Memory Lane Assisted Living

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/29/2025 from 9:10 a.m. to 5:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jill James, Licensing Inspector at (540) 418-2631 or by email at jill.james@dss.virginia.gov

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/13/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: No residents interviews conducted due to limited cognition of residents. Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch. This LI also observed medication being administered to residents. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/01/23. The Acknowledgement of Inspection form was signed and left at the facility on the date of the inspection. Number of residents present at the facility at the beginning of the inspection: 21. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. No issues were identified. The facility was clean and odor free. Housekeeping carts were locked or accompanied. Number of resident records reviewed: 5. Number of staff records reviewed: 6. Number of interviews conducted with residents: 1. Number of interviews conducted with staff: 2. Observations by licensing inspector: Outside inspections were current as were related drills. Postings were as required. In additional to a weekly menu the facility has a daily menu posted for each meal. Residents were observed actively participating in a music activity complete with instruments upon arrival of this inspector. No medication issues were identified, and the cart was clean and organized. The facility is just starting to transition from using only nurses for medication to also utilizing registered medication aides. A review of the schedule indicates staffing is as per the standards. Additional Comments/Discussion: No complaints during this licensing inspection period. Fire ? 4/12/23 Health ? 1/2/23 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with one applicable standard or law, and the violation was documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:6/17/2022 10:30am Number of residents present at the facility at the beginning of the inspection: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility - Virtual Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: N/A Virtual Inspection Number of interviews conducted with staff: 1 Observations by licensing inspector: Records were complete. Outside inspections current. Drills current. Postings as required. Fire 4/27/22 Health 3/4/22 Additional Comments/Discussion: An on-site walk through will be completed at a later date. The administrator has completed AIT training and will be sitting for her exam in July. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov Violation Notice Issued: No A copy of the final document will be sent to the licensee/provider for signature.

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 05/03/2021 and concluded on 05/07/2021. The administrator was contacted by email to initiate the inspection. The administrator reported that the current census was 15. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records plus additional 3 medication records, 2 new staff records and 1 additional background check for a staff hired since the last inspection, documentation related to the fire inspection which is to be completed the week of May 7 and a letter from VDH regarding the health inspection. Additionally health care over site, emergency drills, pharmacy review, dietary oversight, staff schedules and additional training and certification records for staff as well as training related to the facilities Covid 19 policies and procedures was reviewed. The facility has had no complaints during this licensure period. The information gathered during the inspection determined no violations and applicable standards or law. No violations were issued. Thank you to the staff for your assistance and cooperation during this remote inspection process. Should there be additional questions or concerns please call (540)332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.