DLC Report Finds Harmful Lack of Proper Care for Patients at Bear Mountain Nursing Facility in Worcester

Understaffing, overmedicating, and isolating practices plague facility’s long-term patients;

Weak state standards; lackluster enforcement contribute to woeful conditions


BOSTON, MA (January 31, 2024): 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.


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Investigation at Bear Mountain at Worcester

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