DLC Report Finds Harmful Lack of Proper Care for Patients at Bear Mountain Nursing Facility in Worcester
Disability Law Center, January 31, 2024
Understaffing, overmedicating, and isolating practices plague facility’s long-term patients; Weak state standards; lackluster enforcement contribute to woeful conditions
The Disability Law Center, Inc. (DLC), the Commonwealth’s Protection and Advocacy system, today released an investigative report detailing harmful practices at the Bear Mountain Worcester nursing facility. The report finds the facility, part of a large for-profit healthcare group, demonstrates a detrimental lack of proper patient care. Understaffing, overmedication, and neglect are among the practices of concern highlighted in the report.
The report, the result of a two-year investigation into complaints originating from patients and their families, outlines the worries of those skeptical of the facility’s safekeeping of their loved ones. The federal Nursing Home Reform Act (NHRA) sets standards for ensuring proper care for nursing home residents for a facility to be deemed operable. DLC found many NHRA violations that also constituted abuse or neglect under the statutes that protection and advocacy systems utilize when conducting investigations.
“Our investigation uncovered deeply troubling practices at Bear Mountain’s Worcester facility. The treatment of patients in this facility violates their rights and reflects a wider issue within the industry,” said Nina Loewenstein, lead author of the report and Senior Attorney at DLC. “It’s imperative that immediate action be taken to ensure the safety and well-being of these vulnerable residents.”
In their research, DLC uncovered evidence of a reliance on antipsychotic drugs, questionable schizophrenia diagnoses, isolation, a lack of effective interdisciplinary behavior plans, and minimal engagement with patients in the neuro-behavioral unit. These typically derive from a severe lack of staffing and clinical expertise at facilities, a common issue within the industry, particularly among for-profit providers. The facility lacks any nursing staff who are trained and credentialed in psychiatric nursing, lacks a psychologist, and most importantly, lacks on-site psychiatric and neurological consultations.
Additionally, DLC found that patients have been routinely medicated with multiple antipsychotics and other psychotropic medications, raising compelling questions as to whether this is a consequence of the facility’s understaffing and lack of adequate training and oversight. This practice is prevalent within the neurobehavioral unit, where patients with varying diagnoses, including brain injuries, anxiety, depression, dementia, trauma, and similar behavioral health conditions, reside. The unit comprises two locked floors within Bear Mountain Worcester and is not frequented by other residents.
The report also notes that guardians and families of residents have reported widespread, serious infections spreading on site, as well as known rodent infestation and unclean communal spaces. Many residents are unable to report these hazardous conditions themselves.
In response to DLC’s audit, Bear Mountain has agreed to make changes within the facility, including working to certify identified staff on the neurobehavioral unit as certified brain injury specialists through the Brain Injury Association of Massachusetts, as well as conducting a 3-hour Fundamentals of Behavior Management course and an Applied Behavioral Analysis course. Additionally, Bear Mountain is refurbishing its van to facilitate offsite social and community activities, including offering special trips, such as personalized shopping trips, and increasing the number of therapeutic programs offered to residents, related to money management, activities of daily living, hygiene, social skills, and education about healthy eating and exercise.
“The conditions at Bear Mountain have been appalling. It has been a dire situation, and we must hold the Commonwealth accountable for its duty to inspect and ensure proper care in these facilities,” said Barbara L’Italien, Executive Director of DLC, the Commonwealth’s Protection and Advocacy (P&A) system and a nonprofit organization advocating for human rights, empowerment, and justice for people with disabilities.
DLC’s research shows negligence and misconduct are common issues in for-profit healthcare facilities. Their report informs that staffing nursing homes is often a costly endeavor with little return for the investor. Therefore, operating with as few staff as possible is often preferred within the for-profit nursing home sector. Nearly two-thirds of all Massachusetts nursing homes are for-profit.
“Patients and families trusted Bear Mountain to provide proper care, and the facility has failed them time and again,” said Rick Glassman, Director of Advocacy for DLC. “Our research unequivocally shows that the Commonwealth must promptly and carefully examine the negligent or abusive practices at Bear Mountain in Worcester. We are grateful to Bear Mountain for their cooperation in our review and the measures they are taking to improve their facility and we appreciate new state policies to oversee the use of antipsychotics. Our position remains that the Commonwealth is duty-bound to inspect these facilities with an eye towards identifying root causes of deficiencies. Also, the state must impose more rigorous sanctions and corrective action plans when necessary. In this instance, they have not done so.”
