The deficiency, tagged F0610, affected a small number of residents.
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The Director of Nursing told inspectors that all the nurses know which patients are NPO and that the medication was given via tube.
The inspection report does not say how many.
It is among the first things taught in certified nursing assistant training.
She was not describing this from a chair or a bed.
Federal health inspectors documented both failures during a complaint inspection conducted November 13, 2025.
The citation, issued under F0689, covers accidents resulting in injury.
The resident, identified in inspection records only as Resident 4, received Narcan on July 29, 2025.
The inspection, triggered by a complaint, found that Avenue Care had failed to provide and implement an infection prevention and control program.
The care planning citation, recorded under federal tag F0656, describes a gap that sits at the center of how nursing homes are supposed to function.
Federal inspectors cited the facility for abuse and neglect following a complaint inspection on October 30, 2025.
The infected pressure injury on the right hip of Resident 26 measured nearly two inches wide, almost two inches long, and nearly half an inch deep.