Health inspection·August 8, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide a comfortable, homelike environment for one of four sampled residents (Anonymous Witness 1) when, after repeated complaints, the facility continued to use a floral-scented air freshener near Anonymous Witness 1's bedroom.This deficient practice resulted in Anonymous Witness 1 experiencing headaches and episodes of throat irritation and had the potential to offend or harm other residents of the facility. Findings:A review of Anonymous Witness 1's admission Record, dated 8/8/25, indicated Anonymous Witness 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), acute bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs) & pulmonary hypertension (a condition where blood pressure in the pulmonary arteries [vessels carrying blood from the heart to the lungs] is abnormally high).A review or Anonymous Witness 1's Minimum Data Set, Section C (MDS - a standardized, comprehensive evaluation of residents in Medicare and Medicaid certified nursing homes), dated 6/11/25, it indicated Anonymous Witness 1 had a BIMS (Brief Interview for Mental Status- indicates a resident's cognitive (related to a resident's conscious intellectual activity such as reasoning, thinking or remembering) function. The score, ranging from 0 to 15, helps identify potential cognitive impairment and informs care planning) score of 14, indicating no cognitive impairment. During a telephone interview with Anonymous Witness 1 on 8/7/25 at 1:00 pm, Anonymous Witness 1 stated the facility used mechanical air freshener devices about a year prior, and after he complained they were removed. Anonymous Witness 1 stated after the ownership of the facility had changed, the new owner had resumed using air fresheners. Resident 1 described the air freshener scent as a heavy baby powder or clothing detergent smell, which caused Anonymous Witness 1 headaches and throat irritation. Anonymous Witness 1 stated he had complained about this to facility staff, but they had not done anything about it.During an observation on 8/8/25 at 10:35 a.m., a noticeable floral fragrance was noticed in the hallway outside [room [ROOM NUMBER]].During an interview on 8/8/25 at 12:25 p.m. with a facility housekeeper (HK), HK stated she used an air freshener spray in her routine cleaning duties. HK also stated there were several mechanical air freshener devices in the hallways that were maintained by the facility maintenance department. HK stated Anonymous Witness 1 specifically asked her not to use spray air freshener in his bedroom, so she didn't. HK stated she did not know any details about the filler ingredients or chemicals used in the mechanical air freshener devices.During an interview on 8/8/25 at 12:35 p.m. with the Maintenance Assistant ([NAME]), [NAME] stated he started working at the facility a month prior, and he knew nothing about the mechanical air fresheners or what the refills were made of. [NAME] stated that the Maintenance Director knew, but he was out on leave for about a month.During a record review of Anonymous Witness 1's Care Plan Report, printed 8/8/25, it indicated on 6/12/23, the following focus was created, Page 1 of 2 555703 555703 08/08/2025 Ridgeway Post Acute 523 Hayes Lane Petaluma, CA 94952

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few claims that he is allergic (where your body reacts to something that's normally harmless like pollen, dust or animal fur. The symptoms can be mild, but for some people they can be very serious) to air fresheners but is not listed as one of his allergies and has not have/had any change of condition recently such as allergies. Interventions included the following, Air freshener was removed closer [sic] to resident's room.During a concurrent observation and interview on 8/8/25 with the Social Services Director (SSD) and [NAME], the SSD stated she could smell the floral odor in the hallway directly outside of [room [ROOM NUMBER]]. SSD and [NAME] pointed out one of the mechanical air fresheners (a two-inch x two-inch white plastic box) attached to the hallway wall near the ceiling, approximately six feet away from [room [ROOM NUMBER]]. [NAME] stated that he believed the device had a setting that controlled the amount of fragrance released, and it was set at the lowest setting due to a prior complaint.During a interview on 8/8/25 at 3:00 p.m. with the Director of Nursing (DON), she stated there were no issues with using air fresheners because there was no specific regulation prohibiting its use in facilities.A review of the facility policy titled, Homelike Environment, dated 2/2021, indicated, staff provides person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences.facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.pleasant neutral scents, and The facility staff and management minimize to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include.institutional odors. 555703 Page 2 of 2