Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the facility incident and accident log, review of the Electronic Information Dissemination and
Collection (EIDC - system used by facilities to report incidents to the State Survey Agency [SSA]) system,
review of the facility Self-Reported Incidents (SRI), staff interview and review of the facility policy, the facility
failed to report an incident of resident elopement to the SSA for Resident #3 and further failed to ensure
allegations of abuse were thoroughly investigated for four (#26, #28, #30, and #31) residents reviewed for
abuse. The facility census was 87.
Residents Affected - Some
Findings include:
1. Review of the incident and accident log for the past three months revealed an incident of elopement for
Resident #3 on 04/12/25.
Review of the medical record for Resident #3 revealed an admission date of 03/28/25 with diagnoses of
senile degeneration of the brain, anxiety, and diabetes mellitus type II. Review of the admission Minimum
Data Set (MDS) assessment, dated 04/04/25, revealed Resident #3 was cognitively impaired and had no
wandering behaviors.
Review of the nursing progress note dated 04/12/25 at 6:08 P.M. revealed Resident #3 was spotted in the
parking lot of the facility, walking and heading toward [NAME] Road (a four-lane road). Staff were notified
and Resident #3 was brought back into the facility and nurses and aides were informed of the situation and
told to keep an eye on the patient. The Director of Nursing (DON) and Nurse Practitioner (NP) were notified.
Interview on 4/29/25 at 2:40 P.M. with Licensed Practical Nurse (LPN) #354 verified Resident #3 eloped
from the facility on 04/12/25. LPN #354 stated she was in the parking lot, attending to another resident,
when she noticed Resident #3 heading toward the road. LPN #354 stated she alerted another staff member
and Resident #3 was returned to the facility.
Review of the EIDC system from 04/01/25 through 04/29/25 revealed the facility did not report Resident
#3's elopement to the SSA.
2. Review of the medical record for Resident #26 revealed an admission date of 01/28/25 with diagnoses of
acute respiratory failure, chronic obstructive pulmonary disease (COPD).
Review of the quarterly MDS assessment, dated 03/21/25, revealed Resident #26 was cognitively intact.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
365339
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365339
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Terrace Rehabilitation Center
2735 Darlington Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the facility submitted SRI, created on 04/05/25 at 3:17 P.M. and completed on 04/11/25 at 3:32
P.M., revealed the facility reported an allegation of verbal abuse after Resident #26 alleged a facility
Certified Nursing Assistant (CNA) was verbally abusive.
Review of the facility investigation for the SRI revealed the file only included a copy of the SRI submitted to
the SSA. Further review revealed no evidence a thorough investigation, including staff interviews or
statements, resident statements, assessment of like residents, or staff education was completed.
3. Review of the medical record for Resident #28 revealed an admission date of 05/31/23 with a diagnosis
of dementia.
Review of the annual MDS assessment, dated 03/15/25, revealed Resident #28 was cognitively impaired.
Review of the facility submitted SRI, created on 04/18/25 at 11:33 A.M. and completed on 04/28/25 (one
day past the investigation due date) at 1:12 P.M., revealed the facility reported an injury of unknown source
to the SSA when Resident #28 was found with a bump and a bruise to the eyebrow.
Review of the facility investigation for the SRI revealed the file only included a copy of the SRI submitted to
the SSA. Further review revealed no evidence a thorough investigation, including staff interviews or
statements, resident statements, assessment of like residents, or staff education was completed.
4. Review of the medical record for Resident #30 revealed an admission date of 03/30/25 with diagnoses of
Alzheimer's dementia and Parkinson's.
Review of the admission MDS assessment, dated 04/06/25, revealed Resident #30 was cognitively intact.
Review of the facility submitted SRI, created on 04/08/25 at 6:24 P.M. and completed on 04/18/25 (one day
past the investigation due date) at 11:56 A.M., revealed the facility reported an allegation of physical abuse
to the SSA when Resident #30 alleged another resident hit him with a cane.
Request for the facility investigation related to the allegation revealed the facility had no documentation
related to an investigation.
5. Review of the medical record for Resident #31 revealed an admission date of 03/31/23 with a diagnosis
of Parkinson's and multiple sclerosis.
Review of the quarterly MDS assessment, dated 03/19/25, revealed Resident #31 was cognitively intact.
Review of the facility submitted SRI, created on 04/08/25 at 10:58 A.M. and completed on 04/18/25 (three
days past the investigation due date) at 11:51 A.M. revealed Resident #31 alleged a facility Certified
Nursing Assistant (CNA) did not treat her properly.
