Charter Senior Living of Dedham

AGE reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency.

During the month of August 2025, there were 78 e-call response times over the 15-minute limit.

EOEA reviewed the Residence’s dietary plan reviews from January 2024 through the date of the Compliance Review to confirm consistency with the most recent edition of the Dietary Guidelines.

A Dietary Review was missing for the second half of the 2024 calendar year.

The 2025 Dietary Review lacked the inclusion of the required language designation that the meal selections meet the minimum dietary standards of the daily recommended allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.

AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the Residence is complying with all the required safeguards.

Age identified deficiencies with operational safeguards related to the risk of secured entry and physical hazards:

-Main SCR secure door alarms did not trigger when opened for an extended period of time.

AGE reviewed the documentation of five Resident Records from January 2024 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Five records were without documentation of a Resident’s ability to perform independent medication administration and documentation to confirm that assessments noted the name and scope of any Legal Representative

Four records were missing documentation of staff access to the Resident’s unit, the presence of behaviors, Resident goals, the provision of a 24-hour, on-site staff and documentation of Resident or Representative signatures.

Three records were missing documentation of a service plan review required within 30 days after the commencement of residency.

Three records were missing documentation of individualized enrichment activities provided to the Residents in the SCR.

AGE reviewed the Residence records of five Residents utilizing bed rails / U-bars or similar devices for the period of 2024 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.

Five records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar.

AGE reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Safety Assurances, and Medication Quality from January 5, 2024, through the date of the Compliance Review.

Documentation of the date the audit was completed, residents identified by number or code, target date, the person responsible for follow-up action and clear outcomes was missing for the 2024 and 2025 calendar years.

Resident Safety Assurances

Documentation that an audit was completed for the 2024 calendar year was missing.

Documentation of a target date, the person responsible for follow-up action and clear outcomes was missing for the second and third quarters of 2025.

AGE reviewed the Residence’s quarterly medication documentation audits from January 5, 2024, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.

Documentation that an audit was completed for the last three quarters of the 2023 calendar year was missing.

Documentation of a target date, the person responsible for follow-up action and clear outcomes was missing for the second and third quarters of 2025.

AGE observed one Personal Care (PC) staff and one nurse providing medication assistance to five Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

AGE observed an unsecured medication storage cabinet in one Resident’s unit.

AGE observed LMA medications not stored separately from SAMM medication in two Resident’s medication storage units.

AGE observed prescribed LMA medications missing from two Resident’s

Medication storage units.

AGE reviewed the Residence records and incident reports from January 5, 2024, through the date of the Compliance Review to determine whether the Residence complied with the requirement to report qualifying incidents to AGE within 24 hours after the occurrence of the incident or accident.

The Residence filed 24 incident reports greater than 24 hours after the occurrence of an incident or accident.

AGE reviewed the Controlled Substance (CS) policy and procedure for Residents who participate in SAMM and LMA.

Documentation of a disposal procedure was missing from the CS policy.

CS count procedure by staff was inconsistent on the day of the compliance review.

AGE reviewed the personnel records of five staff members to determine compliance with personnel record requirements.

Three personnel records were missing documentation of a signed job description.

AGE reviewed all current Correspondence Logs required to communicate information necessary to maintain the continuity of care for all Residents.

The Traditional and SCR logs did not consistently document all significant or pertinent information.

AGE reviewed the Residence records to determine compliance with Staffing Level requirements.

Documentation to confirm the Residence conducted quarterly staffing level assessments was missing for all four quarters of the 2024 calendar year.

AGE reviewed the personnel records of five staff members to determine compliance with Health Screening requirements.

Five records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 flu season.

AGE reviewed the Residence records to determine compliance with annual training needs assessment requirements.

Documentation of an annual training needs assessment was missing for the 2024 calendar years reviewed.

AGE reviewed the personnel records of five staff members to determine compliance with orientation requirements.

Documentation of General Orientation was missing in five staff records.

AGE reviewed the records of four Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements in the calendar year 2024 through the date of the Compliance Review.

Documentation confirming the completion of skills evaluations every six months was missing from four records for the 2024 and 2025 calendar years reviewed.

AGE reviewed five personnel records to determine compliance with training requirements.

Three records were missing documentation to confirm completion of required LGBTQ training.

AGE reviewed Resident records as required by 651 CMR 12.09.

By the completion of the compliance review the following requested Residence documentation and / or records had not been presented to AGE:

-E-call response times and reviews for December 2024.