F0558

D

Failure to Provide Appropriately Sized Bed for Tall Resident

Edmonds, Washington Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The facility failed to reasonably accommodate a resident’s needs and preferences by not providing an appropriately sized bed, despite the resident’s height and dependence on staff for bed mobility. Facility policy on bed safety and bed rails, revised in August 2022, states that bed dimensions are to be appropriate for the resident’s size and that consideration is to be given to comfort, safety, and freedom of movement, with input from the resident and family. The admission MDS dated 01/20/2026 documented that the resident was cognitively intact, had a height of 78 inches, and was dependent on staff for bed mobility. Observations on multiple days showed the resident wearing pressure-relieving boots with their feet pressed against the footboard.

During observations, the resident reported that their feet were touching the footboard and that this caused knee pain, and stated that staff were aware and had to repeatedly scoot them up in bed. A CNA acknowledged that the bed was “small but not too small,” confirmed that the resident required two-person assistance to be repositioned when they slid down, and had not requested a longer bed. A joint observation with this CNA showed the resident’s toes touching the footboard when the head of the bed was raised. The Maintenance Director stated that requests for longer beds must come from the nurse manager and be care planned, and that admissions typically notify maintenance if an incoming resident is tall so an appropriate bed can be provided or rented. The DON stated that staff should notify maintenance if a resident requested a longer bed or if staff observed that a bed was too small, and the Administrator stated they expected residents to have appropriately sized beds, indicating that the established process was not followed for this resident.