Health inspection·November 19, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to the activity room and then began to kick the activity room door when it closed and at that time CNA A came out of the activity room and told everyone around to step back as she sprayed pepper spray on the back of Resident #1's head. The notes also reflected that Resident #1 had called the police after the incident, and the resident had refused a head-to-toe assessment or have the pepper spray washed off his head until the police arrived at the facility. The notes reflected RN B observed multiple small clear liquid scattered on Resident #1's head and once the 2 police men left, the resident allowed RN B to assess/wash his head and she did not notice any redness, bruises, or a rash to Resident #1's head nor did he complain of burning or irritation to his eyes and his speech was clear. Record review of Resident #1's hospital records dated 11/16/25 reflected the resident was seen for toxic effect of lacrimogenic gas (tear gas), assault, initial encounter. Further review of the hospital records reflected there were no injuries documented and no further orders. Observation and interview on 11/18/25 at 10:31 AM revealed Resident #1 was sitting in a wheelchair outside in the courtyard patio socializing with a female resident. CNA C sat near the residents monitoring them. Resident #1 was moved to another part of the patio for a private conversation. Resident #1 stated a staff member (CNA A) had sprayed him with [NAME]. He stated it happened out of nowhere, and he denied having an altercation with CNA A. The resident stated he was going down the hall and CNA A was staring at him, and then all a sudden he had to back out because the CNA was coming at him with the [NAME]. The resident said he was sprayed on the back of the head with [NAME], and some had gotten in his eyes. He stated that both areas began to burn. After CNA A sprayed him with the [NAME], he stated he called the police. He stated he later went to the hospital due to the burning sensation. Interview on 11/18/25 at 12:06 PM, RN B revealed Resident #1 had been placed on one-to-one supervision a few days prior to the incident on 11/16/25 due to an unrelated incident. RN B said the morning of 11/16/25, Resident #1 started having verbal behaviors towards CNA C, who was providing one-to-one supervision. RN B stated Resident #1 began to yell, curse, and call the staff around him names including RN B. RN B stated as Resident #1 began to go down another hall, she instructed CNA C to follow behind the resident at a distance in case Resident #1 became physically aggressive. As the resident and CNA C got further down the hall, RN B said she heard people raising their voices. RN B stated she heard Resident #1 yell and curse again. She stated there were multiple staff present including CNA A. RN B said as Resident #1 continued to yell and curse, she heard CNA A call 911 due to the resident's behaviors. RN B stated CNA A claimed Resident #1 had swung at another staff member at that time (Housekeeper D). RN B said the police came to the facility and spoke with Resident #1 and CNA A. The police left the facility, and the resident remained calm for the next few hours. RN B said sometime after lunch, she heard people screaming. She stated she went down the hall, and she noticed Resident #1 had some liquid dots on the back of his head. She stated staff around the resident were coughing. At that time both Resident #1 and CNA A were calling the police. RN B stated someone, whom she did not recall, stated that CNA A had sprayed Resident #1 with pepper spray. RN B said she tried to assess Resident #1, but he would not allow her to wash the back of his head until he spoke with the police. After the police completed their visit at the facility, RN B said Resident #1 allowed her to wash his head and face. She stated she did not notice any redness or swelling to his eye or the back of his head. RN B said after a while, Resident #1 stated he wanted to be sent to the emergency room because the back of his head, neck, and eyes were burning. The resident was sent to the hospital, and he returned from the hospital with no new orders. Interview on 11/18/25 at 12:46 PM, CNA C revealed she was asked to provide one-to-one supervision to Resident #1 related to previous behaviors. CNA C said the morning of 11/16/25 Resident #1 was upset and began to curse and insult her along with other staff. