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Home My WebLink About2025 06/02 Life Safety Code BRAD LITTLE – Governor ALEX J. ADAMS - Director LAURA STUTE-- ADMINISTRATOR DIVISION OF LICENSING & CERTIFICATION NATE ELKINS - Chief BUREAU OF FACILITY STANDARDS 450 W. State St. 7th Floor P.O. Box 83720 Boise, ID 83720-0009 PHONE 208-334-6626Email: fsb@dhw.idaho.gov June 12, 2025 Trent Clegg, Administrator Creekside Transitional Care And Rehabilitation 1351 West Pine Avenue Meridian, ID 83642-5031 Provider #: 135125 RE: EMERGENCY PREPAREDNESS SURVEY REPORT COVER LETTER Dear Mr. Clegg: On June 2, 2025, an Emergency Preparedness survey was conducted at Creekside Transitional Care And Rehabilitation by the Bureau of Facility Standards/Department of Health & Welfare to determine if your facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs. Your facility was found to be in substantial compliance with Federal regulations during this survey. Enclosed is a Statement of Deficiencies/Plan of Correction, Form CMS-2567, which states that the facility complies with the requirements of CFR 42, 483.70(a) of the federal requirements. Please sign and date Form CMS-2567 and return via email to us at email address FSB@dhw.idaho.gov. Thank you for the courtesies extended to us during the survey. If you have any questions, please contact this office at (208) 334-6626, option 3. Sincerely, Sam Burbank, Supervisor AHJ, Fire Life Safety/EP Program Division of Licensing & Certification Bureau of Facility Standards SB/df RECEIVED Bureau of Facility Standards TIME/DATE:5:22pm, 6/12/25 June 12, 2025 Trent Clegg, Administrator Creekside Transitional Care And Rehabilitation 1351 West Pine Avenue Meridian, ID 83642-5031 Provider #: 135125 RE: FACILITY FIRE SAFETY & CONSTRUCTION SURVEY REPORT COVER LETTER Dear Mr. Clegg: On June 2, 2025, a Facility Fire Safety and Construction survey was conducted at Creekside Transitional Care And Rehabilitation by the Department of Health & Welfare, Bureau of Facility Standards to determine if your facility was in compliance with State Licensure and Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs. This survey found that your facility was not in substantial compliance with Medicare and Medicaid program participation requirements. This survey found the most serious deficiency to be a widespread deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy, as documented on the enclosed CMS-2567, whereby significant corrections are required. Enclosed is a Statement of Deficiencies and Plan of Correction, Form CMS-2567, listing Medicare and/or Medicaid deficiencies. If applicable, a similar State Form will be provided listing licensure health deficiencies. In the spaces provided on the right side of each sheet, answer each deficiency and state the date when each will be completed. Please provide ONLY ONE completion date for each federal and state tag in column (X5) Completion Date to signify when you allege that each tag will be back in compliance. NOTE: The alleged compliance date must be after the "Date Survey .BRAD LITTLE – Governor ALEX J. ADAMS - Director LAURA STUTE-- ADMINISTRATOR DIVISION OF LICENSING & CERTIFICATION NATE ELKINS - Chief BUREAU OF FACILITY STANDARDS 450 W. State St. 7th Floor P.O. Box 83720 Boise, ID 83720-0009 PHONE 208-334-6626 Email: fsb@dhw.idaho.gov Completed" (located in field X3) and on or before the "Opportunity to Correct" (listed on page 2). After each deficiency has been answered and dated, the administrator should sign the Statement of Deficiencies and Plan of Correction, CMS-2567 Form in the spaces provided and return the originals to this office. If a State Form with deficiencies was issued, it should be signed, dated and returned along with the CMS-2567 Form. Your Plan of Correction (PoC) for the deficiencies must be submitted by June 25, 2025. Failure to submit an acceptable PoC by June 25, 2025, may result in the imposition of civil monetary penalties by July 17, 2025. Your PoC must contain the following: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action(s) will be taken; What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; and, Include dates when corrective action will be completed. The administrator must sign and date the first page of both the federal survey report, Form CMS-2567. If a State Form was issued as well, it should also be signed, dated and returned. All references to federal regulatory requirements contained in this letter are found in Title 42, Code of Federal Regulations. Remedies may be recommended for imposition by the Centers for Medicare and Medicaid Services (CMS) if your facility has failed to achieve substantial compliance by July 17, 2025, (Opportunity to Correct). Informal dispute resolution of the cited deficiencies will not delay the imposition of the enforcement actions recommended (or revised, as appropriate) on September 2, 2025. A change in the seriousness of the deficiencies on July 17, 2025, may result in a change in the remedy. The remedy, which will be recommended if substantial compliance has not been achieved by September 2, 2025, includes the following: Trent Cle , Administrator June 12, 2025 Page 2 of 4 Denial of payment for new admissions effective September 2, 2025. 