure. The record showed a Risk for Impaired Communication care plan initiated on 9/21/25 with interventions to consult speech therapy, evaluate the resident’s ability to comprehend, and provide verbal feedback and updates on care. A progress note dated 9/22/25 documented a BIMS score of 4, indicating severe cognitive impairment. However, the admission communication assessment completed by the SW documented the resident’s communication method as verbal, stated the resident made self understood and understood others, and listed no barriers. On 9/23/25, staff attempted to use a laminated communication board with pictures and English words, but the resident’s RR said it would be difficult for the resident to use. An LPN later used the board and said it was not useful. The RN/UM stated the board was used to facilitate two-way communication and that Arabic-speaking staff were available to interpret, while the RR stated the resident could read Arabic and might be able to use a board with pictures and Arabic writing. The SW acknowledged she did not attempt to interview the resident for the BIMS because of the language barrier, despite the availability of Arabic-speaking interpreters. The DON and NHA both stated that the language barrier should have been identified on admission and that the resident’s communication needs were not effectively addressed in the admission assessment or care plan.
Missed inhaler doses due to MAR transcription error
Penalty
Summary
The facility failed to ensure that one resident was free from a significant medication error when the resident missed three consecutive doses of a prescribed inhaler. On 9/23/2025 during medication administration observation and record review, it was found that the physician’s order for Tiotropium 2.5 MCG/ACT inhaler, 2 inhalations by inhalation daily, entered on 9/19/25, had not been transcribed onto the MAR. As a result, the resident did not receive the medication on 9/20/25, 9/21/25, or 9/22/25. The resident was admitted with diagnoses including COPD and dementia. Review of the EHR showed the hospital physician’s admission orders included the Tiotropium inhaler order, but there were no progress notes documenting a change in medication orders or admission orders. During interview, the RN who completed the admission orders confirmed that the resident was prescribed two inhalers on admission, but only one was transcribed to the MAR, and acknowledged that the Tiotropium inhaler was missed and not placed on the MAR. The DON also confirmed that the resident missed the three doses.
Deficiency in Meal Temperature and Presentation
Penalty
Summary
The facility failed to provide meals that were palatable and at a safe and appetizing temperature for three residents who consumed meals in their rooms. Residents reported that the food was often cold and visually unappealing, leading to some residents skipping meals. Observations and interviews revealed that the food was served in Styrofoam containers covered with tightly wrapped saran wrap, which caused condensation and made the food appear mashed and merged. A lunch test tray confirmed that the food temperatures were below acceptable levels, with chopped steak at 103.2°F, au gratin potatoes at 110°F, peas and carrots at 83°F, and vanilla pudding at 53.2°F. The deficiency was further compounded by the facility's failure to maintain the heating system used to keep food at the proper temperature, which had been broken for approximately two years. The supervisor present during the test tray was unaware of the status of the repair or replacement of the heating system. Despite being informed of the complaints and the issue with the heating unit, the administrator did not provide evidence of when the unit would be repaired or replaced. Additionally, a policy regarding food temperature maintenance was requested but not provided by the facility.
Facility Fails to Maintain Sanitary and Functional Environment
Penalty
Summary
The facility failed to maintain a sanitary and functional environment, affecting all 69 residents. Observations revealed heavily soiled, stained, and worn carpeting on the first, second, and third floors, with dust and lint accumulation. Interviews with the Maintenance Director and Housekeeping Director indicated a lack of responsibility and a cleaning rotation for the carpets. Additionally, the facility's kitchen and kitchenettes had several issues, including a broken dish machine, missing freezer curtain slots, a broken heating system for resident food, and detached floor ceiling plate covers. The ceiling vents in two kitchenettes were heavily soiled, and the coffee machine and ice machine on different floors were not functioning. Hand washing sinks and eye washing apparatuses on the first and third floors were also not working properly. Interviews with residents R9 and R22, both with intact cognition, revealed concerns about the facility's cleanliness. R9, admitted with Type II diabetes, noted a decline in upkeep and cleanliness, while R22, admitted with necrotizing fasciitis, expressed that staff could improve their cleaning efforts. The Administrator acknowledged the broken equipment issues but did not provide a timeline for addressing them. A requisition for a replacement or rental contract for the dish machine was approved, but no implementation date was provided.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for a resident, identified as R291, resulting in dissatisfaction and a tripping hazard. On multiple occasions, R291 was observed in their room where a significant patch of floor covering was missing near their bed. This defect caused the resident's tray table to get stuck, creating a potential tripping hazard. R291, who has a history of muscle weakness and seizures, expressed concerns about the hole in the floor, fearing it could lead to a fall. Despite the resident's intact cognition and awareness of the risk, the facility had not addressed the issue. Interviews with facility staff, including an LPN and the Maintenance Director, confirmed awareness of the flooring issue. The Maintenance Director admitted that room audits are conducted when residents discharge, but was unable to provide documentation for recent months. The Director of Nursing also acknowledged the hole as a trip hazard and an infection control concern, as it could not be cleaned properly. The facility's maintenance policy, revised in 2009, mandates that maintenance personnel keep the building in good repair and free from hazards, which was not adhered to in this case.
