Margate Health and Rehab: Infection Control Failures - NC
Inspectors observed the wound nurse treat Resident 10 at Margate Health and Rehabilitation on the afternoon of February 10, 2026. The resident had pressure ulcers in three locations. The nurse started correctly, washing her hands before putting on a gown and gloves. What followed was a pattern of removing dirty gloves and pulling on clean ones without washing or sanitizing her hands in between, repeated across all three wound sites.
The first lapse came at the left hip wound. After removing the soiled dressing and peeling off her dirty gloves, the nurse applied clean gloves directly, without any hand hygiene. She cleansed the wound, applied skin prep, then removed those gloves, sanitized her hands, and put on clean gloves before applying a foam dressing. Then she removed those gloves again and went straight to a new pair without sanitizing. That was two missed steps on a single wound.
She moved the resident to her left side to reach the sacrum and right hip. At the sacrum, she removed the dirty dressing, stripped off her dirty gloves, and this time did perform hand hygiene before applying clean gloves. She cleansed the wound, then removed those gloves and applied clean gloves without sanitizing. She applied gauze and a foam dressing, then removed those gloves and did sanitize before the next pair.
At the right hip wound, she removed the dirty dressing, removed her dirty gloves, and washed her hands before the next pair. She cleansed the wound, then removed her dirty gloves and applied clean gloves without performing hand hygiene. She applied gauze and a foam dressing and removed her gloves, this time performing hand hygiene.
By the end of the treatment session, the nurse had skipped hand hygiene between glove changes at least four times across the three wound sites on the same resident.
When inspectors interviewed the wound nurse forty minutes after the observation, she said she did not realize she had missed the steps. She said she knew she was supposed to sanitize her hands each time. She said she had to change gloves so many times during the treatment that she must have lost track, and that she was nervous being watched.
The facility's own infection preventionist, interviewed three days later on February 13, confirmed what the observation showed: the wound nurse should have washed or sanitized her hands every single time she removed her gloves, whether the gloves were visibly soiled or not.
The administrator told inspectors she had been made aware of what happened. She said the wound nurse explained to her that she had been nervous. The administrator said she had not previously heard of any problems with the wound nurse's technique. Her expectation, she said, was that treatments be performed according to professional standards.
The facility's own hand hygiene policy, which inspectors reviewed, states that staff should perform hand hygiene before applying and after removing personal protective equipment, before and after providing any type of care, and after contact with bodily fluids or potentially contaminated surfaces. The policy applies to all staff in all locations.
Inspectors identified the wound nurse as one of seven staff members observed for infection control practices during the inspection period. She was the only one cited.
The finding was rated as minimal harm or potential for actual harm. Resident 10 had open wounds on three parts of her body when the nurse treated her. What passed between dirty gloves and clean ones, in the gaps where no sanitization happened, the inspection 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 violations during a health inspection on February 13, 2026.
Inspectors observed the wound nurse treat Resident 10 at Margate Health and Rehabilitation on the afternoon of February 10, 2026.
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.