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Disturbing conditions at a Worcester nursing home prompt questions of state oversight

Watchdog report cites overmedication, neglect at Bear Mountain

Peter Zalewski’s sister was living at the Bear Mountain at Worcester nursing home. She was hospitalized repeatedly while there due to the poor conditions at the facility.Suzanne Kreiter/Globe Staff

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.

Bear Mountain at Worcester Nursing Home.Suzanne Kreiter/Globe Staff

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.

Peter Zalewski held a photograph of himself and his sister. Suzanne Kreiter/Globe Staff

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 realty. 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.”

This story has been updated to include a comment from Bear Mountain Healthcare.

Jason Laughlin can be reached at jason.laughlin@globe.com. Follow him @jasmlaughlin.