The September 30 inspection at Continuing Healthcare of Toledo revealed Resident #62's cup contained approximately 60 milliliters of water with a black substance that a nursing assistant identified as mold. A small film floated on the water's surface alongside multiple floating substances.
When inspectors interviewed the resident at 9:45 a.m., she said she would like to use her water cup but couldn't locate it. Less than an hour later, they found it on her dresser.
The facility's dietary manager told inspectors that dietary staff were responsible for cleaning all residents' water cups. The manager admitted they had no documentation regarding the cleaning process and said the facility would switch to disposable cups as a corrective action.
But the moldy water cup wasn't the only problem in Resident #62's room.
Inspectors walking down the hallway outside her room at 9:27 a.m. encountered an extremely strong odor of urine and stool. The smell was so powerful it filled the corridor.
Resident #62, who has severe cognitive impairment and is always incontinent of bowel and bladder, told inspectors her incontinence brief had been changed around 8:45 a.m. that morning. She said staff did not wake her during the night to change her brief.
When nursing assistant #182 arrived, she confirmed the strong smell of urine and stool in the hallway. The assistant explained that when she changed the resident's brief that morning, she didn't have the chance to change the bed sheets.
The sheets told the story. Inspectors found Resident #62's mattress sheets were saturated in urine with stool present on the fabric. A strong odor of urine permeated the room. The nursing assistant confirmed the sheets remained soiled and wet.
Resident #62 suffers from metabolic encephalopathy, protein-calorie malnutrition, insomnia, and heart disease with heart failure. Her care plan requires staff to complete peri-care with each incontinence episode. She is completely dependent for toileting and showers according to her quarterly assessment.
The facility's own policy on homelike environment, last revised in February 2021, states that residents should be provided with a safe, clean, sanitary, comfortable, and homelike environment. The policy specifically requires clean bed and bath linens that are in good condition and pleasant, neutral scents.
Federal inspectors documented these violations as part of two separate complaints filed against the facility. The inspection covered four residents but found environmental problems affecting Resident #62 among the facility's 70 residents.
The nursing assistant who identified the mold in the water cup had no explanation for how long the contamination had been present. The dietary manager's admission that no documentation existed for water cup cleaning suggests the problem could have persisted for an extended period.
For Resident #62, admitted to the facility in December 2024, the combination of moldy drinking water and urine-soaked bedding represented a failure of basic care standards. She wanted to drink from her cup but couldn't find it, unaware that when located, it contained black mold that posed health risks.
The facility's decision to switch to disposable cups addresses only part of the problem documented by inspectors. The underlying issue of inadequate cleaning procedures and lack of documentation remains unresolved in the inspection report.
Meanwhile, the strong odors emanating from Resident #62's room into the hallway created an unpleasant environment for other residents, staff, and visitors. The nursing assistant's acknowledgment that she lacked time to change soiled sheets highlights staffing or scheduling problems that left a vulnerable resident lying in her own waste.
The inspection findings represent what federal regulators classify as minimal harm with potential for actual harm, affecting few residents. But for Resident #62, lying in urine-soaked sheets while her water cup grew mold on the dresser, the impact was immediate and personal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Continuing Healthcare of Toledo from 2025-09-30 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Continuing Healthcare of Toledo
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