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated RN B told her to keep her distance from the resident as she monitored him, in case he became physically aggressive. CNA C said a few hours later after lunch, Resident #1 was in the television room and requested to be pushed back to his room because it was too loud. CNA C stated as they passed the activity room, Resident #1 saw CNA A sitting in the room. As soon as Resident #1 saw CNA A, he went into the activity room. CNA C stated Resident #1 and CNA A began to argue. CNA C said she did not understand what was going on. She stated the only thing she understood or heard was CNA A tell Resident #1, Get your ass in here! CNA C said she stood back and watched as Resident #1 and CNA A argued. She then stated suddenly, the activity room door closed, and Resident #1 wheeled backwards. She stated Resident #1 began to kick the activity room door. At that time, the activity room door opened, and CNA A came out and yelled, Everybody move! Everybody move! CNA C stated CNA A then sprayed something in the direction of Resident #1. CNA C said whatever CNA A sprayed made them all cough. CNA C stated she heard someone say it was pepper spray. CNA C said she saw some liquid spots to the back of Resident #1's head, and he said it burned. She stated Resident #1 was taken to his room and assessed by RN B. CNA C said the verbal altercation went on for a while, but she did not know for how long. CNA C revealed she did not try to intervene because she was in shock, so she just stood back and watched. CNA C acknowledged if she had intervened, Resident #1 might not have been sprayed with [NAME] by CNA A. CNA C also revealed she did not inform the Administrator she had not attempted to intervene during the verbal altercation between Resident #1 and CNA A. CNA C stated she was just confused by it all, and she did not know what to do. Interview on 11/18/25 at 1:12 PM, CNA A revealed the morning of 11/16/25 Resident #1 had been in a rage, but she did not know what started it. CNA A said she heard Resident #1 yelling and cursing, so she asked Housekeeper D and Dietary Aide E to assist her. She stated they were male staff, and she thought Resident #1 would respond better to them. CNA A said Resident #1 was yelling, cursing, and calling her names. She stated Resident #1 said to her, Bitch, you are the one I don't like. CNA A said Houskeeper D tried to calm the resident down, but Resident #1 swung at Houskeeper D. CNA A stated the resident then rolled towards her in his wheelchair as he cursed at her. CNA A stated she called 911 because she felt threatened by the resident. CNA A said the police showed up at the facility and spoke to the resident. CNA A stated the police told her they could not do anything to the resident because he had only made verbal threats. CNA A stated the police told her she could call them back if Resident #1 touched her. She stated they advised her to keep her distance from the resident. Later that day after lunch, CNA A stated she was taking her lunch break in the activity room. She stated she saw CNA C pushing Resident #1 in his wheelchair. She stated as they were passing by the activity room, she heard Resident #1 say, Wait a minute. Is that who I think it is? She stated CNA C rolled Resident #1 back to the activity room, and the door to the room was slightly open. Resident #1 proceeded to open the door, and he rolled inside. She stated Resident #1 told her, Bitch, you can't hide from me! I'll kill you and beat you ass! CNA A said at that time she called the Activity Director to tell her she was in her office/room, and she was afraid for her safety because Resident #1 was threatening her and had been all day. CNA A said she kept yelling at Resident #1 to stay away and get out of the room, but the resident continued to yell and curse at her. CNA A stated the verbal exchange went on for several minutes, but she did not recall the exact amount of time. CNA A said she told Resident #1 if he did not leave her alone, she would [NAME] him. CNA A said Resident #1 then stood up out of his wheelchair. CNA A stated her purse was right in front of her, so she pulled out her [NAME]. CNA A stated Resident #1 sat back in his wheelchair and rolled backwards out of the room, and she closed the door. Resident #1 then began kicking the door, so she opened the door, came out of the room, and told everyone to get back as she sprayed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 with [NAME]. CNA A said she recalled Resident #1 turning his head as she sprayed him, and the [NAME] got the side and back of his head. CNA A stated she then went back into the activity room and closed the door again. CNA A said there were other people in the area, but she could not recall who. She stated soon after the incident, she was told she needed to clock out and go home and she had not returned to work. CNA A further stated CNA C, who was providing Resident #1 with one-to-one supervision, never intervened nor did CNA C remove Resident #1 from the area or call other staff for help. Interview on 11/19/25 at 8:49 AM with Housekeeper D revealed the morning of 11/16/25 he was cleaning the dining room when he heard CNA A yell for him. Resident #1 had rolled up on CNA A cursing at her and called her terrible names and CNA A wanted his help to try to calm down Resident #1. Housekeeper D said he attempted to calm the resident down by talking to him, but Resident #1 swung at him striking his arm, so Houskeeper D said he stepped away and let RN B take over. Housekeeper D said when Resident #1 hit him in the arm, CNA A told the resident she was going to call the police. Interview on 11/18/25 at 1:38 PM with the Social Worker revealed the morning of 11/16/25 around 