Massachusetts inspects every assisted living residence at least once every two years. At its most recent compliance review on August 22, 2024, the state cited 5 findings at Traditions of Dedham. 4 of them had already been cited at the previous review. Across the 145 Massachusetts residences with a published report, the median is 6.
This page covers one review, not a history, and it is not a score or a ranking. A finding means the state identified something the residence has to correct; it does not on its own mean a resident was harmed. The state does not publish what happened after this review, so a finding listed here may since have been fixed. Where the state withheld private details, such as a resident's medication or the date of an incident, the text reads [redacted].
Facility details
What the state found
5 findings · 4 repeatEmergency call responseIn the month of June 2023 there were 55 e-call response times over the ten minutes required by the Residence policy.▼
How quickly staff answer a resident's emergency call button.
EOEA reviewed response times and tests of the emergency response system from the calendar years 2022 to 2024 to determine compliance with Service Coordination requirements.
In the month of June 2023 there were 55 e-call response times over the ten minutes required by the Residence policy.
In the month of July 2024 there were 20 e-call response times over the ten minutes required by the Residence policy.
General Requirements for an ALR: Service and Service Coordination Requirements Emergency Response
651 CMR 12.04(2)(b)(2)(d) (3.)(b..)(c.)
Bed rail safety · Resident care plansInconsistent with documenting all requirements of Screening and Assessment and Service Plan Requirements.Repeat finding▼
Bed rail safety: Assessing the risk before a resident's bed is fitted with rails.
Resident care plans: The written plan describing the care each resident is assessed to need.
The state cited these together under one finding.
EOEA reviewed the Residence records of 21 Residents utilizing bed rails / U-bars or similar devices for the period of 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.
Documentation of an assessment conducted by a physical/occupational therapist every six months was missing for three Residents utilizing a bed rail/ U-bar for the calendar years reviewed.
EOEA reviewed the records of nine Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.
Two records were missing documentation of a reassessment and service plan review being completed every six months.
This was also cited at the previous compliance review.
General Requirements for an ALR: -Bed Rail Assessments -Service Plan Requirements
651 CMR 12.04(6) 651 CMR 12.04(8)(a)(3)(c) 651 CMR 12.04(8)(c)
Quality assurance programMissing or incomplete components of the Quality Assurance and Performance Improvement requirements.Repeat finding▼
The residence's own program for auditing and improving the care it gives.
EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for the calendar years 2023 to 2024.
Documentation of a specific target date for follow-up and staff responsible for follow-up actions were missing for the first and second quarters of calendar year 2023.
EOEA observed two PCA staff providing medication assistance to four Residents and one nurse providing medication administration to four Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:
One Resident had one compromised blister pack in the medication storage area.
One Resident had one open bottle of [redacted] that was not dated when opened.
This was also cited at the previous compliance review.
General Requirements for an ALR: Quality Assurance and Perfo1·mance Improvement
651 CMR 12.04(10)(c)
Incident reportingResident specific incident reports submitted late to EOEA.Repeat finding▼
Telling the state, on time, when something happens to a resident.
EOEA reviewed the Residence records and submitted incident reports from September 29, 2022, through August 22, 2024 for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident’s health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident or accident.
The Residence filed 27incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.
This was also cited at the previous compliance review.
General Requirements for an ALR - Emergency Preparedness Plan and Reporting Requirements: Reporting Resident Specific Emergencies
651 CMR 12.04(1I)(e)
Controlled medication handlingControlled Substance policy is not being followed.Repeat finding▼
How tightly the residence tracks medications that are subject to abuse.
EOEA reviewed the Controlled Substance (CS) policy and procedure to prevent the theft or diversion of controlled substances prescribed to Residents who participate in SAMM / LMA.
Upon review of the controlled substance practices of the Residence, it was discovered that the Residence was inconsistent in documenting a controlled substance count for one Resident prescribed a controlled substance in accordance with the Residence policy.
EOEA reviewed nine Resident records to determine compliance with record requirements.
Inconsistent documentation of significant occurrences in the Progress Notes for three Residents.
EOEA reviewed the current 90-day Correspondence Logs for the Traditional and SCR Units required to communicate information necessary to maintain the continuity of care for all Residents.
The Residence did not use the Correspondence Logs to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents.
EOEA reviewed nine personnel records, to determine compliance.
Seven records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine.
EOEA reviewed the records of nine Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident.
Two records were missing signature documentation to support that Introductory Visits have been conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care services.
Corrective Actions.
This was also cited at the previous compliance review.
General Requirements for an ALR: Controlled Substances
651 CMR 12.04(14)(a)
Glossary
Abbreviations the state uses without explaining themWhat the residence must doThe residence must send the state a plan to correct each finding, what it will do to keep it from happening again, who is responsible and by when. The state also asked for specific proof, listed here as written.▼
Submit to EOEA the following:
Confirm that all applicable Residents have a current bed-rail assessment.
Documentation that all care staff and nursing have been re-trained on CS policy and procedures.
Confirm the completion of an Introductory Visit for all current care staff with all Residents.
Other notes from the reviewParts of the state's report that do not belong to a single finding, shown as written.▼
EOEA reviewed the records of nine Residents to determine compliance with requirements with SAMM documentation.
Two records were intermittently missing staff initials/signatures or documentation which would indicate the observation of the Residents’ actions regarding the medication (e.g., whether the Resident took or refused the medication, the date and time).