Aviva River Bend.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the residents when resident #2 pushed resident #1 causing her to fall requiring hospitalization related to multiple fractures. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although, resident #2 did push resident #1 causing fractured bones there was no incidents prior to this one to indicate resident #2 would physically cause harm to another resident. R2’s service plan did include interventions The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted family members. The investigation included review of the resident’s records, facility internal investigation, facility incident reports, staff schedules, related facility policy and procedures. Also, the investigator made an onsite visit to observe staff interaction with residents and memory care floor plan. Resident #1 Resident #1 resided in an assisted living memory care unit. The resident’s diagnoses included dementia. The service plan indicated resident #1 was independent with transfers, wandered within the facility but did not have a history of jeopardizing. Resident #1 was able to follow directions but did require verbal cues or short directions from staff. While walking, resident #1 required prompts or cues but did not require hands-on assistance with no history of behavioral concerns. Resident #2 Resident #2 resided in an assisted living memory care unit. The resident’s diagnoses included severe dementia with agitation. Resident #2’s facility records indicated the resident is a recent admission and has documented bouts of agitation with interventions effectively used. The service plan indicated resident #2 required prompts or cues for safety while ambulating but did not require hands on assistance. Resident #2 was alert and oriented to self only. Due to disorientation, resident #2 required frequent verbal prompts and/or direction from caregivers although there was a reported history of aggression towards others. Incident One evening an unlicensed caregiver heard yelling between two residents and went to resident #1’s room where resident #1 was found on the floor with resident #2 present in the room. Resident #2 told the caregiver she had shoved resident #1. Resident #1, who was in lying on the floor and complaining of pain, told the caregiver resident #2 had pushed her. Resident #2 was removed from the area immediately while 911 was called to transport resident #1 to the emergency department. Interviews During an interview, nurse #1 stated resident #2 did not exhibit aggression towards other residents until this actual incident. Nurse stated resident #2 was verbal aggressive towards staff members and would refuse cares but did not strike out. On admission resident #2 was appropriate for admission with a service plan appropriate for cares. Caregivers did report resident #2’s verbal aggression towards them and interventions were in place to address this concern. Nurse #1 stated the exact details of the incident were unknown as it was unwitnessed by any caregiver although the facility followed up promptly once the incident became known. During an interview, nurse #2 stated resident #2 spent a lot of time out in the common area of memory care sitting in a chair. Nurse #2 stated resident #2 would mumble incoherently and was not easily understood. There had been no prior behaviors such as this. Resident #1 was not aggressive and did walk with a walker. During an interview, the unlicensed caregiver stated on the day of the incident resident #2 was agitated and wandering nonstop in common area and in other resident rooms. Caregiver stated she kept an eye on resident as she wandered and provided redirection. Caregiver stated when providing care to other residents that day unable to be with resident #2 all the time. The caregiver stated staff complete multiple trainings regarding handling behaviors and residents will have care planned interventions. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: NA, deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: NA the Action taken by facility: Resident #2 was transferred from the facility the evening of the incident and did not return to the facility. Action taken by the Minnesota Department of Health: No further action. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 11/06/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 31368 08/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30 SILVER LAKE PLACE NW AVIVA RIVER BEND ROCHESTER, MN 55901 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On August 25, 2025, through August 26, 2025, the Minnesota Department of Health initiated an investigation of complaint #HL313688149C/#HL313684202M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 FIZS11 If continuation sheet 1 of 1