9:00 AM, she saw the police at the facility, and it was her understanding CNA A had called 911 because Resident #1 has been verbally aggressive and threatening. The police told CNA A they could not do anything to Resident #1 unless he became physically aggressive. At about 1:00 PM the Social Worker said she was asked to go to the activity room, did not recall by who, and she saw several people gathered around the room coughing and someone said Resident #1 had been pepper sprayed by CNA A. The Social Woker said the only person she could recall being there was RN B and another CNA but did not recall who. She called the Administrator who told her to send CNA A home. The Social Worker further stated she did not see anything on Resident #1's face/head, nor did he complain of any discomfort other than a cough. Interview on 11/18/25 at 2:06 PM, the Administrator revealed he was called on 11/16/25 and told CNA A called the police early in the morning due to Resident #1's behavior and the police were called again after lunch that same day. The Administrator said after lunch, there appeared to be some verbal exchange between Resident #1 and CNA A and that Resident #1 had tried to kick CNA A, so the CNA told everyone to stand back, and she pulled out pepper spray and sprayed Resident #1. The Administrator said the resident had been sent to the hospital for further evaluation but there did not appear to be any harm. He further stated he was not aware CNA C did not intervene or that she had been a spectator during the verbal exchange between Resident #1 and CNA A. The Administrator stated CNA C did tell him both the resident and CNA A had exchanged words but was not able to understand what was being said. The Administrator said if CNA C did not try to intervene, then they should have in-serviced the staff about that too. Interview on 11/18/25 at 6:04 PM with CNA F revealed the morning of 11/16/25, Resident #1 was yelling and cursing at staff and had been harassing CNA A to the point that CNA A told Resident #1 that if he kept going up to her like that she would go to her car to get her pepper spray. CNA F said she did not tell anyone about the threat that CNA A made about the pepper spray because she claimed, everyone heard, but did not specify who. CNA F said sometime after lunch she heard commotion and loud profanity; Resident #1 was insulting CNA A and CNA A was yelling back at the resident to leave the room. CNA F said as she went down the hall, she saw Resident #1 kick at CNA A and then saw Resident #1 back up and then the activity room door slammed shut as the resident continued to kick the door. At that time, CNA A was seen coming out of activity room and said everyone step back as she sprayed Resident #1 with pepper spray and the people around including the resident, began to cough. CNA F said the whole commotion/verbal exchange lasted about 5 minutes. Interview on 11/19/25 at 9:55 AM with the Activity Director revealed on 11/16/25 around 1:00 PM she received a call from CNA A who stated she was in her office/activity room and fearful for her life (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few because Resident #1 was in the same room with her threatening her. CNA A told the Activity Director that Resident #1 has been on a rampage since 9:00 AM and she did not understand why CNA C had wheeled him in her direction. The Activity Director said that while she was talking to CNA A on the phone, she heard Resident #1 say you can call whoever you want and cursed her and called her names. The Activity Director said during Resident #1 and CNA A's verbal exchange she heard CNA A say, you need to back up or I will spray you. The Activity Director said she was trying to help CNA A calm down and asked her what other staff were around, and CNA A said, I don't know but he needs to get out of my face. The Activity Director said she lived nearby and told CNA A she was on her way and when she got off the phone the Activity Director contacted the Social Worker, who was at the facility to let her know she needed to get to the activity room. The Activity Director looked at her phone and said the phone call with CNA A during her exchange with Resident #1 lasted 8 minutes. Interview on 11/19/25 at 10:38 AM, CNA G revealed the morning of 11/16/25 Resident #1 became upset because he asked CNA C personal questions and CNA C told him she did not wish to talk about her personal life because she was just there to take care of him. CNA G said Resident #1 became belligerent and began to curse at CNA C. Resident #1 went towards another hallway where he saw CNA A and the resident was trying to roll up on CNA A while Housekeeper D tried to calm Resident #1 down. Resident #1 began to curse and yell at CNA A and CNA A then said, if you run up on me again, I'm going to [NAME] you. CNA G said she did not report the threat CNA A made because she assumed other people around heard her. Later around 1:00 PM, CNA G said she was in another hall when she heard what appeared to be people fighting so when she followed the commotion, [NAME] had already been sprayed