Vitality Living of Upsala LLC.

correction orders and documen tthe actions taken to comply in the facility's records. The Departmen treserves the right to return to the facility at any time should the Departmen treceive a complaint or deem it necessar yto ensure the health, safety, and welfare of residents in your care. STAT ECORRECTIO ONRDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are 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 are listed in the "Summary Statemen tof Deficiencies "column. This column also includes the findings that are in violation of the state statute after the statement ,"This MN Requiremen its not met as evidenced by . . ." IMPOSITION OF FINES In accordanc ewith Minn. Stat. § 144G3. 1, Subd .4, fines and enforcemen tactions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcemen tmechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcemen tmechanism authorized in § 144G2. 0; Leve l4: a fine of $3,000 per incident, in addition to any enforcemen tmechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: IS7N REVISED 09/13/2021 Vitality Living Of Upsala LLC Novembe r3, 2025 Page 2 Leve l5: a fine of $5,000 per violation, in addition to any enforcemen tmechanism authorized in § 144G2. 0. Therefore ,in accordanc ewith Minn. Stat. §§ 144G0. 1 to 144G9. 999, the following fines are assessed pursuan tto this survey: 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 Therefore ,in accordanc ewith Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $500.00. You will be invoiced approximately 30 days after receipt of this notice, subjec tto . appeal DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), the licensee must documen tactions 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: x Identify how the area(s) of noncomplianc ewas corrected related to the resident(s)/ employees() identified in the correction order. x Identify how the area(s) of noncomplianc ewas corrected for all of the provider’s resident(s)/ employees that may be affected by the noncompliance. x Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTIO ONRDER RECONSIDERATI PORNOCESS In accordanc ewith Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued, including the level and scope ,and any fine assesse dthrough the correction order reconsideration process T. he 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 REQUESTIN AG HEARING Alternatively ,in accordanc ewith Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, Subd .14 and Subd .18, a request for a hearing must be in writing and received by the Departmen tof Health within 15 busines sdays of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Vitality Living Of Upsala LLC Novembe r3, 2025 Page 3 To submit a hearing request ,please visit: https:/ / forms.web.health.state.mn.us/form/ HRDAppealsForm To appea lfines via reconsideration p, lease follow the procedure outlined above .Please note that you may request a reconsideration or a hearing ,but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing ,please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD )values your feedback about your experience during the survey and/or investigation process .Please fill out this anonymou sprovider feedback questionnaire at your convenienc eat this link: https:/ / forms.office.com/g/Bm5uQEpHV.a Your input is important to us and will enable MDH to improve its processe sand communication with providers .If you have any questions regarding the questionnaire p, lease contact Susan Winkelmann at susanw. inkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this documen tfor your records .It is your responsibility to share the information contained in the letter and state form with your organizations’ Governing Body. If you have any questions ,please contact me. Sincerely, Jessie Chenze S, upervisor State Evaluation Team Email :jessiec. henze@state.mn.us Telephone 2: 18-332-5175 Fax :1-866-890-9290 JMD PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 39080 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 WALNUT AVENUE WEST VITALITY LIVING OF UPSALA LLC UPSALA, MN 56384 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 *****ATTENTION***** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." issued pursuant to a survey. The state Statute number and the corresponding text of the state Statute out Determination of whether violations are corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the Statute number indicated below. column also includes the findings which When Minnesota Statute contains several items, are in violation of the state requirement failure to comply with any of the items will be after the statement, "This Minnesota considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. SL39080016-0 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On October 13, 2025, through October 14, 2025, STATES,"PROVIDER'S PLAN OF the Minnesota Department of Health conducted a CORRECTION." THIS APPLIES TO change of ownership (CHOW) survey at the FEDERAL DEFICIENCIES ONLY. THIS above provider. At the time of the survey, there WILL APPEAR ON EACH PAGE. were 20 residents; all 20 receiving services under the Assisted Living Facility with Dementia Care THERE IS NO REQUIREMENT TO license. 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. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=F LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ZTPK11 If continuation sheet 1 of 11 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 39080 10/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 200 WALNUT AVENUE WEST VITALITY LIVING OF UPSALA LLC UPSALA, MN 56384 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) 0 510 Continued From page 1 0 510 (a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control.