Margate Health: Resident Property Protection Fails - NC
It happened again. And again.
Inspectors from the Centers for Medicare and Medicaid Services observed wound care at Margate Health and Rehabilitation on February 10, 2026, and documented what they saw in a report that cited the facility for failing to follow its own hand hygiene policy. The resident had multiple open pressure wounds: one on her left hip, one on her sacrum, and one on her right hip. Treating all three required the wound nurse to change gloves repeatedly throughout the procedure. Inspectors counted the lapses.
After removing dirty gloves from the left hip wound, the nurse applied clean gloves without performing hand hygiene. She cleansed the wound, applied skin prep, then removed those gloves, sanitized her hands, and applied another clean pair before placing a foam dressing — that step she got right. But when she finished with the foam dressing and removed those gloves, she again applied clean gloves without performing hand hygiene first.
The resident was then repositioned to expose the sacrum wound. The nurse removed the dirty dressing, removed her gloves, and this time did perform hand hygiene before gloving up again. She cleansed the wound, then removed her dirty gloves — and without washing her hands, pulled on clean gloves to apply a soaked gauze and foam dressing. She removed those gloves and did sanitize before the next pair.
Then came the right hip. She removed the dirty dressing, pulled off her dirty gloves, and washed her hands before gloving. She cleansed the wound, removed those gloves, and applied clean gloves without hand hygiene. She applied a soaked gauze, covered it with foam dressing, and removed her gloves. The procedure was finished.
The facility's own hand hygiene policy, reviewed by inspectors, states that staff should always perform hand hygiene before applying and after removing personal protective equipment, including gloves, 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 spoke with the wound nurse twice, the afternoon of the observation and the following morning. She said she did not realize she had failed to sanitize her hands each time she removed dirty gloves, even as she acknowledged she knew she was supposed to. She said she had to change gloves so many times during the treatment that she lost track. She also said she was nervous being watched.
The administrator told inspectors she had been informed of the lapses and had heard the same explanation about nerves. She said she had not previously received any reports of problems with the wound nurse's hand hygiene technique. Her expectation, she said, was that the wound nurse perform treatments according to professional standards for wound care and handwashing.
The infection preventionist was direct. Whether gloves were visibly soiled or not, the wound nurse was required to wash or sanitize her hands every single time she removed them.
Inspectors identified this as the only staff member among seven observed for infection control practices who committed the violation. The cited level of harm was minimal harm or potential for actual harm. Resident 10 had open wounds on three separate sites. Each time the nurse moved from one contaminated surface to a new pair of gloves without cleaning her hands, whatever was on those hands moved with her.
The inspection report does not describe any infection that developed in Resident 10's wounds afterward.
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.
The resident had multiple open pressure wounds: one on her left hip, one on her sacrum, and one on her right hip.
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.