Complete Care at Margate Park: Family Not Notified - IL
The inspection at Complete Care at Margate Park, a nursing facility at 4920 North Kenmore in Chicago, was triggered by a complaint and completed September 23, 2025. What inspectors found centered on a single resident, identified in records only as R1, whose injury and the facility's response to it formed the basis of the citation.
R1 is documented as having severely impaired cognitive skills for daily decision making. He cannot advocate for himself. That responsibility fell to a family member, identified in records as V3, who was supposed to be notified when something went wrong.
Something went wrong on July 28 or 29, 2025.
A progress note dated July 29 recorded that R1 "came up with a skin tear behind his left leg at 3:10pm." The note said the wound care book had been filled out and instructed staff to follow up with the wound department for appropriate dressing. It was authored by a staff member identified as V11.
Two days later, on July 31, a wound care doctor identified as V6 conducted a formal wound evaluation. What V6 documented was not a skin tear. The evaluation classified the wound as a full-thickness burn of the left leg. It measured 18.5 centimeters long, 7.4 centimeters wide, and 0.1 centimeters deep, with a surface area of 136.90 square centimeters, roughly the size of a playing card pressed flat against the back of his leg. Pain was described as severe.
The July 31 evaluation contained no note that V3, the family member, had been notified.
Progress notes from July 28 through August 5 were reviewed by inspectors. None contained documentation of family notification.
On August 11, nearly two weeks after the wound was first recorded, a surgical procedure was performed. Inspectors reviewed the wound evaluation from that date, which described excisional debridement — the surgical removal of necrotic tissue to establish the margins of viable tissue. The consent documentation from August 11 noted that treatment options, risks, benefits, and the possible need for additional procedures had been explained to the patient and his health care surrogate, V3, who agreed to proceed.
That was the first documented contact with the family. Thirteen days after the injury appeared in the record.
When inspectors followed up with facility leadership, the Assistant Director of Nursing, identified as V15, responded by email on September 22. The email stated the facility was "unable to locate SBAR for 7/29/25." An SBAR is a structured communication tool used in healthcare settings to report changes in a resident's condition. Its absence meant there was no documentation that anyone had formally escalated R1's injury through the facility's own internal channels on the day it was discovered.
The facility's own notification policy, dated September 1, 2024, states that the facility must inform the resident, consult with the physician, and notify the family member or legal representative when there is a change requiring notification. The policy lists accidents resulting in injury as circumstances that require that notification.
A full-thickness burn described as causing severe pain, covering more than 136 square centimeters, requiring surgical debridement to remove dead tissue — that is an accident resulting in injury.
The deficiency was cited under F0580, the federal tag governing notification of changes in a resident's condition. CMS assessed the level of harm as minimal harm or potential for actual harm, affecting few residents.
What the record does not contain is any explanation of how R1 sustained a full-thickness burn in the first place. The July 29 progress note called it a skin tear. The wound care doctor two days later called it a burn. No investigation findings appear in the inspection documents. No cause is identified.
V3 learned their family member had a wound requiring surgery to cut away dead flesh on the day they were asked to sign the consent form.
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 violations during a health inspection on September 23, 2025.
R1 is documented as having severely impaired cognitive skills for daily decision making.
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.