Margate Health And Rehabilitation, Llc
Margate Health and Rehabilitation, LLC in Jefferson, NC — inspection on February 13, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the Resident's insurance paid for the medication which was $285.79 per pen.
She stated the insurance
for it.
The Pharmacy Manager stated they received the tirzepatide injections in a box from the
any damage before they sent them to the facilities because they had to label and package each pen.
The Pharmacy Manager could not provide any specific details about damaged or empty pens.
She stated she would expect the facility to report damaged or empty insulin pens to the pharmacy as soon as possible.An interview was conducted with Nurse #3 on 02/10/26 at 10:12 AM.
The Nurse stated she received Resident #24's tirzepatide pens from the pharmacy on the night of 11/21/25 and put the pens in the refrigerator as the normal procedure.
She stated she usually did not inspect the pens to determine whether they were full, but she did not after 12/12/25 because they treated the pens like narcotics and locked them in the refrigerator.
Nurse #3 stated she did not know why the two tirzepatide pens were empty on 12/12/25.
During an interview with Nurse #5 on 02/11/26 at 11:00 AM the Nurse reported she gave Resident #24 her tirzepatide injection on 12/19/25.
She stated she did not know what happened to the two tirzepatide pens or why they would be empty on 12/12/25. On 02/11/26 at 12:00 PM an interview was conducted with a representative from the tirzepatide manufacturer who explained that the tirzepatide pens were supplied to the pharmacy in a box of four pens and it was possible that the pens could leak but the pharmacy would notice they leaked when repacking the pens.An interview was conducted with the Nurse Practitioner on 02/10/26 at 3:35 PM who explained that the Unit Manager reported to him on 12/12/25 that Nurse #1 went to give Resident #24 her tirzepatide and the pen was empty then when they went to use the other pen, they discovered that the other pen was empty as well.
The Nurse Practitioner stated he called the pharmacy and gave them an order to refill the prescription, and they sent the medication the next day and Resident #24 received the medication.
The Nurse Practitioner stated the facility was going to investigate the empty pens, but he did not know the outcome.On 02/11/26 at 9:00 AM an interview was conducted with the Regional Clinical Manager who explained that the Unit Manager called her on 12/12/25 when the empty tirzepatide pens were discovered.
She reported that the Unit Manager did not know how the pens were emptied but because they were expensive and highly sought after she wanted to lock them up and treat them like narcotics, which she thought was a good idea because they do that in other buildings.
The Regional Clinical Manager stated she thought about why the tirzepatide pens were empty and concluded it could be human error or misappropriation but more so human error.On 02/11/26 at 3:19 PM an interview was conducted with the Administrator who explained that she was notified by phone on 12/12/25 by the Unit Manager about the empty tirzepatide pens but she did not go into detail.
The Unit Manager was going to investigate the issue and notify the Nurse Practitioner to get an order for more medication and then notify the Regional Clinical Manager.
The Administrator stated she should have been more diligent in the investigation to determine how the pens were emptied but she did not.
The Administrator stated she did not think about misappropriation of medications because if she did, she would have reported it.
345296 02/13/2026
Margate Health and Rehabilitation, LLC 540 Waugh Street Jefferson, NC 28640
who gave her a verbal order to hold the medication for 12/12/25 until it was obtained from the
syringes looked as if they were empty, but she could not determine why the syringes were empty and
medication with a new order which she obtained from the Nurse Practitioner and the tirzepatide injection was given to Resident #24 on 12/13/25.
The Unit Manager stated she did not think about misappropriation of medication or to investigate about what happened or why the tirzepatide syringes were empty because she was new to the position and the only thing on her mind was what she could do to prevent it from happening again.
During an interview with the Administrator on 02/11/26 at 3:19 PM the Administrator explained that she was notified on 12/12/25 by the Unit Manager via telephone about the empty tirzepatide pens but the Unit Manager did not go into detail, nor did the Administrator think to ask for the details.
She stated she thought the Unit Manager was going to investigate the issue.
The Administrator stated she should have been more diligent in the investigation to determine how the pens were emptied but she did not.
The Administrator stated she did not think about misappropriation of medications because if she had thought about it, she knew she had to report misappropriation and she would have reported it.
345296 02/13/2026
Margate Health and Rehabilitation, LLC 540 Waugh Street Jefferson, NC 28640
not wash or sanitize her hands before applying clean gloves.
This deficient practice occurred for 1 of
of the facility's Hand Hygiene policy read in part:All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.
This applies to all staff working in all locations within the facility.
Review of the facility's Basics of Hand Hygiene policy read in part:You should always perform hand hygiene: before applying and after removing personal protective equipment (e.g., gloves), before and after providing any type of care and after contact with bodily fluids or other potentially contaminated surfaces.Wound care observations were made on 02/10/26 at 2:15 PM on Resident #10 by the Wound Nurse.
The Wound Nurse gathered the supplies and placed them on an over bed table that had been disinfected and a protective barrier had been placed on the table.
The Wound Nurse washed her hands and applied a gown and gloves for the procedure.
The Resident had been positioned on her right hip exposing her left hip wound where the Wound Nurse removed the dirty dressing, removed her gloves and applied clean gloves without performing hand hygiene.
The Wound Nurse then cleansed the wound with a cleansing solution and applied skin prep.
The Wound Nurse removed her gloves, sanitized her hands and applied clean gloves before she applied a foam dressing to the wound.
The Wound Nurse then removed her gloves but did not perform hand hygiene before she applied clean gloves. Resident #10 was then positioned on her left side to expose wounds on her sacrum and right hip.
The Wound Nurse then removed the dirty dressing from Resident #10's sacrum, removed her dirty gloves and performed hand hygiene before she applied clean gloves.
She then cleansed the wound with a wound cleanser and removed her dirty gloves and without performing hand hygiene the Wound Nurse applied clean gloves and applied a soaked gauze and covered the gauze with a foam dressing then removed her gloves and performed hand hygiene before she applied clean gloves.
The Wound Nurse then removed the dirty dressing from Resident #10 right hip and removed her dirty gloves then she washed her hands before she applied clean gloves.
She then cleansed the wound with a wound cleanser and removed her dirty gloves and applied clean gloves without performing hand hygiene.
The Wound Nurse then applied a soaked gauze to the wound and covered it with a foam dressing and removed her gloves and performed hand hygiene.Interviews were conducted with the Wound Nurse on 02/10/26 at 2:50 PM and 02/11/26 at 10:40 AM.
The Wound Nurse stated that she did not realize that she did not wash or sanitize her hands each time after she removed dirty gloves and before she applied clean gloves and stated that she knew that she was supposed to.
She stated that she had to change gloves numerous times during Resident #10's treatment that she must have lost track, and she was nervous being watched.During an interview with the Infection Preventionist (IP) on 02/13/26 at 10:35 AM the IP indicated that according to the facility's policy and standard practice of handwashing the Wound Nurse should have washed or sanitized her hands every time she removed her gloves whether they were visibly soiled or not.An interview was conducted with the Administrator on 02/11/26 at 3:30 PM.
The Administrator explained that she had been made aware of the Wound Nurse not washing or sanitizing her hands between glove changes and the Wound Nurse told her she was nervous.
The Administrator stated she had not heard of any problems with the Wound Nurse's wound treatment technique of not washing her hands after removing dirty gloves and before applying clean gloves previously.
The Administrator indicated her expectation was that the Wound Nurse perform the treatments according to the professional standards of wound care and handwashing.