Autumn Care of Myrtle Grove: Infection Control Failures - NC
Federal inspectors documented the lapse at Autumn Care of Myrtle Grove during a visit on April 22, 2025, at 5:00 in the afternoon. A nurse identified in the inspection report as Nurse #3 was observed providing tracheostomy care, including tracheal suctioning, to a resident identified as Resident #5. The nurse wore gloves and a mask. She did not wear a gown.
The sign outside the room said gloves, gown, and mask. The cart outside the room had gowns on it. Resident #5 was on Enhanced Barrier Precautions specifically because of the tracheostomy.
Interviewed immediately after the observation, Nurse #3 told inspectors she knew she should have put on a gown before going in. She said she had received training on Enhanced Barrier Precautions and on the proper use of personal protective equipment. She called it an error.
Enhanced Barrier Precautions are used for residents who carry or are at elevated risk of spreading certain drug-resistant organisms. A tracheostomy, an opening surgically created in the throat to assist with breathing, requires direct hands-on care that puts both the resident and the caregiver in close contact with respiratory secretions. A gown is part of that protection because it keeps contaminants off clothing that a nurse carries from room to room.
This was not an isolated case. The inspection report also references a separate incident involving a nurse identified as Nurse #2, who was observed performing tracheostomy suctioning and a bolus tube feeding without a gown. The Director of Nursing told inspectors that Nurse #2 should have been wearing a gown during that hands-on care as well.
Two nurses. Two procedures. No gowns. Both knew the requirement.
The Infection Control Preventionist Nurse, interviewed the following morning, confirmed that Resident #5 had been placed on Enhanced Barrier Precautions because of the tracheostomy, that the sign and the supply cart were both present outside the room, and that staff had already received education on donning PPE correctly. Her response to the lapse: more education would be provided.
The Director of Nursing said the same thing. Staff had been trained. Staff knew gloves, gown, and mask were required for tracheostomy care. Nurse #3 should have put on a gown. Education would be provided.
The inspection report rated the violation as causing minimal harm or the potential for actual harm, and noted that some residents were affected.
What the report does not resolve is how many times a nurse walked past that cart, past that sign, and into a room without the full set of protective equipment before an inspector happened to be standing there watching at five o'clock on a Tuesday afternoon. The facility's own infection control nurse said audits were ongoing. The Director of Nursing said audits needed to continue.
A gown was on the cart. The cart was at the door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Care of Myrtle Grove from 2025-04-24 including all violations, facility responses, and corrective action plans.
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.
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Last verified: October 26, 2026 · Our methodology
Autumn Care of Myrtle Grove in Wilmington, NC was cited for violations during a health inspection on April 24, 2025.
Federal inspectors documented the lapse at Autumn Care of Myrtle Grove during a visit on April 22, 2025, at 5:00 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.