Cycle 1
Health 2025-05-08 · Fire 2025-05-08
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fremont, NH
Colonial Poplin Nursing Home
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
442 Main Street, Fremont, NH
(603) 895-3126
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,804
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9916
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.95
Baseline 19.07% · Performance 20.53% · Measure score 1.95 · Achievement 1.95 · Improvement 0
Healthcare-associated infections
8.07
Baseline 5.60% · Performance 5.42% · Measure score 8.07 · Achievement 8.07 · Improvement 2.40
Total nurse turnover
1.99
Performance 55.56% · Measure score 1.99 · Achievement 1.99 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.40
Baseline 3.52 hours · Performance 4.04 hours · Measure score 3.40 · Achievement 3.40 · Improvement 1.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.18% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 253 · Observed rate 7.91% · Lower 95% interval 6.81% |
| Discharge to community | 62.73% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 261 · Observed rate 57.47% · Lower 95% interval 55.93% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.24% |
95.27%
3 pts better
|
Numerator 167 · Denominator 170 |
| Falls with major injury | 0.59% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 170 |
| Discharge self-care score | 61.87% |
53.69%
8.2 pts better
|
Numerator 86 · Denominator 139 |
| Discharge mobility score | 52.52% |
50.94%
1.6 pts better
|
Numerator 73 · Denominator 139 |
| Pressure ulcers or injuries, new or worsened | 1.18% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 170 · Adjusted rate 1.55% |
| Healthcare-associated infections requiring hospitalization | 5.42% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 2.96% · Lower 95% interval 3.09% |
| Staff COVID-19 vaccination coverage | 90.24% |
8.2%
82 pts better
|
Numerator 74 · Denominator 82 |
| Staff flu vaccination coverage | 58.42% |
42%
16.4 pts better
|
Numerator 59 · Denominator 101 |
| Discharge function score | 67.63% |
56.45%
11.2 pts better
|
Numerator 94 · Denominator 139 |
| Transfer of health information to provider | 97.87% |
95.95%
1.9 pts better
|
Numerator 138 · Denominator 141 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 69.41% |
25.2%
44.2 pts better
|
Numerator 59 · Denominator 85 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.9
0.7 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.4%
3.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
4.5%
2.8 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 8.0% · Q3 7.7% · Q4 6.9% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.9% |
9.7%
4.2 pts worse
|
11.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 11.5% · Q4 42.9% · 4Q avg 13.9% |
| Percentage of long-stay residents who lose too much weight | 15.0% |
5.5%
9.5 pts worse
|
5.4%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q3 22.7% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
18.9%
11.5 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q3 9.1% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.3% |
18.7%
0.4 pts better
|
16.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.2% |
19.2%
2 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
21.9%
1.4 pts better
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q3 22.7% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.3%
0.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
2.4%
1.3 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.0% · Q3 3.8% · Q4 3.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
26.7%
About the same
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 20.1% · Q3 24.8% · Q4 37.1% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 10.2% |
4.4%
5.8 pts worse
|
5.1%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 9.1% · Q3 15.1% · Q4 8.7% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
85.6%
11.4 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 97.7% · Q3 98.6% · Q4 96.6% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
14.1%
6.5 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.7%
0.2 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 2.3% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
83.0%
12.5 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
22.1%
0.5 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 19.0% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-01 · Fire 2024-05-01
1 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-05-23 · Fire 2023-05-23
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2025-05-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-22
C · Minimal harm
2025-05-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-22
E · Potential for more than minimal harm
2024-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-23
C · Minimal harm
2024-05-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-23
C · Minimal harm
2024-05-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-23
E · Potential for more than minimal harm
2023-05-23
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-09
D · Potential for more than minimal harm
2023-05-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-09
C · Minimal harm
2023-05-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-09
C · Minimal harm
2023-05-23
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-06-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-30
D · Potential for more than minimal harm
2023-05-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-05-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-06-12
Penalties and ownership
What sits behind the stars
Ownership
White Oak Healthcare At Fremont Inc
5% Or Greater Direct Ownership Interest · Organization
Forbright Bank
5% Or Greater Mortgage Interest · Organization
Goldstein, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Goldstein, Avrohom
Operational/Managerial Control · Individual
Goldstein, Avrohom
Corporate Director · Individual
Goldstein, Avrohom
Corporate Officer · Individual
Kansas SNF Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Mad Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Natr Trust
5% Or Greater Indirect Ownership Interest · Organization
Natr Trust
Operational/Managerial Control · Organization
Piper, Kimberly
Operational/Managerial Control · Individual
Piper, Kimberly
W-2 Managing Employee · Individual
Rarmna Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ratr Trust
5% Or Greater Indirect Ownership Interest · Organization
Ratr Trust
Operational/Managerial Control · Organization
Rnr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wetr Trust
5% Or Greater Indirect Ownership Interest · Organization
Wetr Trust
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Rockingham County Nursing Home
Brentwood, NH
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Riverwoods At Exeter
Exeter, NH
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Derry Center For Rehabilitation And Healthcare
Derry, NH
1-star overall rating with 1-star inspections with Special Focus status with $69,219 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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