The facility had no psychiatrist on staff when the family made their request. Staff failed to place orders for psychiatric consultation or arrange outside care, despite multiple recommendations from providers.
Resident #4's family expressed concerns about their relative's mental health and specifically requested psychiatric evaluation. The family told inspectors the facility never responded to their request.
A nurse practitioner assessed the resident in late October after learning of the family's concerns. The provider wrote a recommendation for psychiatric care but never entered an order into the system.
"The facility did not have a psych provider in house at the time of the family's request, so they did not put an order into the system," Nurse Practitioner #1 told inspectors during a December telephone interview. They explained they wrote the recommendation so the resident could be seen when a psychiatrist became available.
But the facility already had a history with this resident's psychiatric care that staff apparently didn't communicate.
The resident had previously seen a psychiatrist who recommended follow-up care within two weeks in September 2025. No one placed orders to continue that care.
"They were unaware Resident #4 had been seen by the prior psych provider and would have expected the facility to follow through with the previous recommendation," inspectors wrote about the nurse practitioner's response.
The administrator acknowledged the breakdown. They told inspectors there had been "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."
Communication failures extended beyond staffing shortages. The administrator said they would have expected the nurse practitioner to place a psychiatric consultation order so nursing could follow up. They couldn't explain why the resident had seen psychiatry before without proper orders in place.
The Director of Nursing, who started in September, said they expected social work to complete a follow-up evaluation after learning about the resident's negative statements. If psychiatric care couldn't be arranged quickly, they expected staff to send the resident to the hospital.
"They did not know why there was never an order placed previously for Resident #4 to have a psych consult," inspectors noted about the nursing director's interview.
Instead of psychiatric evaluation, the nurse practitioner started the resident on Namenda, a medication for Alzheimer's symptoms, believing the resident's condition was progressing. They also ordered a urinalysis to check for urinary tract infection.
The provider said they didn't consider the resident a danger to themselves or others, "or else they would have taken more action right away."
But the facility's own policies weren't followed. The Director of Nursing said providers were expected to update unit managers about new orders or recommendations. Nurse Practitioner #1 called this breakdown "an issue they came across at the facility often."
The nurse practitioner had written the psychiatric recommendation in their notes, expecting someone else to follow through when a psychiatrist became available. No one did.
The administrator reviewed the October notes during the inspection and said they would have expected proper orders to be placed for psychiatric consultation. They acknowledged the expectation that an evaluation should have been completed.
Federal inspectors found the facility failed to provide adequate psychiatric services. The violation received minimal harm designation, affecting few residents.
The family's request for mental health care for their relative went unanswered while staff passed responsibility between departments. Communication breakdowns, staffing shortages, and missing orders left the resident without the psychiatric evaluation their family had specifically 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.