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. Furthermore, the follow-up survey determined your facility had not corrected all of the state correction orders issued pursuant to the May 24, 2024, initial survey. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a), state correction orders issued pursuant to the last survey completed on May 24, 2024, found not corrected at the time of the September 25, 2025, follow-up survey and/or subject to a penalty assessment are as follows: 1370-Training And Evaluation Of Unlicensed Personn-144g.61 Subd. 2 (a) 1380-Training And Evaluation Of Unlicensed Personn-144g.61 Subd. 2 (b) 1760-Documentation Of Administration Of Medication-144g.71 Subd. 8 1910-Disposition Of Medications-144g.71 Subd. 22 The details of the violations noted at the time of this follow-up survey completed on September 25, 2024, (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. An equal opportunity employer. Letter ID: 292I_Revised 04/14/2023 Aviva River Bend October 4, 2024 Page 2 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, no immediate fines are assessed. DOCUMENTATION OF ACTION TO COMPLY Per Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/or state form with your organization’s Governing Body. Sincerely, Rick Michals, J.D. Executive Regional Operations Manager HHH PRINTED: 10/04/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 31368 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30 SILVER LAKE PLACE NW AVIVA RIVER BEND ROCHESTER, MN 55901 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 000} Initial Comments {0 000} *****ATTENTION****** Minnesota Department of Health is ASSISTED LIVING PROVIDER LICENSING documenting the State Correction Orders CORRECTION ORDER using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95 this correction order(s) has Statutes for Assisted Living Facilities. The been issued pursuant to a survey. assigned tag number appears in the far Determination of whether a violation has been left column entitled "ID Prefix Tag." The corrected requires compliance with all state Statute number and the requirements provided at the Statute number corresponding text of the state Statute out indicated below. When Minnesota Statute of compliance is listed in the "Summary contains several items, failure to comply with any Statement of Deficiencies" column. This of the items will be considered lack of column also includes the findings which compliance. are in violation of the state requirement INITIAL COMMENTS: after the statement, "This Minnesota SL31368015-1 requirement is not met as evidenced by." Following the evaluators ' findings is the On September 23, 2024, through September 25, Time Period for Correction. 2024, the Minnesota Department of Health conducted a follow-up survey at the above PLEASE DISREGARD THE HEADING OF provider to follow-up on orders issued pursuant to THE FOURTH COLUMN WHICH a survey completed on May 24, 2024. At the time STATES,"PROVIDER'S PLAN OF of the survey, there were 66 residents; 57 CORRECTION." THIS APPLIES TO receiving services under the Assisted Living with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. As a result of the WILL APPEAR ON EACH PAGE. follow-up survey, the following orders were reissued. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. {0 480} 144G.41 Subd 1 (13) (i) (B) Minimum {0 480} SS=F requirements LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 UHZF12 If continuation sheet 1 of 18 PRINTED: 10/04/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 31368 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30 SILVER LAKE PLACE NW AVIVA RIVER BEND ROCHESTER, MN 55901 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 480} Continued From page 1 {0 480} (13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: No further action required. {0 780} 144G.45 Subd. 2 (a) (1) Fire protection and {0 780} SS=E physical environment (a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke alarms on each story within a dwelling unit, including basements, but not including crawl spaces and unoccupied attics; (iv) where more than one smoke alarm is required within an individual dwelling unit or sleeping unit, interconnect all smoke alarms so that actuation of one alarm causes all alarms in the individual dwelling unit or sleeping unit to operate; and (v) ensure the power supply for existing smoke alarms complies with the State Fire Code, except that newly introduced smoke alarms in existing buildings may be battery operated; STATE FORM 6899 UHZF12 If continuation sheet 2 of 18 PRINTED: 10/04/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 31368 09/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30 SILVER LAKE PLACE NW AVIVA RIVER BEND ROCHESTER, MN 55901 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 780} Continued From page 2 {0 780} This MN Requirement is not met as evidenced by: No further action required. {0 800} 144G.45 Subd. 2 (a) (4) Fire protection and {0 800} SS=F physical environment (4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance with a maintenance and repair program. This MN Requirement is not met as evidenced by: No further action required. {01370} 144G.61 Subd.