Review of the facility investigation for the SRI revealed the file only included a copy of the SRI submitted to
the SSA. Further review revealed no evidence a thorough investigation, including staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365339
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365339
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Terrace Rehabilitation Center
2735 Darlington Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
interviews or statements, resident statements, assessment of like residents, or staff education was
completed.
Interview on 4/29/25 at 3:20 P.M. with the Administrator revealed her first day in her role at the facility was
the day prior. The Administrator stated that what was included in the investigation files for the SRIs was all
of the information she had and. Further interview with the Administrator verified complete and thorough
investigations were not completed for each of the SRIs and further confirmed she was unable to locate any
file or documentation for the SRI created on 04/18/24 involving Resident #30's allegation of
resident-to-resident physical abuse.
Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated January 2025, revealed
investigation would occur immediately when suspicion of abuse, neglect, or exploitation or reports of abuse,
neglect or exploitation occurred. Further review revealed the written procedure included identifying and
interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other
who might have knowledge of the allegations and providing complete and thorough documentation of the
investigation. Additionally, reporting of alleged violations to the Administrator, state agency, adult protective
services, and all other required agencies would occur no later than 24 hours if the events that caused the
allegation did not involve abuse and did not result in serious bodily injury.
This deficiency represents non-compliance investigated under Complaint Number OH00164991 and is
continued non-compliance from the survey dated 04/11/25.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365339
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365339
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Terrace Rehabilitation Center
2735 Darlington Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure
baseline care plans were completed. This affected one (#53) of one resident reviewed for baseline care
plans. The facility census was 87.
Findings include:
Review of the medical record for Resident #53 revealed an admission date of 04/26/25 with diagnoses of
acute respiratory failure, tracheostomy status, malignant neoplasm of the lung and supraglottis (upper part
of the larynx), anxiety, and chronic obstructive pulmonary disease (COPD).
Review of the admission assessment, dated 04/26/25, revealed Resident #53 was cognitively intact.
Further review revealed a baseline care plan was not part of the admission assessment.
Additional review of Resident #53's medical record revealed no evidence a baseline care plan was
completed.
Interview on 4/30/25 at 1:05 P.M. with the interim Director of Nursing (DON) verified a baseline care plan
was not completed for Resident #53.
Review of the facility policy titled Baseline Care Plan, undated, revealed the facility would develop and
implement a baseline care plan for each resident that included the instructions needed to provide effective
and person-centered care of the resident. The baseline care plan would be developed within 48 hours of
the resident's admission.
This deficiency was an incidental finding discovered during the complaint investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365339
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365339
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Terrace Rehabilitation Center
2735 Darlington Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure
person-centered care plans were completed. This affected one (#3) of four residents reviewed for care
plans. The facility census was 87.
Findings include:
Review of the medical record for Resident #3 revealed an admission date of 03/28/25 with admitting
diagnoses of senile degeneration of the brain, diabetes mellitus type II, and anxiety.
Review of the admission Minimum Data Set (MDS) assessment dated , 04/04/25, revealed Resident #3
was cognitively impaired.
Review of a nursing progress note dated 04/12/25 revealed Resident #3 was spotted in the parking lot,
walking toward the street.
Review of the physician orders revealed on 04/14/25, Resident #3 was admitted to the secure memory care
unit.
Review of Resident #3's plan of care revealed on 04/14/25, a focus area was initiated for the resident
having a behavior problem as evidenced by elopement. Two interventions were implemented, medications
as ordered and anticipate the resident's needs. Further review revealed no evidence of person-centered
interventions or the resident's admission to the secured memory care unit.
Interview on 04/29/25 at 4:27 P.M. with the Director of Nursing (DON) verified the elopement care plan for
Resident #3 did not reflect a person-centered approach for appropriate interventions for elopement.
Review of the facility policy titled, Elopements and Wandering Residents, dated January 2025, revealed the
facility ensured that residents who exhibited wandering behavior and/or were at risk for elopement received
adequate supervision to prevent accidents and received care in accordance with their person-centered plan
of care addressing the unique factors contributing to wandering or elopement risk.
Review of the facility policy titled, Comprehensive Care Plans, undated, revealed the policy of the facility
was to develop and implement comprehensive person-centered care plans for each resident that included
measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological
needs, and all services that were identified in the resident's comprehensive assessment.
