AUSTIN, TX - A federal health inspection completed on May 10, 2025, at Coral Rehabilitation and Nursing of Austin found the facility in immediate jeopardy, the most serious level of deficiency that indicates residents faced significant risk of harm requiring urgent corrective action.
Immediate Jeopardy Designation Issued
The inspection, conducted in response to a complaint, resulted in a citation under F740, which pertains to behavioral health services for nursing home residents. The finding was classified as causing "immediate jeopardy to resident health or safety" and affected multiple residents at the facility located at 6909 Burnet LN in Austin.
Immediate jeopardy is the highest severity level that federal surveyors can assign to a nursing home deficiency. This designation is reserved for situations where the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. When surveyors identify immediate jeopardy, facilities must take rapid corrective action to protect residents.
The inspection documentation indicates that the deficiency was identified on May 8, 2025, prompting the facility to hold an emergency Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting the same day. The facility set an expected compliance date of May 8, 2025, indicating they began implementing corrective measures immediately upon the finding being identified.
Behavioral Health Services Under Scrutiny
The F740 citation specifically addresses the facility's obligation to provide appropriate behavioral health care and services to residents. Federal regulations require nursing homes to ensure residents receive necessary behavioral health services, including appropriate referrals to psychiatric services, monitoring of behaviors, and implementation of care interventions.
According to the inspection findings, the facility's behavioral health protocols came under examination, particularly regarding how staff identify, report, and respond to resident behavioral changes. The documentation reveals a systematic review of the facility's processes for psychiatric referrals and behavioral monitoring.
During interviews conducted on May 10, 2025, the Social Worker at the facility stated that "the expectation was to send psych service referrals for residents with a psychiatric diagnosis or behavior medications evaluations for residents with behaviors when admitted and as needed." The Social Worker further indicated that the expectation was to "follow up on all referrals within two to three days."
The inspection revealed gaps in the facility's execution of these protocols. When nursing homes admit residents with psychiatric diagnoses or behavioral concerns, timely referral to psychiatric services is essential. Delays in psychiatric evaluation can leave residents without appropriate medication management or behavioral interventions, potentially leading to symptom exacerbation, distress, or dangerous behaviors.
Psychiatric Consultation and Monitoring Requirements
The Psychiatric Nurse Practitioner interviewed during the inspection stated he had observed Resident #1 on May 9, 2025, and found the resident to be stable. He indicated that "staff were expected to follow the facility's policy if a resident exhibited new behaviors. Staff were expected to deescalate the resident, notify appropriate parties, and provide psych services."
The Nurse Practitioner outlined plans to see the affected resident weekly for several weeks to monitor medication effectiveness, with plans to reevaluate the frequency of visits based on the resident's response to treatment.
This approach aligns with standard psychiatric care protocols in long-term care settings. Residents receiving new psychiatric medications or experiencing behavioral changes require close monitoring to assess medication efficacy, identify side effects, and adjust treatment plans accordingly. Weekly visits during initial treatment phases help ensure rapid identification of problems and timely intervention.
Staff Training and Competency Verification
In response to the findings, the facility conducted extensive staff education sessions on May 8 and 9, 2025. The documentation indicates that multiple in-service training programs were implemented across all facility departments.
Abuse and Neglect Training: Records show that 1 RN, 9 LVNs, 6 Medication Aides, 20 CNAs, 10 dietary staff, 12 housekeeping staff, 1 maintenance aide, and 7 therapy staff received in-service training on abuse and neglect policies and procedures. This comprehensive training included both direct care staff and support personnel, reflecting the facility-wide nature of abuse prevention responsibilities.
Behavioral Care and Services Training: Nursing and care staff, including 1 RN, 9 LVNs, 6 Medication Aides, and 20 CNAs, received specialized training on behavioral care and services in Texas nursing homes. The training was conducted in person or by telephone by the Administrator, Director of Nursing, and Assistant Director of Nursing.
Documentation Training: Nursing staff received education on proper documentation practices, an essential component of behavioral health care. Accurate documentation of resident behaviors, interventions attempted, and outcomes achieved is critical for continuity of care and regulatory compliance.
New Admission Procedures: The Social Worker and nursing staff received training on reviewing diagnoses in a timely manner and referring residents to psychiatric services when indicated.
Training Content and Objectives
The Regional Director of Operations conducted training for facility leadership on May 8, 2025, focusing on behavioral care and services for residents and the importance of following up on psychiatric referrals after they are submitted.
