The incident occurred on September 19, 2025.
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The inspection, completed October 29, 2025, documented what a surveyor watched firsthand.
The resident, identified in inspection records only as R1, is oriented to person only and frequently gets up without calling for help.
Narcan exists for one purpose: to keep someone alive when an opioid has stopped their breathing or sent them into crisis.
The resident, identified in inspection records as R1, had been placed in a high back wheelchair.
Federal inspectors who visited Avir at Lindale on October 29, 2025, found that promise wasn't being kept.
What they found was a program that existed on paper and, in significant stretches, nowhere else.
The Director of Nursing wasn't told.
The inspection took place on October 30, 2025, during a complaint survey.
At Perry Lutheran, it is not optional.
That gap is at the center of a November 2025 federal inspection finding against the Oak Lane Avenue facility.
Inspectors cited Parkwood Skilled Nursing and Rehabilitation Center on November 6, 2025, following a complaint investigation.