This deficiency was an incidental finding discovered during the complaint investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365339
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365339
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Terrace Rehabilitation Center
2735 Darlington Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the facility incident and accident log, staff interview, medical record review and review of the
facility policy, the facility failed to provide adequate supervision to prevent resident elopement and further
failed to timely implement interventions to ensure resident safety following an incident of elopement. This
affected one (#3) of one resident reviewed for elopement. The facility census was 87.
Findings include:
Review of the incident and accident log for the past three months revealed an incident of elopement for
Resident #3 on 04/12/25.
Review of the medical record for Resident #3 revealed an admission date of 03/28/25 with diagnoses of
senile degeneration of the brain, anxiety, and diabetes mellitus type II.
Review of the admission Minimum Data Set (MDS) assessment, dated 04/04/25, revealed Resident #3 was
cognitively impaired and had no behaviors of wandering.
Review of the admission Wandering Risk Assessment, dated 03/28/25, revealed Resident #3 had no
previous wandering, was cognitively impaired with poor decision-making skills, spoke of desire to go home,
and talked about going on a trip or packing bags. Further review revealed the assessment did not reflect a
score or other indication of what the resident's assessed risk was.
Review of the nursing progress note dated 04/12/25 at 6:08 P.M. revealed Resident #3 was spotted in the
parking lot of the facility, walking and heading toward [NAME] Road (a four-lane road). Staff were notified
and Resident #3 was brought back into the facility and nurses and aides were informed of the situation and
told to keep an eye on the patient. The Director of Nursing (DON) and Nurse Practitioner (NP) were notified.
Review of the Wandering Risk Assessment, dated 04/12/25 and completed following Resident #3's
elopement, revealed the resident was cognitively impaired with poor decision-making skills and wandering
placed the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility).
Further review revealed the assessment did not reflect a score or other indication of what the resident's
assessed risk was.
Review of a physician order dated 04/14/25 revealed Resident #3 was admitted to the secured memory
care unit. unit.
Review of a nursing progress note dated 04/14/25 at 4:42 P.M. revealed Resident #3 to be transferred to
the secure memory care unit.
Review of the care plan, revised 04/14/25, revealed Resident #3 had a behavior problem as evidenced by
elopement. Interventions included to administer medications as ordered and anticipate resident's needs.
Further review revealed no evidence the resident had care plan interventions related to elopement or
wandering prior to 04/14/25.
Further review of Resident #3's medical record revealed no evidence of increased supervision or
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365339
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365339
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Park Terrace Rehabilitation Center
2735 Darlington Rd
Toledo, OH 43606
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
other interventions implemented following the resident's elopement on 04/12/25 until 04/14/25.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 4/29/25 at 2:40 P.M. with Licensed Practical Nurse (LPN) #354 revealed on 04/12/25, she was
in the parking lot, attending to another resident who had fallen, when she saw Resident #3 heading toward
the road. LPN #354 stated she alerted another staff member and Resident #3 was returned to the facility.
Prior to the elopement, LPN #354 stated Resident #3 wandered all over the facility in his wheelchair but did
not display any exit seeking behaviors. LPN #354 stated the incident occurred at the end of her shift and
verified she did not implement any interventions to ensure the resident's safety.
Residents Affected - Few
Interview on 04/29/25 at 4:27 P.M. with the DON revealed he was not notified of Resident #3's elopement at
the time of the occurrence but stated the resident was immediately placed on one-to-one staff observation
until he was moved to the secured memory care unit on 04/14/25. Review of Resident #3's medical record,
with the DON, confirmed there was no evidence of one-to-one staff monitoring or other interventions
implemented following the elopement to ensure the resident's safety and further verified the only monitoring
documented in the resident's medical record was to keep eyes on patient. The DON further stated Resident
#3 was moved to the secured memory care unit on the Monday following the elopement (elopement
occurred on Saturday), when administration learned of the elopement.
Review of the facility policy titled, Elopements and Wandering Residents, dated January 2025, revealed the
facility ensured that residents who exhibited wandering behavior and/or were at risk for elopement received
adequate supervision to prevent accidents and received care in accordance with their person-centered plan
of care addressing the unique factors contributing to wandering or elopement risk.
This deficiency was an incidental finding discovered during the complaint investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365339
If continuation sheet
Page 7 of 7
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the April 30, 2025 survey of PARK TERRACE REHABILITATION CENTER?
This was a inspection survey of PARK TERRACE REHABILITATION CENTER on April 30, 2025. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PARK TERRACE REHABILITATION CENTER on April 30, 2025?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.