because people were coughing including Resident #1. Interview on 11/19/25 at 4:14 PM, the Administrator revealed he was not aware other staff overheard CNA A threaten Resident #1 with pepper spray. The Administrator said if he would have known about the threat made earlier in the day, he would have suspended CNA A and the whole incident could have been avoided. Interview on 11/19/25 at 4:41 PM, the ADON revealed she had gotten a phone call from CNA A the morning of 11/16/25 stating Resident #1 was attacking everyone so CNA A had called 911. The ADON said she spoke with RN B who said Resident #1 was not hitting everyone but had hit Housekeeper D when he tried to calm the resident down. The ADON said she got a phone call from RN B a few hours later and was told CNA A had maced Resident #1 and the police had been called again. The ADON said no one told her they had overheard CNA A threaten Resident #1 with [NAME] or she would have been told to go home at that time. Record review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 reflected the following: Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical and chemical restraint not required to treat the resident's symptoms.1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff. This was determined to be a Past Non-Compliance Immediate Jeopardy on 11/18/25 at 5:20 PM. The Administrator, DON, Regional VP of Operations, Regional Nurse Consultant, and the Director of Regulatory Relations were notified. The Administrator was provided with the IJ template on 11/18/25 at 5:56 PM. The facility took the following actions to correct the non-compliance prior to the survey: Observation on 11/18/25 at 7:55 PM of Resident #1 revealed he remained on one-to-one supervision, and the CNA was assisting the resident in the shower room. Interview on 11/19/25 at 4:41 PM, the Administrator revealed CNA A remained suspended after she was told to go home after the incident with Resident #1. Record review of Record of Employee Counseling dated 11/18/25 reflected CNA C reflected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the following: .Details of Situation: The incident involving resident [Resident #1], [CNA C] should have immediately removed resident from harm .Expectations/Outcome: To immediately remove any resident from situations that would put resident in harm's way. Record review of the in-services dated 11/16/25 reflected staff were educated/re-educated on Resident Rights, Burnout, Staff not able to carry defense paraphernalia to include pepper spray and other weapons, abuse neglect, and crisis intervention and de-escalation. Review of the sign-in sheets also reflected CNA C had been provided with each of the inservices. The following staff from various shifts were interviewed on 11/19/25 from 9:55 AM to 4:41 PM. RN B, CNA C, Housekeeper D, Dietary Aide E, CNA F, Activity Director, CNA G, ADON, RN I, Housekeeper J, Transport, MA K, Receptionist, Housekeeper L, RN M, CNA N, [NAME] O, Dietary Aide P, MA Q, Dietary Aide R, CNA S, CNA T, CNA U, CNA V, CNA W. The staff were able to define and recognize signs/symptoms of burnout, Resident Rights to include the residents had the right to be free from abuse, Abuse/neglect - verbalize the different type of abuse and who to report if they see abuse, staff were able to verbalize they are not allowed to carry weapons in resident rooms to include pepper spray and [NAME], Crisis Intervention/de-escalation of behaviors. Recognizing agitation in residents, techniques to calm them down, staff are not to engage with agitated residents and remove the resident from any dangers or altercation and if the resident is not able to be moved, remove the staff member, if a staff member is involved. The noncompliance was identified as past noncompliance. The noncompliance began on 11/16/25 and ended on 11/18/25. The facility had corrected the noncompliance before the investigation began. Event ID: Facility ID: 676132 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse and neglect, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility for 1 of 3 residents reviewed for abuse and neglect. CNA F and CNA G failed to report to the Administrator when they overheard CNA A threaten to [NAME] Resident #1 during a verbal altercation the morning of 11/16/25. Four hours later, the resident entered into a verbal altercation with CNA A, which escalated to CNA A spraying [NAME] at the resident. The noncompliance was identified as past noncompliance. The noncompliance began on 11/16/25 and ended on 11/18/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of incidents of abuse or neglect not being reported timely and thoroughly investigated.Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included bipolar disorder (a chronic mental health condition characterized by extreme mood swings, energy level shifts, and difficulty with activity levels, ranging from manic episodes to depressive episodes), schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves, causing a distorted perception of reality), and spinal stenosis (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves, causing symptoms like back and leg pain, numbness, tingling, and weakness). The residents' cognition was intact with a BIMS score of 15. The resident had other behavioral symptoms not directed towards others at least 4 to 6 days during the assessment review period but less than daily. Those behavioral symptoms included but were not limited to physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds and had the potential to interfere with the resident's participation in activities or social interactions. These behavioral symptoms had the potential to put others at significant risk of physical injury and/or significantly intrude on the privacy or activity of others. The MDS also showed that Resident #1 used a wheelchair due to impairment on both sides to his lower extremities. Record review of Resident #1's care plan revised on 11/12/25 reflected he had a mood problem related to the disease process of bipolar disorder. Interventions included administering medications as ordered, consulting behavioral health, and monitor/record/report to MD mood patterns, signs/symptoms of depression, anxiety, sad mood, impulsiveness or euphoria as per facility behavior monitoring protocols. Record review of the Provider Investigation Report dated 11/21/25 reflected the following: [Resident #1] was around the Activity room arguing with [CNA A]. [CNA A] sprayed resident with pepper spray to the back side of head Record review of Resident #1's progress notes dated 11/16/25 documented by RN B reflected she was at the nurses' station when she heard people yelling/fighting and hear Resident #1 say CNA A had sprayed pepper spray to the back of his head. Other residents and staff in the area were coughing. RN B documented CNA C, who was providing 1:1 supervision told her (RN B) that Resident #1 had gone to the activity room and then began to kick the activity room door when it closed and at that time CNA A came out of the activity room and told everyone around to step back as she sprayed pepper spray on the back of Resident #1's head. The notes also reflected that Resident #1 had called the police after the incident, and the resident had refused a head-to-toe assessment or have the pepper spray washed off his head until the police arrived at the facility. The notes reflected RN B observed multiple small clear liquid scattered on Resident #1's head and once the 2 police men (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few left, the resident allowed RN B to assess/wash his head and she did not notice any redness, bruises, or a rash to Resident #1's head nor did he complain of burning or irritation to his eyes and his speech was clear. Record review of Resident #1's hospital records dated 11/16/25 reflected the resident was seen for toxic effect of lacrimogenic gas (tear gas), assault, initial encounter. Further review of the hospital records reflected there were no injuries documented and no further orders. Observation and interview on 11/18/25 at 10:31 AM revealed Resident #1 was sitting in a wheelchair outside in the courtyard patio socializing with a female resident. CNA C sat near the residents monitoring them. Resident #1 was moved to another part of the patio for a private conversation. Resident #1 stated a staff member (CNA A) had sprayed him with [NAME]. He stated it happened out of nowhere, and he denied having an altercation with CNA A. The resident stated he was going down the hall and CNA A was staring at him, and then all a sudden he had to back out because the CNA was coming at him with the [NAME]. The resident said he was sprayed on the back of the head with [NAME], and some had gotten in his eyes. He stated that both areas began to burn. After CNA A sprayed him with the [NAME], he stated he called the police. He stated he later went to the hospital due to the burning sensation. Interview on 11/18/25 at 12:06 PM, RN B revealed Resident #1 had been placed on one-to-one supervision a few days prior to the incident on 11/16/25 due to an unrelated incident. RN B said the morning of 11/16/25, Resident #1 started having verbal behaviors towards CNA C, who was providing one-to-one supervision. RN B stated Resident #1 began to yell, curse, and call the staff around him names including RN B. RN B stated as Resident #1 began to go down another hall, she instructed CNA C to follow behind the resident at a distance in case Resident #1 became physically aggressive. As the resident and CNA C got further down the hall, RN B said she heard people raising their voices. RN B stated she heard Resident #1 yell and curse again. She stated there were multiple staff present including CNA A. RN B said as Resident #1 continued to yell and curse, she heard CNA A call 911 due to the resident's behaviors. RN B stated CNA A claimed Resident #1 had swung at another staff member at that time (Housekeeper D). RN B said the police came to the facility and spoke with Resident #1 and CNA A. The police left the facility, and the resident remained calm for the next few hours. RN B said sometime after lunch, she heard people screaming. She stated she went down the