Inspection Reports for
Charter Senior Living of Dedham

Emergency call response and Food and dietary services: During August 2025, there were 78 emergency call response times over the 15-minute limit. A Dietary Review was missing for the second half of 2024, and the 2025 Dietary Review lacked the required nutrition-standards statement (repeat finding).

Memory care unit: Main Special Care Residence secure door alarms did not trigger when opened for an extended period of time.

Resident screening and assessment and Resident care plans: Five resident records lacked documentation of independent medication administration ability and Legal Representative assessments. Four records missed documentation of staff access, behaviors, goals, 24-hour staff presence, and signatures. Three records missed service plan reviews within 30 days of residency start and individualized enrichment activities in the SCR. Five records lacked current assessments for bed rail use (repeat finding).

Quality assurance program: Documentation was missing for audits, target dates, responsible persons, and outcomes for 2023 to 2025 calendar years. Observed unsecured medication storage and improper storage of LMA medications. Prescribed LMA medications were missing from two residents' storage units.

Incident reporting: The residence filed 24 incident reports more than 24 hours after the incident or accident occurred (repeat finding).

Controlled medication handling: The Controlled Substance policy lacked a disposal procedure and staff had inconsistent count procedures on the day of the compliance review.

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

Resident records: The Traditional and Special Care Residence correspondence logs did not consistently document all significant or pertinent information.

Staffing and Staff health screening: Documentation confirming quarterly staffing level assessments was missing for all four quarters of 2024. Five personnel records lacked documentation of seasonal influenza vaccinations or declination statements for the 2024/2025 flu season.

Staff training: Documentation of annual training needs assessments was missing for 2024. Five staff records lacked General Orientation documentation. Four Personal Care staff records lacked biannual skills evaluations for 2024 and 2025. Three records lacked documentation of required LGBTQ training.

Compliance review process: The residence did not provide requested documentation and records to AGE by the completion of the compliance review, including e-call response times and reviews for December 2024.