Allegria Village: Missed Medication Doses Found - MI
The finding came from a complaint inspection conducted November 20, 2025. Federal inspectors cited the facility under a tag covering medication error rates, and classified the violation as causing minimal harm or potential for actual harm, affecting a few residents.
The resident at the center of the finding, identified in inspection records as Resident 48, had been prescribed Metformin 500 mg and Losartan Potassium 100 mg. Metformin is used to manage blood sugar in diabetic patients. Losartan is used to treat high blood pressure and, in some patients, to protect kidney function. Neither was administered as prescribed.
When a registered nurse, identified in the report as RN E, looked into the missed doses, she went to the nurse who had been responsible for the medication pass, identified as LPN D. LPN D could not explain why the medications hadn't been given.
That was the answer. No explanation. No documentation of a hold order. No record that a physician had been contacted. The medications simply hadn't been given, and the nurse assigned to give them couldn't say why.
RN E then went to the medication room and pulled both drugs from the facility's backup supply box to give to Resident 48.
The facility's own medication policy, last revised in April 2019, states that medications are to be administered in a safe and timely manner and in accordance with prescriber orders, including any required time frame. The same policy outlines a specific process for situations where a nurse believes a dose may be inappropriate or suspects it could cause harm: contact the prescribing physician, the attending doctor, or the facility's medical director to discuss the concern. There is no indication in the inspection record that LPN D followed that process, or any process. There is no indication she raised a concern at all.
A separate facility policy on medication holds, last revised in April 2007, makes clear that a temporary hold on a medication requires an order from the resident's attending physician. No such order appears in the inspection record for Resident 48's missed doses.
The inspection was triggered by a complaint, not a routine survey. That means someone, whether a resident, a family member, or a staff member, contacted regulators before inspectors arrived.
Missed doses of Metformin can allow blood sugar to climb in a diabetic patient without the usual pharmacological check. Missed doses of Losartan can leave blood pressure uncontrolled. For an elderly nursing home resident already prescribed both medications, the gap between a scheduled dose and a late retrieval from a backup box is not a paperwork problem. It is a window of unmanaged medical risk.
The inspection record does not say how long the doses were delayed before RN E intervened, or how RN E came to know the medications had been missed in the first place. It does not say whether Resident 48 or their family was told. It does not say whether LPN D faced any disciplinary review.
What the record says is this: a licensed nurse could not account for why she had not given a resident their medication. A supervisor had to go find the drugs herself. And the facility's own policies, one nearly two decades old and one revised six years ago, describe exactly the standard that wasn't met.
Allegria Village is located in Dearborn, Michigan. The complaint inspection was completed November 20, 2025. The violation was assigned deficiency tag F0759.
Resident 48's medications are now presumably back on schedule. Whether anyone at the facility has a clearer answer for why they weren't given in the first place, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Allegria Village from 2025-11-20 including all violations, facility responses, and corrective action plans.
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: August 29, 2026 · Our methodology
Allegria Village in Dearborn, MI was cited for violations during a health inspection on November 20, 2025.
The finding came from a complaint inspection conducted November 20, 2025.
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.