DLC’s report includes recommendations that the Commonwealth should take to ensure the well-being of the residents at the facility. These include requiring clinical expertise in psychiatry and neurology; requiring robust multi-disciplinary behavior plans; and limiting enhanced compensation of specialized facilities to those settings which adhere to enhanced standards of care. The Commonwealth must also ensure the facility is providing training for direct care staff in neurological care and psychotropic medications, as well as human-centered approaches to care and behavioral management; hiring sufficient staff to provide consistent quality care and maintaining basic hygiene; ensuring that residents and legal representatives understand the risks and benefits of medications; and investing in homelike environments and therapeutic spaces with resident involvement and choice. It is also recommended that Bear Mountain restore transportation services to community settings, including shopping and parks, and provide programming to develop activities and skills of daily living and vocational and education counseling.
DLC conducted six site visits from October 2021 until October 2023. During this time, DLC observed the facility’s conditions, reviewed patient records, and interviewed residents and staff, including facility administrators and behavioral health staff from the outside agency providing behavioral health services at Bear Mountain. A psychiatric nurse, a neuropsychiatrist and former nursing home administrator familiar with audits and reviews assisted DLC as experts in assessing the nursing home and final recommendations.
Download the Disability Law Center Report on “A Failure of Care:
An Investigation of the Neurobehavioral Unit at Bear Mountain at Worcester”
*Boston Globe, January 31, 2024
By The Editorial Board
The report, while difficult to read, cries out for a response — from Bear Mountain and the state.
A nursing home can be a supportive environment for elderly residents to live out their last years with companionship and medical care. It can alternatively be a place where vulnerable people with severe physical and mental health needs are warehoused and neglected.
A report released Wednesday by the Disability Law Center examining a neurobehavioral unit at Bear Mountain nursing home in Worcester illuminates in stark terms what allegedly happens when people with schizophrenia, dementia, and other ailments are left alone, with few programs and inadequate staffing. The Disability Law Center writes, speaking broadly about nursing home patients, “They become vulnerable to abuse and neglect because of inadequate staffing and clinical expertise, excessive use of medication, substandard conditions, and prolonged isolation.”
The report, while difficult to read, cries out for a response — from Bear Mountain and the state. Lawmakers and state administrators have responded to nursing homes’ financial needs by increasing reimbursement rates. But as the report points out, rates need to be paired with oversight to ensure the money is going to provide at least a minimal standard of care.
Advocates with the Disability Law Center, which has legal authority to monitor Massachusetts organizations serving people with disabilities, said they began scrutinizing Bear Mountain because of complaints about staffing. But the issues identified are emblematic of larger problems. “You have a for-profit long-term health care system taking people who are complicated and for whom nursing homes aren’t primarily prepared to be caring for,” said Nina Loewenstein, senior attorney for the Disability Law Center.
Arlene Germain, cofounder of Dignity Alliance Massachusetts, which advocates for nursing home reforms, said it is problematic that as more nursing homes establish behavioral health or other specialty units, regulations haven’t kept pace. While there are statewide standards and staffing rules for nursing homes in general, there are no state standards establishing the level of staffing and training required to run specific specialty units, like those focused on behavioral health.
Bear Mountain at Worcester, one in a chain of nursing homes, has about 140 residents, most with Medicaid insurance and complex behavioral needs. It has consistently been given the federal government’s lowest one-star ranking. The 82-page report, covering the period between October 2021 and October 2023, examines a neurobehavioral unit housing about 70 residents with cognitive disabilities, psychiatric disorders, and brain injuries. It found a litany of problems, mostly involving understaffing, neglect, and overuse of psychotropic medications.
The report found that the facility consistently had staffing ratios below federal recommendations and occasionally below Massachusetts’ minimum standards for nursing homes. Between 35 percent and 54 percent of nursing staff left each year. Residents’ family members said there were weekends when one certified nursing assistant was responsible for an entire 35-person floor and residents who needed help getting up were left in bed. The report said staff lacked sufficient training in behavioral health care.
