Complete Care at Margate Park: Burn Wound Unreported - IL
The inspection at Complete Care at Margate Park, located at 4920 North Kenmore in Chicago's Uptown neighborhood, was triggered by a complaint and completed on September 23, 2025.
The resident, identified in inspection records only as R1, was documented as severely cognitively impaired. His minimum data set assessment, completed August 5, 2025, recorded a BIMS summary score of 99, a placeholder value used when a resident cannot complete the standardized cognitive interview. The same assessment noted short-term memory problems, long-term memory problems, and rated his cognitive skills for daily decision-making as severely impaired, the lowest category on the scale.
A staff member noted in a progress note on July 29 that R1 had come up with a skin tear behind his left leg at 3:10 in the afternoon. The note said the wound care book had filled up and asked staff to follow up with the wound department for appropriate dressing. It was signed by a staff member identified in the inspection as V11.
Two days later, a wound care doctor identified as V6 completed an initial wound evaluation. What the doctor documented was not a skin tear.
The wound was classified 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 calculated surface area of 136.90 square centimeters. For reference, a standard playing card is roughly 57 square centimeters. This wound was more than twice that size. The pain assessment was described as severe.
How a severely cognitively impaired resident developed a full-thickness burn wound of that size on the back of his leg was not explained in the inspection records. No cause was documented. No investigation findings were cited. The wound appeared, was noted as a possible skin tear by floor staff, and then was evaluated two days later by a wound specialist who identified it as something far more serious.
Full-thickness burns, sometimes called third-degree burns, destroy both layers of the skin entirely. They do not result from brief or minor contact with heat. A wound of this type on a resident who cannot reliably communicate, cannot make daily decisions independently, and cannot complete a basic memory screening raises the question that inspectors were plainly trying to answer: where did it come from?
The facility had its own answer on paper. Its abuse, neglect and exploitation policy, dated September 1, 2024, defined an alleged violation as any situation or occurrence that could indicate noncompliance with federal requirements related to mistreatment, neglect, or abuse, including, explicitly, injuries of unknown source. The policy required an immediate investigation whenever suspicion of abuse, neglect, or exploitation arose. Written procedures called for identifying responsible staff, interviewing all involved persons including the alleged victim and any witnesses, and providing complete and thorough documentation.
By September 18, 2025, inspectors were asking questions by email. They contacted V1, the administrator, directly: Do you have any reportables for injury of unknown origin?
The administrator's response: Nothing in the past 90 days, and no injuries of unknown for close to a year maybe more.
The wound evaluation had been completed on July 31. The administrator's email was sent on September 18. That is 49 days, well within the 90-day window the administrator claimed was clear. The wound care doctor had documented a full-thickness burn of the left leg, severe pain, a surface area of nearly 137 square centimeters, and the administrator told inspectors there was nothing to report.
There is no record in the inspection documents of the facility having reported the wound to the state, having opened a formal abuse and neglect investigation, or having identified who or what caused a man with severe cognitive impairment to develop a burn wound the size of two playing cards on the back of his leg.
The facility's own policy said an injury of unknown source is, by definition, an alleged violation requiring immediate investigation. The wound's origin was not documented. Under the facility's own written standards, that should have triggered the process. It did not appear to have triggered anything.
R1's cognitive status is worth holding onto here. A BIMS score of 99 is not a low score on a cognitive test. It is the score assigned when a resident is incapable of taking the test at all. His long-term and short-term memory were both flagged as impaired. His daily decision-making was rated severely impaired. He was, by every clinical measure available in his chart, a resident who could not be expected to explain what happened to him, advocate for himself, or flag a problem to staff. He was entirely dependent on the people around him to notice, document, and act.
Staff did notice. A progress note from July 29 recorded the wound. A wound care doctor evaluated it two days later and documented a serious burn. The clinical record existed. The wound existed. The question of where it came from was never publicly answered, and the administrator told inspectors it had never been asked.
Complete Care at Margate Park is a licensed skilled nursing facility on Chicago's North Side. The inspection was a complaint investigation, meaning someone, a resident, a family member, a staff member, or another visitor, contacted regulators before inspectors arrived.
The inspection report does not name R1. It does not say whether his family was notified of the wound's severity or its unknown origin. It does not say whether he recovered. It does not say whether anyone was ever held responsible.
What it says is that a man who could not speak for himself well enough to complete a basic memory test had a burn wound covering 137 square centimeters of his left leg, and the person running the facility where he lived told inspectors, in writing, that nothing like that had happened.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Complete Care at Margate Park in CHICAGO, IL was cited for violations during a health inspection on September 23, 2025.
The resident, identified in inspection records only as R1, was documented as severely cognitively impaired.
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.