The resident, a stroke survivor who has lived at the facility for two years, told inspectors on October 20 that staff had left one of the cans in his room. He had purchased the other can himself. One can displayed a warning label to "keep out of reach of children."
When inspectors returned the next day, both cans remained on the nightstand. The resident was not in his room.
The Director of Nursing, who started at the facility just three weeks earlier, said she was unaware the resident had air fresheners in his possession. "There should not be any residents in the facility to have access to air fresheners," she told inspectors on October 21. She said the aerosols should be locked in a cart or room, never stored in resident rooms.
The DON identified specific risks: "There could be a risk for fires or cause other people to get sick from the inhalants."
The Administrator echoed these concerns, stating residents could face respiratory issues from aerosol exposure. She said staff should keep such products on their carts or lock them in closets after use.
The facility's own hazardous materials policy, revised in July 2017, explicitly addresses this violation. The policy defines a hazard as "anything in the environment that has the potential to cause injury or illness" and specifically lists "access to toxic chemicals" as an environmental hazard that must be controlled.
The policy requires the facility to identify and address all hazardous materials "appropriately to ensure resident safety and mitigate accident hazards to the extent possible."
The resident involved is a diabetic man with morbid obesity and hypertension who suffered a cerebral infarction. His care plan shows he depends on staff for bathing three times weekly and has significant self-care deficits. Despite his stroke history, his cognitive assessment showed no thinking impairments with a perfect score of 15.
During the initial interview, the resident asked inspectors if he needed to remove the cans, showing awareness that their presence might be problematic. He noted that other residents do not wander into his room, suggesting he understood potential safety concerns for more vulnerable patients.
The violation occurred despite clear facility protocols. According to the Administrator's statements, housekeeping staff should have secured the aerosols immediately after any cleaning activities in the resident's room.
The failure represents a breakdown in basic safety monitoring. Neither nursing staff during routine medication passes nor housekeeping during daily cleaning noticed or addressed the hazardous materials sitting openly on the nightstand.
Federal inspectors classified this as minimal harm with potential for actual harm, affecting few residents. However, the violation highlights broader questions about environmental safety oversight at the facility.
The timing is particularly concerning given the DON's recent start date of September 29. The air fresheners were discovered just three weeks into her tenure, suggesting either inadequate safety training during leadership transition or systemic failures in hazardous material protocols.
Aerosol products pose multiple risks in nursing home environments. Beyond fire hazards from pressurized containers, the chemical propellants and fragrances can trigger respiratory distress in elderly residents with compromised lung function. Many nursing home residents take medications that increase sensitivity to airborne chemicals.
The resident's medical history compounds these risks. His diabetes and hypertension medications could interact poorly with chemical inhalants. His stroke history, while not affecting his cognitive function, may have impacted his ability to recognize or respond to respiratory distress from chemical exposure.
The violation occurred during a complaint investigation, suggesting someone reported safety concerns at the facility. The inspection covered accident hazards for nine residents, with this being the only documented failure among those reviewed.
The facility's 2017 policy demonstrates long-standing awareness of toxic chemical risks. The seven-year gap between policy creation and this violation suggests either inadequate staff training or inconsistent policy enforcement.
Both the DON and Administrator acknowledged the violation immediately and committed to addressing it. However, their surprise at finding aerosols in a resident room raises questions about routine environmental safety monitoring throughout the facility.
The resident remains at Wells LTC Nursing & Rehabilitation, where he has lived for two years since his admission. His care plan continues to address his significant physical dependencies, but now facility staff must also ensure his environment remains free from the chemical hazards they inadvertently introduced to his room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wells Ltc Nursing & Rehabilitation from 2025-11-25 including all violations, facility responses, and corrective action plans.
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