The family contacted the facility requesting psychiatric evaluation for their relative, identified as Resident #4, who had been making negative statements. The facility never responded to their request.
Federal inspectors found the breakdown occurred across multiple levels of care coordination. Nurse Practitioner #1 assessed the resident after learning of the family's concerns and recommended psychiatric evaluation in an October 28 note. But no order was placed in the system to actually arrange the consultation.
"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," Nurse Practitioner #1 told inspectors during a December 19 telephone interview.
The practitioner started the resident on Namenda, a medication used to treat Alzheimer's symptoms, believing there was progression of the resident's disease. They also ordered a urinalysis to check for urinary tract infection.
But the psychiatric evaluation never materialized.
The facility's administrator acknowledged the breakdown during interviews with inspectors. They said they would have expected an evaluation to be completed and noted that Nurse Practitioner #1 should have placed an order for a psychiatric consultation so nursing staff could follow up.
"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 told inspectors.
The situation became more complicated when inspectors discovered the resident had previously been seen by a psychiatric provider without any order in place. The administrator said they weren't sure why previous psychiatric consultations had occurred without proper documentation.
Nurse Practitioner #1 expressed surprise at learning about the prior psychiatric 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 to see psych in two weeks if that was the previous recommendation in September 2025," according to the inspection report.
The practitioner noted this was "an issue they came across at the facility often."
The Director of Nursing, who started working at the facility in September, said they expected providers to update unit managers about new orders or recommendations. They would have expected social work to conduct a follow-up evaluation after being made aware of the resident's negative statements.
"Have nursing send them out to the hospital if they could not be seen by psych in a timely manner," the Director of Nursing said should have happened.
The nursing director also said they didn't know why no order had been placed previously for the resident's psychiatric consultation.
Despite the concerning behavioral changes that prompted the family's initial request, Nurse Practitioner #1 said they didn't believe the resident posed a harm to themselves or others, "or else they would have taken more action right away."
The inspection revealed a facility where communication gaps between departments left resident care needs unaddressed. Social work understaffing contributed to missed follow-ups, while providers made recommendations that weren't translated into actionable orders.
The family's December interview with inspectors was brief but pointed: they remained concerned about their relative's mental health and confirmed the facility had never responded to their request for psychiatric evaluation.
Federal inspectors cited the facility for failing to ensure residents received necessary psychiatric services, finding the breakdown affected few residents but created potential for actual harm. The violation occurred despite multiple staff members recognizing the need for mental health intervention.
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.