A 2022 Department of Public Health inspection cited in the DLC report found residents who were dehydrated, had long nails and unbrushed teeth, and were not fully clothed. State inspectors discovered medication errors and staff who failed to properly handle feeding tubes and treat wounds. During the audit period, several residents were hospitalized for infections. Visitors from the Disability Law Center found undressed and ungroomed residents, dirty floors, and smells of urine. Resident activities were minimal, and outdoor space was scant.
The home had high rates of residents receiving psychotropic medication and a lack of robust medical oversight to manage medications, the report found. In several case files reviewed by the DLC, residents appeared to be overmedicated while denied therapy or programs.
Bear Mountain attorney Allison Lennon, in a written response to the Disability Law Center, said the nursing home vehemently denies the allegations, which it said, “are not grounded in fact and, in many respects, are based on overgeneralizations and inferences gleaned from outdated data and reports unrelated to the Facility.” Lennon said Bear Mountain acquired the struggling nursing home just before the COVID-19 pandemic hit and improved its performance despite staffing challenges. She said the home provides specialized and trained staff; has medical oversight of medications; adequately cares for patients’ health needs; and started offering more programming.
While the burden is on Bear Mountain to improve care, the Department of Public Health must provide robust oversight. The report found that one DPH inspection of Bear Mountain was delayed six months due to staffing constraints at DPH and inspectors lacked clinical expertise. When issues were identified, they were not always addressed.
In a written response, Health and Human Services Secretary Kate Walsh said the agency is “engaged in a multi-year initiative across multiple agencies to improve quality of care in nursing facilities,” including improving screening when residents enter a home, ensuring residents have access to necessary services, and offering resources to help residents leave nursing homes. The agency is reworking MassHealth rates and conducting audits related to antipsychotic medication, Walsh wrote.
The DLC report advocates for statewide licensing requirements for behavioral health units to ensure units have enough trained staff to meet residents’ needs. It suggests conditioning higher Medicaid rates for complex patients on facilities demonstrating they have adequate treatment resources. (MassHealth officials reject this approach, arguing that giving extra money to any facility with complex patients preserves consumer choice and geographic access.)
The Massachusetts House in November passed a comprehensive bill aimed at improving nursing home quality. As the Senate deliberates, the Disability Law Center report provides a blueprint for additional changes that could be incorporated.
Bear Mountain is not the only one-star nursing home in Massachusetts. Residents deserve better.
*Boston Globe, January 31, 2024
By Jason Laughlin
Watchdog report cites overmedication, neglect at Bear Mountain
Residents of a for-profit Worcester skilled nursing facility were subjected to inadequate care and neglect that in some cases left the patients with complex neurological or behavioral conditions languishing and dangerously ill, according to a state watchdog agency.
The conditions found at the facility, Bear Mountain at Worcester, raise new concerns that for-profit nursing care companies prioritize revenue over patient well-being, according to a report released Wednesday by the Disability Law Center in Boston. The report also concluded that state oversight of the nursing home industry is inadequate and that Medicaid financially rewards providers who take in patients with complicated needs without ensuring they receive proper care.
“It is another example of the public not getting what they paid for,” said Rick Glassman, the director of advocacy for the Disability Law Center.
The report caps a two-year review of Bear Mountain that began in October 2021 after the center received reports of low staffing, overmedication, and neglect at the Worcester facility, which houses up to 140 people. The facility specializes in the care of people with such neurobehavioral conditions as traumatic brain injury, schizophrenia, and dementia. The concerns raised included understaffing, inadequate staff expertise, and an overreliance on medication to treat patients.
In some cases, investigators found appalling conditions: rodent infestations and patients partially dressed; some patients lying in bed without even a television for stimulation.
In a statement, Bear Mountain Healthcare, which owns 17 facilities in Massachusetts and New Hampshire, said the Worcester facility provides high-quality care that’s subject to scrupulous oversight.
“Bear Mountain takes the report seriously and will consider it in its ongoing efforts to improve the quality of care delivered to its residents,” the statement said.
In a response to the law center, it disputed the findings and emphasized that when it bought the Worcester nursing home in 2019 from Wingate, a national chain, the facility was poorly rated. Only a few months later, the company said, it contended with the COVID-19 pandemic and is still struggling to absorb staff reductions due to the crisis.
