The facility's own administrator admitted they "would have expected an evaluation to have been completed" for Resident #4 after the family raised mental health concerns. Instead, the resident went months without the psychiatric consultation the family had specifically requested.
The breakdown started with a nurse practitioner's recommendation in October. Nurse Practitioner #1 wrote that Resident #4 should see a psychiatric provider, but never entered an actual order into the system. Without an order, nursing staff couldn't follow up.
"They would have expected Nurse Practitioner #1 to have put an order in for a psych consult so that nursing could follow up on it," the administrator told inspectors during a December interview.
The facility blamed staffing problems for the communication failure. "There was a good chunk of time recently that the facility only had one social worker, so things were not communicated correctly, and some things were missed," the administrator explained.
But the problems ran deeper than understaffing. Records showed Resident #4 had previously seen a psychiatric provider in September, with a recommendation to return in two weeks. That follow-up never happened either.
"They were not sure why Resident #4 had seen psych prior without an order in place," the administrator admitted, acknowledging the facility's own confusion about its psychiatric care protocols.
Nurse Practitioner #1 defended their approach during a phone interview with inspectors. They said the facility didn't have a psychiatric provider available when the family made their request, so they wrote a recommendation instead of placing an order.
"They did not put an order into the system, but did write a recommendation for Resident #4 to see a psych provider so that when the facility had one, Resident #4 could be seen," according to the inspection report.
The nurse practitioner also revealed this was a recurring problem. They told inspectors "it was an issue they came across at the facility often" - the lack of proper psychiatric care orders for residents who needed mental health services.
Meanwhile, Resident #4's condition appeared to be declining. The nurse practitioner started them on Namenda, a medication used to treat Alzheimer's symptoms, because they felt there was "a progression of their disease."
The Director of Nursing, who started working at the facility in September, said they would have handled the situation differently. They told inspectors they "would have expected social work to do a follow up evaluation on Resident #4 after being made aware of their negative statements, and have nursing send them out to the hospital if they could not be seen by psych in a timely manner."
The director also couldn't explain why there was never a proper psychiatric order in place for Resident #4, despite the resident's apparent history of psychiatric care needs.
Throughout this period, the family remained in the dark about their loved one's care. During a phone interview with inspectors, Resident #4's family said "they were concerned with Resident #4's mental health and had requested them to be seen by a psych provider, the facility never got back to them on the request."
The nurse practitioner insisted they didn't consider Resident #4 an immediate danger. "They did not feel Resident #4 was a harm to themselves or others, or else they would have taken more action right away."
But that assessment missed the point. The family had specifically asked for psychiatric evaluation because of their concerns about their loved one's mental state and negative statements. The facility's failure to arrange that care - or even communicate about the delay - left both the resident and family without answers for months.
The facility's own staff acknowledged the system had failed. Between communication breakdowns, staffing shortages, and confusion over psychiatric care protocols, Resident #4 never received the mental health evaluation their family had requested.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Williamsville Suburban, L L C from 2025-12-22 including all violations, facility responses, and corrective action plans.