Failure to Assist Resident with Toilet Transfer
Penalty
Summary
The facility failed to provide necessary assistance for a resident, identified as R291, who was dependent on staff for activities of daily living (ADLs), specifically toilet transfers. On one occasion, a Certified Nursing Assistant (CNA) instructed R291 to urinate on themselves instead of assisting them to the toilet, leading to the resident's embarrassment and dissatisfaction. R291, who has diagnoses including muscle weakness and seizures, was assessed with intact cognition and a fall risk. The resident's physical therapy notes indicated they required partial to moderate assistance for toilet transfers. Despite the documented need for assistance, the facility's records showed inconsistent documentation of the care provided, with one CNA marking 'not applicable' and another indicating only 'set up help' was provided. Interviews with staff, including a Licensed Practical Nurse and therapy assistants, confirmed that R291 required moderate assistance for toilet transfers. The Director of Nursing acknowledged that CNAs should empower residents like R291 to use the toilet, aligning with the facility's policy to maintain or improve residents' ability to perform ADLs.
Failure to Provide Vaccinations and Education
Penalty
Summary
The facility failed to ensure that three residents, identified as R4, R18, and R25, received pneumococcal and influenza vaccinations and the necessary education regarding these immunizations. During an interview on August 22, 2024, the Infection Preventionist (IP) reported that residents R4 and R18 lacked documentation of a current pneumococcal immunization or refusal, while R25 lacked documentation of a current influenza immunization or refusal. This lack of documentation indicates that the facility did not offer or record the refusal of these vaccines, which is a requirement according to their policy. Resident R4 was admitted with diagnoses of dementia and cerebral infarction, and resident R18 was admitted with muscle weakness and dementia. Both residents did not have documentation indicating that the pneumococcal vaccine was offered or contraindicated. Resident R25, admitted with hypertensive heart disease and cerebral infarction, similarly lacked documentation for the influenza vaccine. The Director of Nursing (DON) confirmed that these residents should have been educated and offered the respective vaccines, as per the facility's policy, which mandates offering flu, COVID-19, and pneumonia vaccines during the flu season and providing education to those who decline.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to ensure that two residents, R4 and R18, were provided with COVID-19 vaccinations and education, which could potentially lead to the development and spread of COVID-19 among vulnerable residents. During an interview on August 22, 2024, the Infection Preventionist (IP) reported that there was no documentation of a current COVID-19 immunization or refusal for these residents. A review of the Electronic Health Record (EHR) for R4, who was admitted with dementia and cerebral infarction, showed no documentation indicating that the COVID-19 vaccine was offered or contraindicated. Similarly, the EHR for R18, admitted with muscle weakness and dementia, also lacked documentation of the vaccine being offered or contraindicated. The Director of Nursing (DON) confirmed during an interview that both residents should have been educated and offered the COVID-19 vaccine. The facility's undated Vaccine Policy and Procedure requires offering the flu, COVID-19, and pneumonia vaccines to residents during the flu season, along with providing education to those who decline them.
