Inspection·December 1, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Administrator stated at the beginning of October 2025 the facility had converted from paper maintenance request forms to a digital system (TELS). He stated all staff received training on how to use the new system for submitting maintenance requests. He stated the new system allowed himself, the DON, and others at the corporate level to see what issues were being reported to the Maintenance Director.Record review of paper maintenance requests from August and September 2025 reflected none of the environmental issues observed on 10/14/25 had been reported to the Maintenance Director. Record review of the electronic log from TELS for the month of October 2025 reflected none of the environmental issues observed on 10/14/25 had been reported to the Maintenance Director. Interview on 10/14/25 at 10:25 AM, RN A stated maintenance requests were submitted on a paper request form that was then placed in the Maintenance Request binder for maintenance to address. She was not aware of any of the issues found on Halls 500, 600, and 800. She stated the residents needed working toilets and hot water for basic sanitation. Interview on 10/14/25 at 10:40 AM, CNA B stated maintenance requests were submitted on a paper form that was put in the binder for the Maintenance Director to work on. She was not aware of any of the issues on Hall 500. She stated it was important for the residents to have a toilet and hot water to prevent infections and for sanitation. Interview on 10/14/25 at 10:44 AM, RN C stated work orders were placed in the maintenance binder to be fixed. She was not aware of the issues on Halls 100, 200, 300, or 400. She stated the residents needed working toilets, hot water, and safe electrical outlets for safety and infection prevention. Interview on 10/14/25 at 10:48 AM, CNA D stated requests for repairs were placed in the binder for maintenance. She was not aware of the issues on Halls 100 and 300. She stated it was important for residents to have working toilets, hot water, and safe electrical plugs for their safety, comfort, and to prevent infections. Interview on 10/14/25 at 11:00 AM, CNA E stated she did not know how to request for something to be repaired by maintenance. She stated she usually just told the nurse, or the Maintenance Director if she saw him. She stated it was important for the residents to have hot water and flushing toilets for their comfort. Interview on 10/14/25 at 11:13 AM, CNA F stated requests for maintenance were put in their binder at the nurse's station. She was not aware of the issues on Halls 200 and 400. She stated residents needed working toilets and hot water for sanitation and infection reasons. Interview on 10/14/25 at 11:55 AM, Resident #2 stated there were always maintenance issues in the building. He stated when staff were notified about the issues, it took quite a while for things to get fixed. He stated there was never any feedback about whether maintenance knew about the issues, or if there was a wait for parts to be ordered.Interview on 10/14/25 at 12:03 PM, Resident #3 stated there had been no hot water in his bathroom for a while. He stated it made washing his hands uncomfortable. He stated he told the Maintenance Director about the lack of hot water, but he did not know what the status on it was. Interview on 10/14/25 at 12:15 PM, Resident #4 stated his hot water in the bathroom sink ran wide open, and the Maintenance Director had turned it off at the valve under the sink. Resident #4 stated he knew how to turn the valve on when he wanted hot water. Interview on 10/14/25 at 1:00 PM, the Maintenance Director stated he was aware of the sinks that had no water. He stated he had new faucets ordered on 10/06/25, and he was waiting for their delivery. He was not aware of the other issues with the toilets and the electric outlets. He stated staff had been trained on the new TELS system, but the majority still filled out paper forms and put them in the binder. He stated he still checked the binders every morning, and then again before he left for the day. He stated he could not fix things that were not reported to him. He stated he tried to do basic checks weekly on resident rooms but could not always get to them. The Maintenance Director stated it was important for the residents to have safe and functional rooms for their comfort as it was their home. Interview on 10/14/25 at 3:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676132 If continuation sheet Page 2 of 3 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 12/01/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete PM, the DON stated she was not aware of the issues found. She stated staff knew how to use the TELS system. She stated it was supposed to be linked to their electronic record system, but Information Technology was having a hard time making that work. There was a link the staff could click and then sign in to place work orders, but she felt since it was so inconvenient staff were just not reporting anything. She stated it was important to have functioning toilets and hot water for infection control issues as well as basic comfort. Interview on 10/14/25 at 3:12 PM, the Administrator stated staff had been trained on the TELS system before it went live at the beginning of the month, so there was no reason for them not to report anything needing repairs. He stated he would have the DON in-service staff again. The Administrator stated it was important for the residents to have a functional and safe environment for their comfort and for basic sanitation reasons. The Administrator was unable to provide a policy that addressed a safe, comfortable, homelike environment. Event ID: Facility ID: 676132 If continuation sheet Page 3 of 3