Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Colonial Poplin Nursing Home during CMS and state inspections, most recent first.
Incomplete Water Management Plan: The facility’s water management plan did not include all required elements to prevent Legionella and other opportunistic waterborne pathogens. The plan lacked an accurate description of the water system, did not identify all areas where Legionella could grow and spread, and did not specify how to respond when control limits were not met. It also did not state how often hot water storage tank temperatures should be monitored, and the maintenance log showed no recorded tank temperatures. The IP and Administrator identified unused resident bathtubs and eyewash stations as additional low-use risk areas that were not included in the plan.
The facility failed to implement their policy and procedures for Transmission Based Precautions for three residents who tested positive for COVID-19. Staff were observed interacting with these residents without wearing the required PPE, including N95 masks, gowns, gloves, and eye protection. Interviews with staff confirmed the lack of adherence to PPE protocols, despite the facility's policies and CDC guidelines requiring such measures.
Incomplete Water Management Plan
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program because its water management plan did not include all necessary elements to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens. Review of the Water Management Plan, revised on 2/23/26, showed it did not contain an accurate description of the facility water system, did not identify specific areas where Legionella could grow and spread, and did not establish ways to intervene when control limits were not met. The plan identified that the hot water storage tank temperature should be maintained between 130 and 150 degrees Fahrenheit and recorded, but it did not specify how often the temperature should be monitored. Staff B, the Infection Preventionist, stated that the facility had two resident rooms with bathtubs that were not in use and eyewash stations, which were low-use areas. Review of the maintenance log book from December 2025 through April 2026 showed no water temperatures had been recorded for the hot water storage tanks. Staff A, the Administrator, confirmed that the plan did not include all risk areas such as the two unused resident bathtubs and the eyewash stations.
Failure to Implement Transmission Based Precautions for COVID-19
Penalty
Summary
The facility failed to implement their policy and procedures for Transmission Based Precautions (TBP) for three residents who tested positive for COVID-19. Resident #4, who tested positive on 4/20/24, was observed interacting with staff who were not wearing the required personal protective equipment (PPE). Specifically, Staff A and Staff B were seen in close proximity to Resident #4 without wearing an N95 mask, gown, or gloves, despite the posted Droplet and Contact Precautions sign outside the resident's room. Staff A was also observed entering another resident's room without changing the mask, which was a KN95 mask not intended for medical use. Interviews with staff confirmed the lack of adherence to PPE protocols, with some staff members believing that full PPE was unnecessary if they did not touch anything in the room. Similarly, Staff A was observed in the room of Residents #36 and #38, who also tested positive for COVID-19, without wearing the required PPE. Staff A was seen approximately three feet away from the residents, wearing only a KN95 mask and no gown, gloves, or eye protection. Interviews with the Assistant Director of Nursing, Director of Nursing, Infection Preventionist, and Administrator confirmed that all staff should be wearing full PPE when in the rooms of residents under Droplet and Contact Precautions. The facility's policies on Transmission-Based Precautions and Personal Protective Equipment, as well as the CDC's Interim Infection Prevention and Control Recommendations, were reviewed and found to require the use of N95 masks, gowns, gloves, and eye protection for staff entering the rooms of residents with suspected or confirmed COVID-19. The facility's failure to adhere to these guidelines was confirmed through observations, interviews, and record reviews, indicating a significant lapse in infection control practices.
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What surveyors actually found near you
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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 Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockingham County Nursing Home | 4.3 mi | ★★★★★ | 10 | 0 |
| Riverwoods At Exeter | 7.3 mi | ★★★★★ | 2 | 0 |
| Derry Center For Rehabilitation And Healthcare | 10.9 mi | ★★★★★ | 5 | 0 |
| Exeter Center | 11 mi | ★★★★★ | 5 | 0 |
| Pleasant Valley Nursing And Rehab Center | 11.5 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.