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F0584
D

Failure to Provide Homelike Environment Due to Air Freshener Use

Petaluma, California Survey Completed on 08-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a comfortable, homelike environment for a resident with significant respiratory diagnoses, including respiratory failure, acute bronchitis, and pulmonary hypertension. Despite repeated complaints from the resident about headaches and throat irritation caused by a strong floral-scented air freshener near his bedroom, the facility continued to use both spray and mechanical air fresheners in the hallway adjacent to his room. The resident had previously requested the removal of air fresheners, and while staff refrained from using spray air freshener in his bedroom, mechanical devices remained in use nearby. Staff interviewed were unaware of the specific chemicals in the air fresheners, and the maintenance assistant was not familiar with the devices or their contents. Observations confirmed a noticeable floral fragrance in the hallway outside the resident's room, and a mechanical air freshener device was found mounted on the wall near the ceiling, approximately six feet from the room. The care plan noted the resident's claim of being allergic to air fresheners, but this was not listed among his documented allergies, and no recent change in condition was recorded. The facility's policy emphasized providing a homelike environment with pleasant, neutral scents and minimizing institutional odors, but the continued use of air fresheners despite the resident's complaints and medical history constituted a failure to honor the resident's right to a safe and comfortable environment.

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