The administrator, who served as the facility's grievance official, told federal inspectors on December 29 that he communicated investigation findings verbally to complainants. He said he didn't give written results because he wasn't aware the grievance policy required something in writing.
"The policies were all new due to the company change," he told inspectors. He added that none of the administrators he had spoken with gave out written resolutions, and his boss wasn't familiar with that process either.
But the facility's own grievance policy, dated April 2017, clearly states that residents "will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems."
The disconnect left residents in the dark about whether their complaints had been resolved or what actions the facility had taken.
In confidential interviews, residents who had filed grievances told inspectors they never received written findings. Some said they never received verbal investigation findings either and weren't aware if staff they had complained about received education or disciplinary action.
All the residents recalled being interviewed by the administrator to gather additional information about their grievances. But not all remembered him returning to inform them of the outcome or what actions would be taken to correct identified problems.
The facility's grievance logs showed active complaint handling. November records documented five grievances, all with follow-up dates and resolutions noted. December showed seven grievances with similar documentation.
Yet none of the residents who participated in this process received the written closure they were entitled to under facility policy.
The administrator acknowledged that providing written resolutions would be important "so the griever had something to refer to later."
The violation affects residents' fundamental right to voice concerns and receive proper responses. Federal regulations require nursing homes to establish grievance policies and make prompt efforts to resolve complaints without discrimination or reprisal against residents who speak up.
Written responses serve as documentation that complaints were taken seriously and investigated thoroughly. They also provide residents with a record of what corrective actions the facility committed to taking.
The inspection, conducted in response to a complaint, found the facility failed to ensure prompt resolution of grievances for all four residents interviewed about the grievance process.
Federal inspectors cited the facility for failing to honor residents' right to voice grievances and receive proper follow-up. The violation was classified as causing minimal harm or potential for actual harm, affecting some residents.
The administrator's admission that he and other facility leaders weren't familiar with written response requirements suggests the problem may extend beyond individual cases to systemic gaps in grievance handling procedures.
For residents who took the step of filing formal complaints, the lack of written responses meant they had no way to verify whether their concerns were addressed or what specific steps the facility took in response to their grievances.
The facility's policy clearly outlined the requirement for both verbal and written communication of investigation findings. The gap between written policy and actual practice left residents without the documentation they were promised when they chose to speak up about their care concerns.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Western Hills from 2025-12-29 including all violations, facility responses, and corrective action plans.