DFW Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at DFW Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF600Oct 14, 2025

  Based on observation, interviews and record reviews, the facility failed to ensure the residents had the right to be free from abuse for 1 of 5 residents (Resident #2) reviewed for abuse, neglect, and or exploitation. The facility failed to ensure Resident #2 was free from repeated resident-to-resident abuse by Resident #3, which occurred on 05/24/2025, 08/17/2025, and 10/03/2025. A past Immediate Jeopardy (IJ) was found on 08/17/25 and the immediacy was removed on 10/05/25. While the IJ was removed on 10/025/25, the facility remained out of compliance at a severity of actual harm due to the facility's need to monitor the effectiveness of their corrective systems. […]

• Immediate jeopardy, patternF656Aug 22, 2025

  Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for4 (Res#1, Res#2, Res#3 and Res#4) of 5 residents reviewed for updated care plans. The facility failed to provide Resident#1,2,3,4 with updated care plans to reflected concerns for health and safety when leaving the facility unsupervised. An IJ was identified on 08/21/25. […]

• Immediate jeopardy, patternF600May 20, 2025

  Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. -The facility failed to ensure Resident #1 was free from deprivation of services and goods abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and prevent him from sexually abusing others, which could lead to harm to himself and others. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. […]

• Immediate jeopardy, patternF607May 20, 2025

  Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. -The facility failed to implement policies and procedures to ensure Resident #1 was free from deprivation of goods and services abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and in-service staff on measures to properly handle the behaviors to prevent Resident #1 from sexually abusing others. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. […]

• Immediate jeopardy, patternF689May 20, 2025

  Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #2) reviewed for accidents. -The facility failed to ensure Resident #2 was provided with adequate supervision to prevent the resident from using nonprescription drugs at the facility. On 2/15/25 Resident #2 was found exhibiting signs of an overdose and was transported to the local hospital where he tested positive for marijuana. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. […]