Finding: Inconclusive Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected a resident when the facility failed to assess, monitor, and implement interventions for multiple skin concerns. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was inconclusive. The Minnesota Department of Health determined neglect was inconclusive. The facility consistently failed to document skin checks and interventions, despite the resident being at risk for skin break down due to edema and incontinence. However, due to the lack of documentation it is unknown if interventions were provided or if the physician was notified. It could not be determined if maltreatment occurred. The investigator conducted interviews with facility staff members, including nursing staff, and unlicensed staff. The investigation included review of facility policies and procedures, resident, and hospital records. An equal opportunity employer. The resident resided in an assisted living facility. The resident’s diagnoses included history of leukemia, anemia, and edema (swelling). The resident’s service plan included assistance with activities of daily living, toileting, bathing, escorts to meals, medication administration, and application of ace wraps to lower legs. The resident’s assessment indicated the resident’s skin was intact, but the resident was at risk for skin breakdown related to incontinence. The assessment did not identify lower extremity edema or application of ace wraps. The treatment and therapy plan indicated the resident did not receive any treatment or therapies. Approximately one month prior to hospitalization, the resident’s medical record indicated the resident experienced a significant change in condition and required assistance with all activities of daily living. The resident’s legs were weeping (fluid leaking from legs, often due to swelling) and a dressing was placed to the weeping area. The record also indicated the resident had multiple weeks of incontinent diarrhea. The record did not include documentation of physician notification or new orders. One week prior to hospitalization, a quarter sized area was noted on the resident’s right buttocks. The resident’s medical record did not include documentation of physician notification, interventions, or changes to the resident services. The resident’s Services Provided document was blank, it is unknown what cares were provided by facility staff. The resident’s medication administration record (MAR) indicated staff applied ace wraps to both legs but did not identify treatments for the resident’s weeping legs or buttocks wound. Hospital records indicated the resident was sent to the hospital for weakness and failure to thrive. The records indicated the resident had a recent and fast decline in functional status and the facility was no longer able to provide the care required to meet her needs. The resident arrived in the emergency department with an unstageable pressure injury (unable to see the wound bed) on the resident’s left buttocks measuring 1.5 x 1.2 x 1.8 centimeters (cm), along with multiple other skin issues including skin tears to both wrists and an open area on the resident’s right lower leg. A discharge summary completed by the facility, one week following the resident’s hospitalization, indicated the resident had a right buttocks pressure ulcer, a skin tear to her right arm, and significant edema that was difficult to manage. The summary indicated the resident was incontinent throughout the day which contributed to the pressure ulcer. The summary further indicated the resident experienced a sharp decline in health status and was hospitalized. During an interview, unlicensed personnel (ULP) recalled the resident had “leaky legs” and ace wraps had to be changed frequently. The ULP indicated she was trained on the application of ace wraps but not trained on how to care for the open areas of skin. The ULP could not recall if the resident had a pressure ulcer. During an interview, the licensed practical nurse (LPN) stated the resident’s legs were both weeping. The LPN said the facility requested an order for ace wraps, but no orders were provided. The LPN was unaware if the physician was notified of the resident’s edema and weeping legs. The LPN also indicated the family was very involved in the resident’s care and would initiate treatments without notifying the facility. The LPN could not recall if the resident had a pressure ulcer prior to hospitalization. During an interview, the registered nurse (RN) stated he was only aware of one time the resident’s legs were weeping. The RN said the LPN oversaw treatments and provision of direct resident care. The RN was not aware of the resident having any skin concerns. The RN stated if there were skin integrity concerns, the physician should have been notified. The RN did not know if the physician was notified regarding the resident’s change in condition or open area on the residents’ buttocks since it was not documented. The RN also indicated the resident was taken to the physician frequently by family members. During an interview, the resident’s family member stated the resident was independent with activities of daily living until one month prior to hospitalization. The family member stated the resident had leukemia that was progressing and developed heart failure, causing the resident legs to swell. The family member stated there was no consistency or accuracy with staff wrapping the resident’s legs and was surprised the facility did not check the resident’s skin more often. The family members said the physician was aware of the resident’s leg swelling, change in condition, and pressure ulcer. The resident’s family member was trying to get the resident admitted into a higher level of care facility prior to the hospitalization. The resident’s family member thought the resident was seen by a physician approximately two weeks prior to hospitalization. In conclusion, the Minnesota Department of Health determined neglect was inconclusive. Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 Neglect means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: None. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 06/15/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 31368 05/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 30 SILVER LAKE PLACE NW AVIVA RIVER BEND ROCHESTER, MN 55901 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On May 9, 2023, the Minnesota Department of Assisted Living Provider 144G. Health initiated an investigation of complaint #HL313682663M/HL313684481C. No correction Minnesota Department of Health is orders are issued. documenting the State Correction Orders using federal software. Tag numbers have been assigned to Minnesota State Statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state Statute number and the corresponding text of the state Statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators ' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE.