Federal inspectors found DFW Nursing & Rehab violated abuse prevention requirements after the facility's director of nursing claimed she didn't know about the resident's history of sexually inappropriate behavior — even though his previous facility's medical notes explicitly warned about "multiple complaints and issues regarding inappropriate sexual behavior with staff and residents."
The resident, identified in inspection records as a male with dementia, metabolic encephalopathy and other conditions, was admitted in early 2025. His clinical notes from March 21, 2025 at his previous nursing facility stated: "I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors."
On April 23, high school students visiting DFW Nursing & Rehab were participating in activities with residents in the dining area when one student ran out visibly upset. Another student told the activity director that the male resident had grabbed one of the students' thighs.
The activity director immediately removed the resident from the area and reported the incident to the administrator and director of nursing. The resident was placed on 15-minute monitoring and issued an immediate discharge notice. But the facility never found him another placement, and his responsible party said she couldn't care for him at home.
More troubling, the administrator never completed a full investigation or reported the incident to state authorities, despite facility policy requiring both. He told inspectors he reviewed security camera footage but couldn't determine exactly what happened because "a pole blocked the view." He said he only saw the student "jump back then get up and run from the area."
"Since he could not determine what happened from the footage, he did not proceed with a full investigation, report it to the state agency, or notify law enforcement," inspectors wrote. The administrator acknowledged "the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed."
The incident created a pattern of fear among female residents. One resident told inspectors she felt uncomfortable around the male resident, calling him "a sex offender, because he always stared at her while making sexual gestures." She said female residents complained to the administrator and director of nursing, "and they never did anything about it."
Another female resident described the man as "creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her." She said he did this to many female residents, making them all uncomfortable. Though she reported the behavior to her nurse, "Resident #1's behavior did not stop."
The high school students never returned to the facility after the April incident.
Staff also experienced inappropriate sexual contact. A certified nursing assistant told inspectors the resident "would grab at her breast and thighs while she was showering him, and it made her very uncomfortable." She reported this to the director of nursing, who placed the resident on two-person assist for care, "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 with someone about what happened. This "made the staff concerned for the safety of everyone in the facility," the nursing assistant said.
During initial interviews with inspectors on May 16, both the administrator and director of nursing denied knowing about the resident's history of sexually inappropriate behaviors. The director of nursing said she was responsible for reviewing clinical notes before admitting residents but "did not remember seeing" the previous facility's recommendation for a male secured unit.
She told inspectors that if she had seen the recommendation, "she probably would not have admitted Resident #1, or she would have put appropriate interventions in place."
Only when questioned again later that day did the director of nursing acknowledge awareness of the student incident, claiming she "did not know the state surveyor was referring to that incident during the earlier interview."
The facility's own abuse prevention policy, revised in January 2011, required staff to "protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual."
The policy also mandated the facility "identify and assess all possible incidents of abuse" and "investigate and report any allegations of abuse within timeframes as required by federal requirements."
An ombudsman who investigated the case told inspectors she had "deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home." She said the resident "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."
The resident's responsible party confirmed the facility tried to discharge him to a group home after the incident, though she said he "could not help it due to his dementia." She was told she would have to pay for continued one-to-one supervision, which she couldn't afford, and couldn't bring him home.
By mid-May, the facility had started the resident on estradiol, a medication for hypersexuality, and connected him to psychiatric services. His care plan was revised to require two staff members when providing care and to keep him away from female residents during activities and dining "when at all possible."
Federal inspectors declared the situation an immediate jeopardy to resident health and safety on May 19. The facility implemented emergency staff training on recognizing and reporting sexual abuse, established protocols for immediate one-to-one supervision of any resident exhibiting sexual abuse behaviors, and began searching for appropriate placement.
The immediate jeopardy was lifted on May 20 after the facility's corrective actions, but inspectors noted the facility "remained out of compliance" pending evaluation of whether the new systems would be effective.
The resident remained at DFW Nursing & Rehab as of the inspection's completion, with the facility "still looking for proper placement."
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.