hall, and she noticed Resident #1 had some liquid dots on the back of his head. She stated staff around the resident were coughing. At that time both Resident #1 and CNA A were calling the police. RN B stated someone, whom she did not recall, stated that CNA A had sprayed Resident #1 with pepper spray. RN B said she tried to assess Resident #1, but he would not allow her to wash the back of his head until he spoke with the police. After the police completed their visit at the facility, RN B said Resident #1 allowed her to wash his head and face. She stated she did not notice any redness or swelling to his eye or the back of his head. RN B said after a while, Resident #1 stated he wanted to be sent to the emergency room because the back of his head, neck, and eyes were burning. The resident was sent to the hospital, and he returned from the hospital with no new orders. Interview on 11/18/25 at 12:46 PM, CNA C revealed she was asked to provide one-to-one supervision to Resident #1 related to previous behaviors. CNA C said the morning of 11/16/25 Resident #1 was upset and began to curse and insult her along with other staff. She stated RN B told her to keep her distance from the resident as she monitored him, in case he became physically aggressive. CNA C said a few hours later after lunch, Resident #1 was in the television room and requested to be pushed back to his room because it was too loud. CNA C stated as they passed the activity room, Resident #1 saw CNA A sitting in the room. As soon as Resident #1 saw CNA A, he went into the activity room. CNA C stated Resident #1 and CNA A began to argue. CNA C said she did not understand what was going on. She stated the only thing she understood or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few heard was CNA A tell Resident #1, Get your ass in here! CNA C said she stood back and watched as Resident #1 and CNA A argued. She then stated suddenly, the activity room door closed, and Resident #1 wheeled backwards. She stated Resident #1 began to kick the activity room door. At that time, the activity room door opened, and CNA A came out and yelled, Everybody move! Everybody move! CNA C stated CNA A then sprayed something in the direction of Resident #1. CNA C said whatever CNA A sprayed made them all cough. CNA C stated she heard someone say it was pepper spray. CNA C said she saw some liquid spots to the back of Resident #1's head, and he said it burned. She stated Resident #1 was taken to his room and assessed by RN B. CNA C said the verbal altercation went on for a while, but she did not know for how long. CNA C revealed she did not try to intervene because she was in shock, so she just stood back and watched. CNA C acknowledged if she had intervened, Resident #1 might not have been sprayed with [NAME] by CNA A. CNA C also revealed she did not inform the Administrator she had not attempted to intervene during the verbal altercation between Resident #1 and CNA A. CNA C stated she was just confused by it all, and she did not know what to do. Interview on 11/18/25 at 1:12 PM, CNA A revealed the morning of 11/16/25 Resident #1 had been in a rage, but she did not know what started it. CNA A said she heard Resident #1 yelling and cursing, so she asked Housekeeper D and Dietary Aide E to assist her. She stated they were male staff, and she thought Resident #1 would respond better to them. CNA A said Resident #1 was yelling, cursing, and calling her names. She stated Resident #1 said to her, Bitch, you are the one I don't like. CNA A said Houskeeper D tried to calm the resident down, but Resident #1 swung at Houskeeper D. CNA A stated the resident then rolled towards her in his wheelchair as he cursed at her. CNA A stated she called 911 because she felt threatened by the resident. CNA A said the police showed up at the facility and spoke to the resident. CNA A stated the police told her they could not do anything to the resident because he had only made verbal threats. CNA A stated the police told her she could call them back if Resident #1 touched her. She stated they advised her to keep her distance from the resident. Later that day after lunch, CNA A stated she was taking her lunch break in the activity room. She stated she saw CNA C pushing Resident #1 in his wheelchair. She stated as they were passing by the activity room, she heard Resident #1 say, Wait a minute. Is that who I think it is? She stated CNA C rolled Resident #1 back to the activity room, and the door to the room was slightly open. Resident #1 proceeded to open the door, and he rolled inside. She stated Resident #1 told her, Bitch, you can't hide from me! I'll kill you and beat you ass! CNA A said at that time she called the Activity Director to tell her she was in her office/room, and she was afraid for her safety because Resident #1 was threatening her and had been all day. CNA A said she kept yelling at Resident #1 to stay away and get out of the room, but the resident continued to yell and curse at her. CNA A stated the verbal exchange went on for several minutes, but she did not recall the exact amount of time. CNA