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.