Failure to Supervise Cognitively Impaired Resident During Appointment
Penalty
Summary
The facility failed to provide adequate supervision for a resident with impaired cognition, resulting in an elopement incident. The resident, who had a diagnosis of aphasia following a cerebral infarction and a Brief Interview for Mental Status (BIMS) score indicating impaired cognition, was taken to an appointment without supervision. The resident was left unattended from approximately 8:30 AM until 3:51 PM when the facility was notified of their absence. The resident was eventually found at 8:30 PM by an ambulance service walking along an expressway and was returned to the hospital. The facility's policy on Safety and Supervision did not include specific interventions for escorting residents with cognitive or physical impairments to outside appointments. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the resident should have been provided with supervision due to their cognitive impairment. The incident occurred on a day when temperatures reached a high of 90 degrees Fahrenheit, posing additional risks to the resident's safety.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers for two residents, resulting in unmet hygiene needs. Resident R506, who had cognitive impairment and multiple fractures, was readmitted to the facility and had no documented showers or bed baths for the last 30 days. The resident's scheduled shower days were Wednesday and Saturday on the 6-2 shift. Despite the schedule, there was no documentation of showers or bed baths for the entire month of April 2024. The facility's NHA was unable to provide the requested shower documentation for R506. Similarly, Resident R508, who had no cognitive impairment and was diagnosed with enterocolitis due to C-Diff and a displaced intertrochanteric fracture, also had no documented showers or bed baths for the last 30 days. R508's scheduled shower days were Monday and Thursday on the 2-10 shift. Although there was a progress note indicating that R508 declined a shower and bed bath on one occasion, there was no documentation for the rest of the month. Interviews with various staff members, including LPNs, CNAs, and the DON, confirmed that showers should be documented in the POC system, but no such documentation was found for either resident.
Failure to Perform Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to properly assess a resident (R603) after an unwitnessed fall, which included not obtaining vital signs and not completing neurological checks. R603, who was on anti-coagulant therapy, reported the fall to a CNA, who then informed the nursing staff. Despite this, no neurological checks were performed, and the resident's vital signs were not documented between 9 am and 6 pm on the day of the fall. Later that day, the resident called 911 and was taken to the emergency department, where a CT scan revealed a large brain bleed. The resident subsequently underwent emergency surgery but died from the injury. Interviews with the Nursing Home Administrator, Director of Nursing, and other staff confirmed that the required neurological checks were not performed following the fall, despite the facility's policies mandating such assessments for residents on anti-coagulant therapy who experience unwitnessed falls and head injuries. The facility's policies on change in condition and fall risk management were not followed, as detailed observations and neurological checks were not conducted. The Director of Nursing acknowledged that neuro checks should have been completed to assess the resident for changes. The incident report and interviews with staff indicated a lack of adherence to these policies, leading to the resident's hospitalization and subsequent death due to a brain bleed. The failure to perform these critical assessments represents a significant deficiency in the care provided to the resident.
Failure to Inform Family of Resident's Fall
Penalty
Summary
The facility failed to inform the family of a fall experienced by a resident (R603). R603 was admitted to the facility with diagnoses including chronic atrial fibrillation and abnormalities of gait and mobility. The resident had no cognitive impairment as indicated by a BIMS score of 14 out of 15. On 2/17/24, a CNA reported that R603 mentioned falling, although the CNA did not witness the fall. The resident was found in bed with the call light on and reported hitting his head on the door. The oncoming nurse was notified to monitor the resident for any changes, but the family was not informed of the incident. The Director of Nursing confirmed in an interview that the family should have been notified of the fall. Additionally, a concerned family member reported that they were not informed by the facility about the fall or the subsequent transfer of R603 to the hospital. The family was only notified by the hospital that R603 was in the ER with a brain bleed. The facility's guidelines for falls indicate that the family or emergency contact should be informed of any falls and whether the resident is sent to the hospital, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dearborn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corewell Health Rehabilitation & Nursing Center - | 1.9 mi | ★★★★★ | 13 | 0 |
| Fairlane Senior Care And Rehab Center | 2 mi | ★★★★★ | 14 | 0 |
| Heritage Manor Nursing And Rehabilitation Center | 3.9 mi | ★★★★★ | 26 | 0 |
| Sheffield Manor Nursing & Rehabilitation Center | 5.1 mi | ★★★★★ | 15 | 0 |
| Optalis Health And Rehabilitation Of Dearborn Heig | 5.3 mi | ★★★★★ | 20 | 0 |
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