Complete Care at Margate Park: Burn Wound Neglect - IL
The wound was documented on July 31, 2025, by the facility's wound care doctor. It measured 18.5 centimeters long and 7.4 centimeters wide, roughly the size of an open hand pressed flat against the back of a leg. The pain was described as severe.
Two days earlier, on July 29, a progress note recorded that the resident, identified in inspection records as R1, had come to staff's attention with what was described as a skin tear behind his left leg at 3:10 in the afternoon. The nurse who authored that note flagged it for wound care follow-up. No one had documented how the injury occurred.
R1 is deaf. He has type 2 diabetes, hypertensive heart disease, chronic kidney disease, and chronic systolic congestive heart failure. His most recent cognitive assessment, completed in August 2025, placed him at a score of 99 on the Brief Interview for Mental Status, a designation used when a resident cannot complete the standard interview. The same assessment documented short-term and long-term memory problems and rated his cognitive skills for daily decision-making as severely impaired.
He moves around the facility on his own. He uses the elevator. Staff told inspectors he knows where he is going and when to come back to his floor.
A supervisor identified in the report as V15 told inspectors that nurses and aides are supposed to supervise R1 while he is on the floor. She said she does not know how the wound happened and is still asking herself that question. She said she is not sure whether anyone supervises him in the elevator, because he knows where he is going. Then she said something that inspectors recorded almost verbatim: with an injury like that, somebody should know and should report it. She said it is not expected of a resident to be injured at the facility without anyone knowing. She said if no one knew how the injury happened, he was not supervised adequately.
That last sentence was hers, not the inspector's conclusion.
Federal inspectors cited the facility under F0689, the regulation governing accident hazards and supervision, at a level of actual harm. The citation covers a pattern of failure to protect residents from preventable injury through adequate oversight.
The facility's own policy, included in the inspection record, states that each resident will receive adequate supervision and assistive devices to prevent accidents, and that supervision is an intervention and a means of mitigating accident risk.
R1's records do not document any investigation into the origin of his wound. No incident report explaining the burn's cause appears in the inspection findings. The progress note from July 29 describes it as a skin tear. The wound care evaluation two days later classified it as a full-thickness burn. Those two descriptions are not the same injury, and the record does not reconcile them.
What the record does show is a man with severe cognitive impairment, multiple serious medical conditions, and a wound that nobody witnessed, nobody reported promptly, and nobody could explain weeks later when a federal inspector asked.
The supervisor said she wishes she could explain how it happened.
R1's wound measured nearly 137 square centimeters. His pain was documented as severe. He cannot reliably remember what happened to him, and the people responsible for watching him do not know either.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Margate Park from 2025-09-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
Complete Care at Margate Park in CHICAGO, IL was cited for neglect violations during a health inspection on September 23, 2025.
The wound was documented on July 31, 2025, by the facility's wound care doctor.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.