Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colonial Haven during CMS and state inspections, most recent first.
Incomplete informed consent for psychotropic medications: The facility failed to ensure a resident or representative was fully informed before psychotropic meds were started or increased. Records for multiple residents showed consent forms that omitted dose, frequency, symptoms being treated, potential adverse effects, and alternative or non-pharmacological options for meds such as Alprazolam, Zoloft, Trazodone, Seroquel, Ativan, Cymbalta, Rexulti, Wellbutrin, Paroxetine, Lorazepam, Quetiapine, and Sertraline. The DON confirmed several consents were incomplete or missing.
Failure to Identify Causes and Individualize Fall Interventions: A resident with severe cognitive impairment, incontinence, and multiple psychoactive meds had repeated falls in the room and bathroom area. The facility often documented no causal factors or used limited interventions such as a reminder sign, med review, video monitoring, and alarms, while not addressing issues noted in the events such as toileting needs, feces in the bathroom, poor lighting, and refusal to wear gripper socks or shoes.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure residents were fully informed and understood their health status, care, and treatments before psychotropic medications were administered or increased. The deficiency involved Residents 4, 5, 9, 18, and 27, and the record review showed that informed consent forms often did not include the current dose, frequency, symptoms being treated, potential effects or adverse effects, or alternative/non-pharmacological treatment options. The facility policy required residents or their representatives to be informed in advance of the benefits, risks, and alternatives for psychotropic medications, including black box warnings for antipsychotics, and to document that this information was provided. For Resident 9, the record showed multiple new or changed orders for Alprazolam and other psychotropic medications, but there was no documentation that the resident or representative was informed of the risks, benefits, or alternatives before those orders were implemented. Several consent forms for Zoloft, Alprazolam, Trazodone, Seroquel, and a one-time Alprazolam dose lacked documentation of symptoms, adverse effects, and non-pharmacological interventions. The DON confirmed that consents were not completed for several Alprazolam orders and that the forms did not include non-pharmacological interventions attempted, symptoms displayed, or potential effects or adverse effects. For Resident 4, the record showed psychotropic medication consents for Cymbalta, Rexulti, Ativan, and Wellbutrin, but the forms did not identify how often the medications were to be given, the dose in some cases, the symptoms being displayed, potential effects or adverse effects, or non-pharmacological interventions attempted. The DON confirmed these consent forms did not contain the required information. For Resident 18, consent forms for Trazodone, Zyprexa, Ativan, and Zoloft similarly lacked dose, frequency, symptoms, adverse effects, and non-pharmacological interventions, and the DON confirmed the omissions. For Resident 5, the record showed consent for Paroxetine without an alternative treatment plan and no informed consent completed for Lorazepam. For Resident 27, consent forms for Trazodone, Lorazepam, Quetiapine, and Sertraline did not state the dose and did not include an alternative treatment plan, and the DON confirmed the consents did not include the current dose ordered and/or alternative treatment plans.
Failure to Identify Causes and Individualize Fall Interventions
Penalty
Summary
The facility failed to identify causal factors for repeated falls and failed to develop fall prevention interventions based on those causal factors for a resident with severe cognitive impairment, dependence on staff for all cares, bowel and bladder incontinence, and diagnoses including non-Alzheimer's dementia, fractures, malnutrition, depression, and anxiety. The resident was receiving antipsychotic, antidepressant, and opioid medications. The facility’s fall prevention program required assessment of fall risk, monitoring for changes in cognition, gait, balance, and ability to rise/sit, and use of individualized interventions based on the resident’s level of risk. The resident had multiple falls in the room and bathroom area. After one fall, the resident was found on the floor between the bed and dresser and the only documented intervention was a sign on the wall reminding the resident to call for help, despite the resident’s severe cognitive impairment. After another fall, the resident was found on the floor in front of the bathroom door; the resident said the walker had been moved, but the walker was not near the fall location, and the only listed intervention was a medication review. Another fall occurred when the resident was found on the floor between the bed and bathroom with feces observed on the brief and in the bathroom, yet there was no evidence the facility reviewed or revised the bowel and bladder program. Additional falls showed the same pattern of incomplete assessment and intervention. The resident was found on the floor between the bed and dresser when no lights were on in the room and the resident was barefoot, but the facility did not address the lighting or the resident’s refusal to wear gripper socks or shoes. After another fall, the resident was found on the floor by the bed after removing gripper socks and stating the resident was on the way to the bathroom; the facility added a video monitor and alarms, but did not address the toileting schedule or the refusal to wear gripper socks. The DON confirmed that no causal factors were identified for several of the falls and that the interventions used did not address the resident’s cognition, toileting needs, lighting, or footwear issues.
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Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beemer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wisner Care Center | 6.7 mi | ★★★★★ | 0 | 0 |
| St Joseph's Hillside Villa | 7.9 mi | ★★★★★ | 0 | 0 |
| Oakland Heights | 19 mi | ★★★★★ | 0 | 0 |
| Clarkson Community Care Center Inc | 21.9 mi | ★★★★★ | 2 | 0 |
| Stanton Health Center | 22.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.