The in-service training materials outlined several key objectives for staff, including:
- Recognizing common behavioral and psychological symptoms in residents - Responding effectively and compassionately to behavioral issues - Understanding the role of the interdisciplinary team in behavioral health care - Following documentation best practices - Implementing non-pharmacological approaches as first-line interventions
The training emphasized that behavioral care is an integral component of holistic resident care and that interdisciplinary collaboration leads to better outcomes for residents with behavioral health needs.
Competency Verification and Ongoing Monitoring
Following the initial training sessions, staff members were interviewed to verify comprehension of the training content. From May 10, 2025, surveyors interviewed staff from all shifts, including the Assistant Director of Nursing, Licensed Vocational Nurses, Certified Nursing Assistants, Medication Aides, the Social Worker, and the Housekeeping Supervisor.
All interviewed staff members demonstrated knowledge of abuse and neglect reporting requirements, identifying the Administrator as the facility's Abuse Coordinator and understanding the need to report suspected abuse immediately. Staff members also articulated their responsibilities regarding behavioral monitoring and reporting, including the need to report new behaviors or increases in behavioral frequency to the charge nurse.
The Administrator stated during her interview on May 10, 2025, that she expected psychiatric referrals to be sent in a timely manner when residents with psychiatric diagnoses were admitted. She confirmed that the Social Worker was responsible for following up on referrals to ensure services were provided. Importantly, she indicated that the facility had "implemented audit tools and now monitored for compliance."
These audit tools were designed to monitor compliance with the facility's communication procedures for contacting physicians and confirming orders on behavioral health matters, representing a systematic approach to preventing future lapses.
Resident Observation and Current Status
Surveyors conducted direct observation of Resident #1, who was identified in the inspection narrative as being at the center of the incident that triggered the immediate jeopardy finding. On May 10, 2025, at 3:39 PM, Resident #1 was observed sitting calmly in her wheelchair with no signs or symptoms of distress. When asked, the resident stated she was fine before moving away.
A Certified Nursing Assistant assigned to monitor Resident #1 confirmed she was specifically tasked with observing the resident for behaviors such as yelling, throwing things, or being aggressive towards others. The CNA reported that none of these behaviors were exhibited by the resident during the monitoring period.
This one-on-one monitoring represents an appropriate intervention for residents who have exhibited concerning behaviors, allowing for immediate staff response if behaviors recur while the resident's psychiatric treatment plan is optimized.
Medical Context: Why Behavioral Health Services Matter
Behavioral health care in nursing homes addresses a critical need. Many nursing home residents have psychiatric diagnoses, dementia-related behavioral symptoms, or adjustment difficulties that can manifest as agitation, aggression, or other concerning behaviors. Without appropriate psychiatric evaluation and treatment, these conditions can escalate, placing the affected resident and others at risk.
Delays in psychiatric referrals can have significant consequences. Residents experiencing untreated psychiatric symptoms may have poor quality of life, difficulty participating in their care, and increased risk of altercations with other residents or staff. Appropriate psychiatric intervention, including medication management and behavioral strategies, can dramatically improve outcomes.
The emphasis on non-pharmacological approaches as first-line interventions, as outlined in the facility's training materials, reflects current best practices in geriatric behavioral health. Environmental modifications, structured activities, consistent routines, and de-escalation techniques should be attempted before or alongside medication interventions.
Industry Standards and Regulatory Framework
Federal regulations under the Medicare and Medicaid programs require nursing homes to ensure residents receive medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This includes timely referrals to specialty services, including psychiatric care, when clinically indicated.
The Centers for Medicare and Medicaid Services expects facilities to have systems in place to identify residents needing behavioral health services, initiate appropriate referrals, follow up to ensure services are provided, and monitor resident response to treatment. The immediate jeopardy finding in this case suggests surveyors identified deficiencies in one or more of these systemic components.
Additional Issues Identified
The inspection documentation indicates that the surveyor conducted a comprehensive review of facility practices related to behavioral health services. Key areas examined included:
- Referral Timeliness: The facility's procedures for initiating psychiatric referrals upon admission and when behavioral changes occur - Follow-up Protocols: Systems for tracking referral status and ensuring psychiatric services are actually provided - Communication Procedures: Processes for contacting physicians and confirming orders related to behavioral health matters - Documentation Practices: Recording of behavioral observations, interventions, and outcomes
The facility's corrective actions addressed each of these areas through targeted training, implementation of audit tools, and enhanced monitoring procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Retirement and Nursing Center Austin from 2025-05-10 including all violations, facility responses, and corrective action plans.
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