Complete Care at Margate Park failed to follow basic medication safety protocols for a resident who had been applying the prescription cream to treat itching on his back and thighs, according to a November 20 federal inspection report.
The violation came to light when an inspector observed the tube of hydrocortisone cream sitting openly on the resident's bedside table during morning medication rounds on November 18. The resident, identified as R16 in the report, told the licensed practical nurse he needed a new tube because his was almost empty.
He explained that a night shift nurse had given him the medication "a long time ago" and that nursing assistants had been helping him apply it to his back because he couldn't reach the area himself.
The nurse immediately recognized the problem. "He should not have the hydrocortisone cream at bedside because anyone might come in his room and take the medication," the nurse told inspectors.
Federal regulations require nursing homes to conduct safety assessments before allowing residents to keep any medications in their rooms. Facilities must verify that residents can safely handle the drugs and obtain specific doctor's orders for self-administration.
None of that had happened at Complete Care.
The unit manager, who serves as assistant director of nursing, admitted to inspectors that proper protocols weren't followed. "For resident on self-administration of medication, there should be an assessment first to make sure he can safely administer the medication," she said. "It also needs a doctor's order and to care plan the self-administration of medication."
The resident's medical records showed he had been prescribed the hydrocortisone cream since April 23, with orders to apply it twice daily for itching. But nowhere in his file was there any doctor's authorization for self-medication.
The resident appeared mentally capable of handling his own medications. His cognitive assessment scored 15 points on a standard mental status test, indicating he was "cognitively intact." He also managed diabetes and chronic obstructive pulmonary disease.
But federal rules don't allow nursing homes to make assumptions about medication safety based on mental capacity alone. Each situation requires formal evaluation by the facility's interdisciplinary team.
The facility's own policy, dated September 1, 2024, clearly outlined the required steps. It stated that residents "may only self-administer medications after the facilities interdisciplinary team has determined which medications may be self-administered safely."
The policy required that assessment results be recorded on official forms and that care plans "must reflect that self-administration and storage arrangement for such medications."
After inspectors discovered the violation, managers rushed to complete the missing paperwork. The unit manager conducted a medication self-administration safety screening on November 18 at 4:52 pm, the same day the cream was found in the resident's room.
She also created a care plan entry that day stating the resident "has a physician order for self-administration of medication" and obtained a retroactive doctor's order.
The facility's policy acknowledged that residents have "the right to self-administer medication" when it's clinically appropriate. But it also required multiple safeguards to prevent medication errors, theft, or accidental ingestion by other residents.
Complete Care operates in a building at 4920 North Kenmore in Chicago's Uptown neighborhood. The facility treats residents with various medical conditions including diabetes, respiratory diseases, and skin conditions requiring topical medications.
The hydrocortisone violation affected just one of 21 residents reviewed during the inspection, but highlighted gaps in the facility's medication management system. Federal inspectors classified it as causing "minimal harm or potential for actual harm."
The case illustrates how nursing homes sometimes allow informal medication practices to continue without proper oversight. While the resident may have benefited from having direct access to his skin cream, the lack of formal authorization created safety risks.
The resident had been managing his condition with help from nursing assistants who applied the cream to areas he couldn't reach. But without official protocols in place, there was no systematic way to monitor his medication use or ensure the cream remained secure.
The inspection occurred in response to a complaint, though the report doesn't specify who filed it or what initially prompted the investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Margate Park from 2025-11-20 including all violations, facility responses, and corrective action plans.
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