Hillcrest Commons: Resident Moved Twice Without Notice - MA
The resident, identified in federal inspection records only as Resident #199, was admitted to the facility in June 2024 after suffering a cerebral infarction that left him with hemiplegia and hemiparesis on his left side. Despite those physical limitations, inspectors noted he had clear speech and was usually able to make himself understood and understand others. He was not someone who couldn't be told what was coming.
He was moved on March 12, 2025. Then again on March 15.
When a federal inspector sat down with him on March 18, Resident #199 said he had been very pleased with his previous room. The facility told his guardian he needed to change rooms. He moved. Then he moved again. He told the inspector it was very frustrating.
The social worker assigned to his case, identified in the report as SW #1, acknowledged in an interview on March 20 that she had spoken with Resident #199's guardian before the room changes. She had not spoken with Resident #199 himself before either move. She had not given him any written documentation before either move.
Then she said something that stopped the inspection in its tracks: she was unaware of any written forms or documentation that was supposed to be provided to a resident before a room change.
A review of his medical record confirmed it. Nothing in writing. No documentation that he had been informed before March 12. No documentation that he had been informed before March 15.
The social worker's explanation for why he was moved at all was straightforward enough: Resident #199 no longer needed ventilator care, so he was transferred to a different unit. A clinical reason, handled administratively, communicated to a guardian. The resident himself was the last to know, both times.
What the inspection record doesn't show is anyone asking Resident #199 what he thought about leaving a room he described as one he was very pleased with. A man who can speak clearly, who can understand what is said to him, who has the capacity to express frustration to a federal inspector, was treated as someone to be informed after the fact, if at all.
The deficiency was cited at a level of minimal harm or potential for actual harm, the lowest tier on the federal scale. Inspectors noted few residents were affected.
That framing, minimal and few, sits uneasily against what Resident #199 actually said. He had moved twice recently. It was very frustrating. He had been pleased with the room he lost. He found out it was gone the way people find out about a lot of things in nursing facilities: after the decision was already made, by someone else, somewhere else, without him.
Hillcrest Commons is located at 169 Valentine Road in Pittsfield. The inspection was completed March 25, 2025.
SW #1 said she was unaware of any written forms that were supposed to be used. That is its own finding, separate from what happened to Resident #199. It means the gap wasn't a one-time oversight. It was a gap in how the facility understood its own obligations, and the social worker responsible for room change notifications didn't know the documentation was supposed to exist.
Resident #199 told the inspector the room changes had been very frustrating. That was March 18. He had moved for the second time three days earlier. Whether he has moved again since, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillcrest Commons Nursing & Rehabilitation Center from 2025-03-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 2, 2026 · Our methodology
HILLCREST COMMONS NURSING & REHABILITATION CENTER in PITTSFIELD, MA was cited for violations during a health inspection on March 25, 2025.
Despite those physical limitations, inspectors noted he had clear speech and was usually able to make himself understood and understand others.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.