42 CFR §488.417(a) If you do not achieve substantial compliance within three (3) months after the last day of the survey identifying noncompliance, the CMS Regional Office and/or State Medicaid Agency must deny payments for new admissions. We must recommend to the CMS Regional Office and/or State Medicaid Agency that your provider agreement be terminated on November 29, 2025, if substantial compliance is not achieved by that time. Please note that this notice does not constitute formal notice of imposition of alternative remedies or termination of your provider agreement. Should the Centers for Medicare & Medicaid Services determine that termination or any other remedy is warranted, it will provide you with a separate formal notification of that determination. If you believe these deficiencies have been corrected, you may contact Sam Burbank, Supervisor, Facility Fire Safety and Construction, Bureau of Facility Standards, 450 W. State Street, 7th Floor, PO Box 83720, Boise, ID 83720-0009, Phone #: (208) 334-6626, option 3; Fax #: (208) 364-1888, with your written credible allegation of compliance. If you choose and so indicate, the PoC may constitute your allegation of compliance. We may accept the written allegation of compliance and presume compliance until substantiated by a revisit or other means. In such a case, neither the CMS Regional Office nor the State Medicaid Agency will impose the previously recommended remedy, if appropriate. If, upon the subsequent revisit, your facility has not achieved substantial compliance, we will recommend that the remedies previously mentioned in this letter be imposed by the CMS Regional Office or the State Medicaid Agency beginning on September 2, 2025, and continue until substantial compliance is achieved. Additionally, the CMS Regional Office or State Medicaid Agency may impose a revised remedy(ies), based on changes in the seriousness of the non-compliance at the time of the revisit, if appropriate. In accordance with 42 CFR §488.331, you have one opportunity to question cited deficiencies through an informal dispute resolution process. You may also contest scope and severity assessments for deficiencies, which resulted in a finding of immediate jeopardy. To be given such an opportunity, you are required to send your written request and all required information as directed in the Informal Dispute Resolution Guidelines for Nursing Facilities dated January 2016. Informal Dispute Resolution Process: Trent Cle , Administrator June 12, 2025 Page 3 of 4 https://publicdocuments.dhw.idaho.gov/WebLink/DocView.aspx?id=5939&dbid=0&re po=PUBLIC-DOCUMENTS&cr=1 Informal Dispute Resolution Request Document: https://publicdocuments.dhw.idaho.gov/WebLink/DocView.aspx?id=11533&dbid=0&r epo=PUBLIC-DOCUMENTS&cr=1 This request must be received by June 25, 2025. If your request for informal dispute resolution is received after June 25, 2025, the request will not be granted. An incomplete informal dispute resolution process will not delay the effective date of any enforcement action. Please email the signed and dated Plan of Correction to Jeremy Wilson at email address FSB@dhw.idaho.gov. Thank you for the courtesies extended to us during the survey. If you have any questions, please contact us at (208) 334-6626, option 3. Sincerely, Sam Burbank, Supervisor AHJ, Fire Life Safety/EP Program Division of Licensing & Certification Bureau of Facility Standards SB/df Enclosures Trent Cle , Administrator June 12, 2025 Page 4 of 4 RECEIVED Bureau of Facility Standards TIME/DATE:5:22pm, 6/12/25 June 13, 2025 Trent Clegg, Administrator Creekside Transitional Care And Rehabilitation 1351 West Pine Avenue Meridian, ID 83642-5031 Provider #: 135125 RE: PLAN OF CORRECTION ACCEPTANCE--FIRE LIFE SAFETY SURVEY Dear Mr. Clegg: On June 2, 2025, a Facility Fire Safety and Construction survey was conducted at your facility. You have alleged that the deficiencies cited on that survey will be corrected. We are accepting your Plan of Correction. If you have any questions, please contact me at (208) 334-6626, option 3. Sincerely, Sam Burbank, Supervisor AHJ, Fire Life Safety/EP Program Division of Licensing & Certification Bureau of Facility Standards SB/df BRAD LITTLE – Governor ALEX J. ADAMS - Director LAURA STUTE-- ADMINISTRATOR DIVISION OF LICENSING & CERTIFICATION NATE ELKINS - Chief BUREAU OF FACILITY STANDARDS 450 W. State St. 7th Floor P.O. Box 83720 Boise, ID 83720-0009 PHONE 208-334-6626 Email: fsb@dhw.idaho.gov