Hillcrest Commons: Untrained Nurse Handled Controlled Substances - MA
The finding came during a federal inspection on March 25, 2025. An inspector reviewing the controlled substance register on Unit Two found something missing — no prescription numbers, no dates showing when the drugs had been received from the pharmacy. The nurse who had signed the register, identified in the inspection report as Nurse #9, had been receiving controlled substance counts and was in possession of the drugs.
When the inspector asked about the missing information, Nurse #9 said there was no need to document prescription numbers in the register. She also said there was no need to document when the controlled substances had arrived from the pharmacy.
Nobody had told her otherwise.
Nurse #9 had been hired on March 2, 2025, twenty-three days before the inspection. According to the facility's Staff Development Coordinator, she had not completed the competency evaluation for medication administration. She had not completed the competency for controlled substance documentation either. Both were required before a nurse could be cleared to work the medication cart independently.
The Staff Development Coordinator confirmed all of this to the inspector in a morning interview. Then, in a follow-up conversation that afternoon, she went further: Nurse #9 should not have been in receipt of the controlled substances at all. She should not have been at the medication cart by herself.
The inspection report does not say how many days Nurse #9 had been working the cart alone before the inspector arrived. It does not say how many controlled substance counts she had signed off on, or how long the register had been missing the required documentation. The record shows only what the inspector found on that Tuesday morning: an incomplete register, a nurse who didn't know what was missing from it, and a facility that had placed her there without the required sign-off.
Controlled substance registers exist for a specific reason. Narcotics and other controlled medications are tracked by prescription number and receipt date precisely because those records form the chain of accountability if drugs go missing, are diverted, or are administered incorrectly. A register with neither piece of information is not a record of accountability. It is a signature on a page.
The Staff Development Coordinator did not tell the inspector that the gap had been caught internally before the survey, or that Nurse #9 had been pulled from the cart at any point prior to that morning.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, affecting a small number of residents. That is among the lower severity classifications in the federal rating system. It reflects what inspectors could document, not necessarily what the incomplete records might conceal.
Hillcrest Commons is a nursing and rehabilitation center at 169 Valentine Road in Pittsfield. The inspection was completed March 25, 2025.
Nurse #9, by the account of the facility's own Staff Development Coordinator, was new, was untrained for this task, and was alone with the drugs anyway. When asked why the register lacked prescription numbers and receipt dates, she said she didn't think they were needed.
She had been taught nothing to the contrary.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
HILLCREST COMMONS NURSING & REHABILITATION CENTER in PITTSFIELD, MA was cited for violations during a health inspection on March 25, 2025.
The finding came during a federal inspection on March 25, 2025.
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.