The social worker at DFW Nursing & Rehab told state inspectors on October 14 that she conducted trauma assessments with Resident #2 after the assaults but took no further action with that information. When asked about referring the victim for psychological evaluation or therapy despite positive responses on the trauma screenings, the social worker said she had not made any referrals because Resident #2 was "known to refuse services in the past such as dental and vision."
But the family had no trouble getting Resident #2 to participate with outside providers.
The assaults occurred on October 3, when Resident #3 attacked Resident #2 multiple times. The social worker acknowledged that Resident #2 had "no real short-term memory from the dementia" and initially acted like she didn't know what happened when EMTs arrived to assess her. Hours later, Resident #2 called her family member and recounted the attacks in detail.
The facility's own administrator said he expected behavioral health services to be offered to residents after they were assaulted by another resident. He told inspectors that staff should follow recommendations from mental health providers who were "in the building on Wednesdays every week" and call on them as needed to alert them to situations that had happened since their last visit.
None of that occurred.
The director of nursing told inspectors that psychology services were available in the facility multiple times per week, but they had not referred Resident #2 for evaluation or services because of her "advanced dementia." The director said the social worker had done trauma screenings but sent no referrals because Resident #2 was "difficult to assess."
Instead, the facility placed Resident #2 on one-to-one monitoring with a staff member. The director of nursing said they wanted to keep an eye on her for safety since she had a history of taking things from other residents, though she had not seen or heard any negative response from Resident #2 about the constant supervision.
Staff were instructed to tell Resident #2 that they were following her around "to keep her company" if she asked why.
The administrator, who had been employed at the facility since September 10, said he felt Resident #2 did not remember the altercation from October 3. But he acknowledged that hours later, she was able to call her family member and provide details about what had happened.
A family member told inspectors that Resident #2 became more withdrawn after the incidents of abuse but returned to baseline shortly after. The family member was "frustrated and concerned" for Resident #2's safety in the facility and focused on finding a suitable place for the resident to relocate.
The social worker said she had not noticed any change in Resident #2's behaviors since Resident #3 was discharged from the facility.
Resident #2 received no behavioral services after each incident. Resident #3 continued to abuse Resident #2 until being discharged.
The facility's own policies required immediate action when residents became abusive or assaultive. The "Unmanageable Residents" policy, revised in April 2010, stated that when a resident's behavior became "abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others," the nurse supervisor or charge nurse must immediately provide for everyone's safety and notify the resident's attending physician for instructions.
The facility's resident rights policy, revised in December 2016, guaranteed residents the right to "a dignified existence," to "be treated with respect, kindness, and dignity," and to "be free from abuse, neglect, misappropriation of property, and exploitation." It also guaranteed residents the right to "communication with and access to people and services, both inside and outside the facility" and to "be supported by the facility in exercising his or her rights."
The inspection found that despite having mental health providers available multiple times per week and a family willing to arrange outside services, facility staff made a unilateral decision that a dementia patient who had been repeatedly assaulted did not need or could not benefit from behavioral health services.
The social worker's reasoning that Resident #2 had previously refused dental and vision services ignored the family's demonstrated ability to help the resident participate with outside providers. The director of nursing's claim that Resident #2 was too difficult to assess contradicted the social worker's completion of trauma assessments that showed positive responses.
The administrator's expectations for staff behavior directly contradicted what actually happened. He told inspectors that staff should have offered behavioral health services, followed mental health provider recommendations, and alerted the weekly mental health team to situations that had occurred. None of those steps were taken.
The family member's observation that Resident #2 became more withdrawn after the assaults suggested exactly the kind of behavioral change that would warrant mental health intervention. But staff either failed to notice or chose not to act on signs of trauma response in a vulnerable resident.
The facility's decision to place Resident #2 under constant surveillance while telling her it was for companionship represented a fundamental misunderstanding of trauma-informed care. Rather than addressing the psychological impact of being repeatedly assaulted, staff focused on physical monitoring and deception about the reasons for increased supervision.
The director of nursing's comment about Resident #2's history of taking things from other residents suggested that staff may have viewed her as partly responsible for the attacks, despite her status as the victim of assault by another resident.
State inspectors determined that the facility's failure to provide appropriate behavioral health services to an assault victim constituted actual harm to few residents. The finding indicates that DFW Nursing & Rehab's policies and procedures for responding to resident-on-resident violence were inadequate and poorly implemented.
The family member's focus on relocating Resident #2 to another facility suggests that the assaults and the facility's inadequate response had destroyed their confidence in the staff's ability to protect vulnerable residents from harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dfw Nursing & Rehab from 2025-10-14 including all violations, facility responses, and corrective action plans.