A said she told Resident #1 if he did not leave her alone, she would [NAME] him. CNA A said Resident #1 then stood up out of his wheelchair. CNA A stated her purse was right in front of her, so she pulled out her [NAME]. CNA A stated Resident #1 sat back in his wheelchair and rolled backwards out of the room, and she closed the door. Resident #1 then began kicking the door, so she opened the door, came out of the room, and told everyone to get back as she sprayed Resident #1 with [NAME]. CNA A said she recalled Resident #1 turning his head as she sprayed him, and the [NAME] got the side and back of his head. CNA A stated she then went back into the activity room and closed the door again. CNA A said there were other people in the area, but she could not recall who. She stated soon after the incident, she was told she needed to clock out and go home and she had not returned to work. CNA A further stated CNA C, who was providing Resident #1 with one-to-one supervision, never intervened nor did CNA C remove Resident #1 from the area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few or call other staff for help. Interview on 11/19/25 at 8:49 AM with Housekeeper D revealed the morning of 11/16/25 he was cleaning the dining room when he heard CNA A yell for him. Resident #1 had rolled up on CNA A cursing at her and called her terrible names and CNA A wanted his help to try to calm down Resident #1. Housekeeper D said he attempted to calm the resident down by talking to him, but Resident #1 swung at him striking his arm, so Houskeeper D said he stepped away and let RN B take over. Housekeeper D said when Resident #1 hit him in the arm, CNA A told the resident she was going to call the police. Interview on 11/18/25 at 1:38 PM with the Social Worker revealed the morning of 11/16/25 around 9:00 AM, she saw the police at the facility, and it was her understanding CNA A had called 911 because Resident #1 has been verbally aggressive and threatening. The police told CNA A they could not do anything to Resident #1 unless he became physically aggressive. At about 1:00 PM the Social Worker said she was asked to go to the activity room, did not recall by who, and she saw several people gathered around the room coughing and someone said Resident #1 had been pepper sprayed by CNA A. The Social Woker said the only person she could recall being there was RN B and another CNA but did not recall who. She called the Administrator who told her to send CNA A home. The Social Worker further stated she did not see anything on Resident #1's face/head, nor did he complain of any discomfort other than a cough. Interview on 11/18/25 at 2:06 PM, the Administrator revealed he was called on 11/16/25 and told CNA A called the police early in the morning due to Resident #1's behavior and the police were called again after lunch that same day. The Administrator said after lunch, there appeared to be some verbal exchange between Resident #1 and CNA A and that Resident #1 had tried to kick CNA A, so the CNA told everyone to stand back, and she pulled out pepper spray and sprayed Resident #1. The Administrator said the resident had been sent to the hospital for further evaluation but there did not appear to be any harm. He further stated he was not aware CNA C did not intervene or that she had been a spectator during the verbal exchange between Resident #1 and CNA A. The Administrator stated CNA C did tell him both the resident and CNA A had exchanged words but was not able to understand what was being said. The Administrator said if CNA C did not try to intervene, then they should have in-serviced the staff about that too. Interview on 11/18/25 at 6:04 PM with CNA F revealed the morning of 11/16/25, Resident #1 was yelling and cursing at staff and had been harassing CNA A to the point that CNA A told Resident #1 that if he kept going up to her like that she would go to her car to get her pepper spray. CNA F said she did not tell anyone about the threat that CNA A made about the pepper spray because she claimed, everyone heard, but did not specify who. CNA F said sometime after lunch she heard commotion and loud profanity; Resident #1 was insulting CNA A and CNA A was yelling back at the resident to leave the room. CNA F said as she went down the hall, she saw Resident #1 kick at CNA A and then saw Resident #1 back up and then the activity room door slammed shut as the resident continued to kick the door. At that time, CNA A was seen coming out of activity room and said everyone step back as she sprayed Resident #1 with pepper spray and the people around including the resident, began to cough. CNA F said the whole commotion/verbal exchange lasted about 5 minutes. Interview on 11/19/25 at 9:55 AM with the Activity Director revealed on 11/16/25 around 1:00 PM she received a call from CNA A who stated she was in her office/activity room and fearful for her life because Resident #1 was in the same room with her threatening her. CNA A told the Activity Director that Resident #1 has been on a rampage since 9:00 AM and she did not understand why CNA C had wheeled him