Hillcrest Commons: Weight Loss Unreported to Doctor - MA
That is what inspectors found at Hillcrest Commons Nursing & Rehabilitation Center on Valentine Road during a March 25 survey. The facility failed to ensure the treating provider was notified of the weight loss or was overseeing the resident's nutritional care, according to the inspection report filed with the Centers for Medicare and Medicaid Services.
The resident, identified in inspection records only as Resident #224, had been admitted to Hillcrest Commons in February 2025 with diagnoses including anoxic brain damage, posterior reversible encephalopathy, aphasia, and a gastrostomy, meaning the resident received a significant portion of daily calories through a feeding tube rather than by mouth. Staff assessed the resident as having some difficulty with decision-making in new situations. Between 25 and 50 percent of the resident's caloric intake came from tube feeding.
The weight record tells a stark story. On February 21, the resident weighed 196.6 pounds. By March 4, that number had dropped to 189. The following day, March 5, a second measurement showed 186.6 pounds. That was a loss of more than five percent of body weight in under thirty days, a threshold that should have triggered immediate physician notification.
It didn't.
When the surveyor sat down with Unit Manager #1 on the morning of March 25 to go through the weight records, the unit manager acknowledged the provider should have been made aware and said she would review the file. Thirty-two minutes later, she came back with an answer that raised more questions than it resolved.
The March 5 measurement, she explained, had been a reweigh and was not accepted. A second reweigh was then completed on March 13. But waiting eight days to reweigh a resident who had already crossed the five-percent loss threshold, the unit manager told the surveyor, was not an acceptable timeframe, because the weight could have changed again in that window.
She could find no evidence in the medical record that the provider had ever been notified.
The inspection report covers 36 residents in the survey sample. Inspectors identified this failure for one of them. CMS classified the level of harm as minimal harm or potential for actual harm, its lower tier of deficiency severity.
That classification reflects regulatory language. What it doesn't fully capture is the medical context. Anoxic brain damage, the condition resulting from oxygen deprivation to the brain, leaves patients with limited ability to communicate distress or advocate for themselves. Aphasia compounds that, stripping away the ability to speak or understand language. A resident in that condition, losing weight while partially dependent on a feeding tube, cannot flag the problem to staff. The monitoring systems that exist in a nursing home are, for that resident, the only safeguard.
Those systems failed here. A weight was taken, a threshold was crossed, a reweigh was ordered and then not done for more than a week, and at no point did anyone document that the physician responsible for the resident's care had been brought into the loop.
The unit manager, to her credit, did not dispute any of this when the surveyor walked her through it. She confirmed the gap herself.
What the record cannot answer is how long the resident's nutritional status went without medical oversight, or what, if anything, changed in the weeks between the March 5 measurement and the day inspectors arrived.
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 2, 2026 · Our methodology
HILLCREST COMMONS NURSING & REHABILITATION CENTER in PITTSFIELD, MA was cited for violations during a health inspection on March 25, 2025.
That is what inspectors found at Hillcrest Commons Nursing & Rehabilitation Center on Valentine Road during a March 25 survey.
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.