DFW Nursing & Rehab: Immediate Jeopardy Violations - TX
The incident at DFW Nursing & Rehab on April 23 triggered an immediate jeopardy citation from federal inspectors, who found the facility failed to report or investigate the alleged abuse despite clear policies requiring both actions within two hours.
The resident involved had been recommended for placement on a male-only secured unit at his previous facility due to "multiple complaints and issues regarding inappropriate sexual behavior with staff and residents." His doctor wrote in March that the patient was "no longer safe to remain at the facility given sexual aggression towards other residents."
DFW Nursing & Rehab admitted him anyway.
The Activity Director reported to the Director of Nursing that a student had been touched inappropriately, with another student witnessing the incident. The DON asked if police had been contacted and was told they had already left the scene. She instructed staff to notify the abuse coordinator and placed the resident on 15-minute monitoring.
But the Administrator never opened a formal investigation.
"Since he could not determine what happened from the footage, he did not proceed with a full investigation or report it to the state agency," inspectors wrote. Security camera footage was blocked by a pole, showing only the student jumping back before running from the area.
The Administrator acknowledged that failing to investigate and report incidents of alleged abuse "could place the residents at risk of being harmed."
Multiple residents described an atmosphere of fear around the male resident. One woman called him "a sex offender" and said he "always stared at her while making sexual gestures." Another resident said he would come to her room door and "stick his tongue out, wink, and blow kisses at her."
"A lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it," one resident told inspectors.
The high school visits stopped after the April incident.
A certified nursing assistant who worked with the resident said he "would grab at her breast and thighs while she was showering him, and it made her very uncomfortable." She reported the behavior to the DON, who placed him on two-person care assistance, but "there was not always an extra staff to help when needed."
The evening after the student incident, a man identifying himself as the student's father came to the facility asking to speak to someone about what happened. Staff reported feeling concerned for everyone's safety.
The facility issued an immediate discharge notice but couldn't find placement. The resident's responsible party said she couldn't care for him at home. Three months later, he remained at the facility on hormone medication for hypersexuality, with no psychiatric services ordered.
The Ombudsman opened a case after the resident's family contacted her about the inappropriate discharge attempt to a group home. She reviewed his previous facility records and found the male secured unit recommendation.
"Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit," she told inspectors.
The facility's problems extended beyond sexual misconduct. A second resident was hospitalized in February after staff found him with "weakness abnormal from baseline," pinpoint pupils, confusion, and difficulty talking. Hospital tests revealed marijuana in his system.
That resident had been reported to his parole officer earlier in February for "bringing drugs into the building to sell to other residents." He received a 30-day discharge notice but remained at the facility three months later while his parole officer searched for placement.
Multiple residents reported smelling marijuana regularly throughout the facility, particularly during smoke breaks. The Resident Council President said there was "a lot of talk going around the facility about residents bringing in drugs to use and give to other residents."
One resident admitted ordering THC products delivered to the facility, though she claimed they were for family members. The Administrator said he couldn't search residents' belongings without violating their rights.
When marijuana was smelled during a smoke break, the Administrator stopped that day's session but didn't drug test anyone or investigate further. He "could not state why he did not investigate or report these incidents."
The Director of Nursing acknowledged staff weren't trained to recognize signs of drug use or proper reporting procedures after the incidents.
Federal inspectors found the facility violated multiple regulations around abuse prevention, investigation, and accident prevention. The immediate jeopardy was removed after the facility implemented emergency training on recognizing and reporting abuse, but inspectors determined the corrective systems needed evaluation for effectiveness.
During the inspection, nursing staff described their training on the facility's updated procedures for sexual abuse incidents: removing residents exhibiting inappropriate behaviors from the area, placing them on one-to-one supervision, immediately reporting to the medical director and family, and following new orders.
But the training came only after federal inspectors arrived.
The facility's abuse prevention policy, last revised in January 2011, required staff to "investigate and report any allegations of abuse within timeframes as required by federal requirements." The policy was not followed in either case.
The male resident with sexual behavior issues had not been care-planned for those behaviors upon admission, despite clear documentation in his transfer records. His admission MDS assessment incorrectly indicated he had no physical or verbal behavioral symptoms.
Federal regulations require facilities to code sexual behaviors directed toward others as physical behavioral symptoms on MDS assessments. The facility's MDS coordinator acknowledged that not updating care plans "could place the residents at risk of not getting their care needs met by the facility."
The drug-using resident similarly had no care plan addressing substance abuse, despite documented incidents and hospitalization.
Inspectors interviewed 11 residents during their review, finding no additional signs of abuse or neglect among those at risk. A resident safety survey conducted after the student incident asked 30 residents about abuse and neglect from staff but included no questions about sexual abuse by other residents.
The facility disputed all citations but implemented immediate corrective measures including comprehensive staff training, updated policies for sexual abuse incidents, and enhanced monitoring systems for residents with behavioral issues.
The Administrator and DON acknowledged their responsibilities to identify, report, and investigate suspected abuse, neglect, and exploitation, and to implement effective interventions. They understood the facility's obligation to evaluate the effectiveness of corrective systems.
Three months after the student incident, the male resident remained at the facility. The drug-using resident was still awaiting placement by his parole officer, who had indicated he would either find another facility or the resident would return to jail.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dfw Nursing & Rehab from 2025-05-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
DFW Nursing & Rehab in Fort Worth, TX was cited for immediate jeopardy violations during a health inspection on May 20, 2025.
The Activity Director reported to the Director of Nursing that a student had been touched inappropriately, with another student witnessing the incident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at DFW Nursing & Rehab?
- The Activity Director reported to the Director of Nursing that a student had been touched inappropriately, with another student witnessing the incident.
- How serious are these violations?
- These are very serious violations that may indicate significant patient safety concerns. Federal regulations require nursing homes to maintain the highest standards of care. Families should review the full inspection report and consider whether this facility meets their safety expectations.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Fort Worth, TX, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from DFW Nursing & Rehab or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 455881.
- Has this facility had violations before?
- To check DFW Nursing & Rehab's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.