Charter Senior Living of Dedham

• Service and Service Coordination Requirements-Emergency Response
• 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.

Dietary Reviews

• 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.
• Service and Service Coordination- Special Care
• 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.
• General Requirements for an Assisted Living Residence (ALR)-
• 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.

Screening and Assessment

• 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

Service Plan Development and Requirements

• 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.

Bed Rail Assessments

• 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.
• Quality Assurance and Performance Improvement
• 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.

Service Planning

• 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.

Medication Quality Plan

• 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.

Medication administration observation

• 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.

SAMM

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

LMA

• 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.
• Reporting Resident-specific Emergencies- Incident Reports
• 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.
• Controlled Substances
• 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.
• Record Requirements- Personnel Record Requirements
• 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.
• Record Requirements- Correspondence Log
• 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.
• Staffing Requirements-

Staffing Levels

• 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.

Health Screening Requirements

• 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.
• Training Requirements-

Training Needs Assessment

• 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.

General Orientation

• 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.

Supervision

• 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.

LBGTQ Training

• AGE reviewed five personnel records to determine compliance with training requirements.
• Three records were missing documentation to confirm completion of required LGBTQ training.
• Compliance Reviews of Assisted Living Residences- Compliance Review Requirements
• 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.