Williamsville Suburban failed to arrange a psychiatric evaluation for Resident #4 despite months of recommendations from medical providers and explicit requests from family members, according to a December inspection by federal regulators.
The breakdown began in September when a psychiatric provider recommended that Resident #4 return for follow-up care in two weeks. No order was ever placed to make this happen.
By October, family members had grown worried about their loved one's mental health and specifically requested psychiatric care. The facility's nurse practitioner agreed, writing a recommendation on October 28 that Resident #4 should see a psychiatric provider.
But again, no order was placed. No appointment was scheduled. The family heard nothing back.
"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 family told inspectors in December.
The facility's administrator acknowledged the failures during interviews. They said they would have expected an evaluation to be completed and blamed communication problems on having only one social worker for an extended period. "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 also criticized the nurse practitioner's approach. They said when Nurse Practitioner #1 made the psychiatric recommendation in October, "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."
But Nurse Practitioner #1 explained they had a reason for not placing the order. "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, 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."
The nurse practitioner said they were unaware that Resident #4 had been seen by a psychiatric provider before. They said they "would have expected the facility to follow through with the previous recommendation to see psych in two weeks if that was the previous recommendation in September."
"There should have been an order in place already if Resident #4 was being seen by psych," Nurse Practitioner #1 told inspectors. "It was an issue they came across at the facility often."
Instead of arranging psychiatric care, the nurse practitioner started Resident #4 on Namenda, a medication used to treat Alzheimer's symptoms, because they felt there was progression of the resident's disease. They also ordered a urinalysis to check for a urinary tract infection.
The Director of Nursing, who started working at the facility in September, said they expected providers to update unit managers on new orders or recommendations. They said social work should have done a follow-up evaluation after learning about the negative statements "and have nursing send them out to the hospital if they could not be seen by psych in a timely manner."
The nursing director said they didn't know why no order had ever been placed for Resident #4 to have a psychiatric consultation.
Nurse Practitioner #1 told inspectors they didn't feel Resident #4 was a harm to themselves or others, "or else they would have taken more action right away."
But the family's concerns went unaddressed for months. Their request for psychiatric evaluation disappeared into a communication breakdown between departments, leaving their loved one without the mental health care they had specifically sought.
The facility received a minimal harm citation for failing to ensure residents received necessary psychiatric services.
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.