in her direction. The Activity Director said that while she was talking to CNA A on the phone, she heard Resident #1 say you can call whoever you want and cursed her and called her names. The Activity Director said during Resident #1 and CNA A's verbal exchange she heard CNA A say, you need to back up or I will spray you. The Activity Director said she was trying to help (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few CNA A calm down and asked her what other staff were around, and CNA A said, I don't know but he needs to get out of my face. The Activity Director said she lived nearby and told CNA A she was on her way and when she got off the phone the Activity Director contacted the Social Worker, who was at the facility to let her know she needed to get to the activity room. The Activity Director looked at her phone and said the phone call with CNA A during her exchange with Resident #1 lasted 8 minutes. Interview on 11/19/25 at 10:38 AM, CNA G revealed the morning of 11/16/25 Resident #1 became upset because he asked CNA C personal questions and CNA C told him she did not wish to talk about her personal life because she was just there to take care of him. CNA G said Resident #1 became belligerent and began to curse at CNA C. Resident #1 went towards another hallway where he saw CNA A and the resident was trying to roll up on CNA A while Housekeeper D tried to calm Resident #1 down. Resident #1 began to curse and yell at CNA A and CNA A then said, if you run up on me again, I'm going to [NAME] you. CNA G said she did not report the threat CNA A made because she assumed other people around heard her. Later around 1:00 PM, CNA G said she was in another hall when she heard what appeared to be people fighting so when she followed the commotion, [NAME] had already been sprayed because people were coughing including Resident #1. Interview on 11/19/25 at 4:14 PM, the Administrator revealed he was not aware other staff overheard CNA A threaten Resident #1 with pepper spray. The Administrator said if he would have known about the threat made earlier in the day, he would have suspended CNA A and the whole incident could have been avoided. Interview on 11/19/25 at 4:41 PM, the ADON revealed she had gotten a phone call from CNA A the morning of 11/16/25 stating Resident #1 was attacking everyone so CNA A had called 911. The ADON said she spoke with RN B who said Resident #1 was not hitting everyone but had hit Housekeeper D when he tried to calm the resident down. The ADON said she got a phone call from RN B a few hours later and was told CNA A had maced Resident #1 and the police had been called again. The ADON said no one told her they had overheard CNA A threaten Resident #1 with [NAME] or she would have been told to go home at that time. Record review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 reflected the following: Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical and chemical restraint not required to treat the resident's symptoms. Review of the facility's Abuse and Neglect education provided to the staff reflected the following: .Report suspected abuse immediately to the Abuse Coordinator (Administrator) if not available DON or supervisor when neither is available. This was determined to be a Past Non-Compliance Immediate Jeopardy on 11/18/25 at 5:56 PM. The Administrator was provided with the IJ template on 12/04/25 at 9:00 AM. The facility took the following actions to correct the non-compliance prior to the survey: Interview on 11/19/25 at 4:41 PM, the Administrator revealed CNA A remained suspended after she was told to go home after the incident with Resident #1. Record review of Record of Employee Counseling dated 11/18/25 reflected CNA C reflected the following: .Details of Situation: The incident involving resident [Resident #1], [CNA C] should have immediately removed resident from harm .Expectations/Outcome: To immediately remove any resident from situations that would put resident in harm's way. Record review of the in-services dated 11/16/25 reflected staff were educated/re-educated on Resident Rights, abuse and neglect. Review of the sign-in sheets also reflected CNA C had been provided with each of the inservices. The following staff from various shifts were interviewed on 11/19/25 from 9:55 AM to 4:41 PM. RN B, CNA C, Housekeeper D, Dietary Aide E, CNA F, Activity Director, CNA G, ADON, RN I, Housekeeper J, Transport, MA K, Receptionist, Housekeeper L, RN M, CNA N, [NAME] O, Dietary Aide P, MA Q, Dietary Aide R, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Fort Worth 7100 Trail Lake Dr Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Immediate jeopardy to resident health or safety CNA S, CNA T, CNA U, CNA V, CNA W. The staff were able to define abuse/neglect - verbalize the different type of abuse and who to report if they see abuse. The noncompliance was identified as past noncompliance. The noncompliance began on 11/16/25 and ended on 11/18/25. The facility had corrected the noncompliance before the investigation began. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 12 of 12