The law center report included details about a patient with schizoaffective disorder, Parkinson’s, and chronic kidney disease who became increasingly immobile, incontinent, and emaciated during her stay at Bear Mountain. She spent much of 2022 in and out of hospitals, including for a case of septic shock, said her brother, Peter Zalewski of Gardner. At one point she weighed about 80 pounds, he said.
Bear Mountain wasn’t equipped or staffed to provide the care that might have helped her, the report stated, and as her condition deteriorated it never acted with urgency to address and treat the causes of her decline. After one hospital stay, the woman returned with a discharge plan that was ignored, according to the report.
Zalewski and his family were desperate to find another nursing facility for her, but many are reluctant to accept residents with mental health conditions, he said. Finally, after one hospitalization in late 2022, the family found a home in Fitchburg that would take her. Now, Zalewski said, his sister uses the bathroom on her own, gets around with a walker, and is independent enough to take the bus to stores.
“They almost killed her,” he said. “The whole thing was a nightmare.”
Investigators found signs the Worcester facility overmedicated residents, which Bear Mountain denied, relying on drugs when activities or programs could benefit patients. One patient with traumatic brain injury received antipsychotics for decades even though she does not have psychotic symptoms, the report said. The nursing facility didn’t have justifications for some diagnoses and treatment, the report stated.
Bear Mountain stated in its response to the review investigation that patients’ behavioral difficulties can make maintaining grooming and dressing a challenge. It has pest control in the building four days a week, it said, but must contend with an 80-year-old building and some residents with hoarding tendencies.
The Massachusetts Department of Public Health inspected Bear Mountain in 2022 and found 93 deficiencies but did not conduct another inspection until 18 months later — a concerning delay, according to the law center’s report, though the state noted that it also responded to complaints in those years, contributing to surveyors’ presence on site four times in 2022 and six times in 2023. Also concerning, the center’s report said, was that the state surveyors lacked the clinical expertise to evaluate the quality of the medical diagnoses and treatment residents received. The survey teams comply with federal qualification requirements, the state said.
The Worcester home relies heavily on Medicaid for payments, and MassHealth’s reimbursement policies incentivize companies that care for patients with complicated conditions, including behavioral symptoms. MassHealth, though, does not have mechanisms in place to ensure that extra money is translating into the care the population needs, said Nina Loewenstein, a lawyer with the law center and an author of the report.
“There’s a real public responsibility on the part of the state to be providing ongoing, strong oversight,” Loewenstein said.
The state’s Executive Office of Health and Human Services, in its response to the law center’s report, said it is implementing steps to better identify and track patients with significant mental illness, and will do more to help those residents able to leave a nursing setting to transition to other living arrangements. The state office noted it has penalized the Worcester nursing home for understaffing.
State Senator Pat Jehlen, a member of the Joint Committee on Elder Affairs, said the report’s findings were a call to action.
“There’s a need to require that there be regulations about these specialized units,” said Jehlen, a Somerville Democrat.
During the law center investigation, there were signs of improvements at Bear Mountain, with staff added. But significant concerns still exist.
“Even if Bear Mountain has improved, it remains in the bottom 3 percent of Massachusetts nursing homes,” in the Executive Office of Health and Human Services’ evaluation of facilities statewide, the report stated.
Bear Mountain is owned by Sabra Healthcare REIT, a publicly traded investment company focused on health care reality. The involvement of for-profit investors, real estate investment trusts, such as Sabra, and private equity in health care has become an increasingly urgent concern in Massachusetts. Private equity is playing a role in everything from slow wheelchair repairs to poor health care at state prison facilities. Steward Health Care, which faces a financial crisis that threatens its Massachusetts hospitals, is owned by a private equity firm.
In a response to the law center’s report, Bear Mountain stated, “the implication that the Bear Mountain corporate structure somehow limits the resources that the facility can use to improve the quality of life and care for its residents could not be further from the truth.”
The law center’s report, though, asserts that when private equity firms or real estate investment trusts such as Sabra enter health care, that ownership structure shapes decisions that affect care.
“It gets to the point where the system is basically broken,” said Jim Lomastro, a former nursing home administrator on the coordinating committee of the Dignity Alliance, a Massachusetts advocacy group for seniors and people with disabilities. “The state is really going to have to look at putting a lot of resources in to get this system back in shape.”