Margate Health and Rehab: Abuse Prevention Failures - NC
The inspection took place on February 10, 2026, at 2:15 in the afternoon. The resident, identified in the report as Resident 10, had open pressure ulcers on her left hip, her sacrum, and her right hip. The wound nurse was treating all three.
Inspectors watched her work through the entire session. She washed her hands at the beginning. Then, after removing the dirty dressing from the left hip wound and stripping off her soiled gloves, she pulled on a clean pair without stopping to sanitize. She cleansed the wound, applied skin prep, then removed those gloves and sanitized before the next step. But after applying a foam dressing and removing her gloves again, she went straight to clean gloves a second time. No hand hygiene.
The resident was then repositioned to treat the sacrum wound. The nurse removed that dirty dressing, took off her gloves, and this time did sanitize before gloving up. She cleansed the wound. Then she removed those gloves and, again without hand hygiene, applied clean gloves to pack the wound with soaked gauze and cover it with foam. She removed her gloves and sanitized before the next step. Moving to the right hip wound, she removed the dirty dressing, stripped off her gloves, and washed her hands before applying clean ones. She cleansed the wound, then removed those gloves and applied clean gloves without sanitizing. She packed the wound with gauze, covered it with foam, and removed her gloves.
By the end of the session, inspectors had counted at least four instances where the nurse changed from dirty gloves to clean ones without performing any hand hygiene in between.
The nurse was interviewed twice, first at 2:50 that afternoon and again the following morning. She said she didn't realize she had skipped hand hygiene each time she removed dirty gloves. She knew she was supposed to do it. She told inspectors she had to change gloves so many times during the treatment that she lost track, and that she was nervous being observed.
Nervousness under observation is understandable. What it doesn't change is what happened to the resident on the table.
The facility's own infection control policies are unambiguous. Staff are required to perform hand hygiene before applying gloves and after removing them, every time, whether the gloves are visibly soiled or not. The Infection Preventionist confirmed this to inspectors on February 13, stating that the nurse should have sanitized her hands with every single glove change, no exceptions.
The administrator said she learned about the hand hygiene lapses and that the nurse had told her she was nervous. She said she had not previously heard of any concerns about the wound nurse's technique. Her expectation, she told inspectors, was that treatments be performed according to professional standards.
The gap between that expectation and what inspectors actually watched play out is the whole of the problem. The wound nurse was not a new employee performing an unfamiliar task. She was the facility's designated wound care specialist, treating a resident with multiple open pressure sores, moving from wound to wound on the same body, and repeatedly skipping the single step designed to keep contamination from traveling on her hands from one site to the next.
Inspectors rated the violation as having minimal harm or potential for actual harm. Resident 10 had wounds on three separate parts of her body when the nurse began. Whether any of them were made worse by what happened that afternoon, the report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Margate Health and Rehabilitation, LLC from 2026-02-13 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: August 5, 2026 · Our methodology
Margate Health and Rehabilitation, LLC in Jefferson, NC was cited for abuse-related violations during a health inspection on February 13, 2026.
The inspection took place on February 10, 2026, at 2:15 in the afternoon.
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.