The inspection was triggered by a complaint, filed under Complaint Number 2630192.
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The facility's own policy made the expectation plain.
Not the on-call nurse practitioner.
The medication was Entresto, a drug used to treat heart failure and high blood pressure.
The incident was recorded on facility surveillance.
She did not verify that isolation orders had been entered.
The burn and wound center physician had ordered cocoa butter to be applied three times per day.
Nobody had a system in place to make sure the doors were locked in the first place.
The inspection, conducted October 23, 2025, was triggered by a complaint.
The paperwork in question is called a Notification of Specialized Services, or NFSS.
The deficiency, recorded under a federal pharmacy services standard, found that the facility's error rate had reached or exceeded 5 percent.
The October 2025 inspection, triggered by a complaint, resulted in a citation under F0600, the federal tag covering abuse.