Autumn Care of Myrtle Grove: Lab Sample Lost in System - NC
The resident at Autumn Care of Myrtle Grove, a skilled nursing facility on Carolina Beach Road, was already being treated for a urinary tract infection when her physician ordered a urinalysis with culture and sensitivity on April 15, 2025. The culture would have shown whether the antibiotic she was taking was actually working against the specific bacteria causing her infection. It was never run.
Nurse #4 collected the urine sample that same day. She entered the order into the electronic medical record. She entered it into the lab services website. What she did not do, and later told inspectors she could not recall whether she had done, was write it in the lab book kept at the nurses' station.
That logbook was the one place the lab company actually looked.
When the lab company came to the facility, a unit manager explained during the April 24 inspection, their process was to review the lab book to determine what needed to be collected. The electronic record and the lab services website were not enough. Without the handwritten entry, the courier left without the sample. The unit manager said she normally checked the lab book herself to make sure entries were recorded. That check did not happen either. "It was done in error," she told inspectors.
The Director of Nursing said she learned about the missed pickup the day inspectors arrived, nine days after the sample was collected. She described the three-step process and confirmed the third step had not been followed. She said education would be provided.
The physician who ordered the test, identified in the inspection report as Physician #2, also learned about it on April 24. She told inspectors there had been no significant outcome from not obtaining the urinalysis. The resident had remained on antibiotics throughout. But the physician was direct about what she expected: lab orders entered correctly, results made available. That had not happened.
The inspection, completed April 24, 2025, cited the deficiency at a level of minimal harm or potential for actual harm, affecting few residents. The regulatory finding was narrow. The practical consequence was that a resident being treated for a urinary tract infection went more than a week without the test that would have confirmed whether her treatment was appropriate.
Urinary tract infections are among the most common and most dangerous infections in nursing home residents. They can progress to sepsis. The standard of care for a UTI with culture and sensitivity is to match the antibiotic to the specific organism identified in the lab. Without that result, a physician is treating blind, relying on the antibiotic chosen before the culture came back. Physician #2 said the resident had no significant outcome. What the inspection report does not say is whether the antibiotic she was on was ultimately the right one.
The breakdown was not a failure of technology or equipment. The electronic medical record worked. The lab services website worked. The sample was collected correctly and on time. The entire chain collapsed at a paper logbook sitting at the nurses' station, a manual backup step in a process that depended on every person completing every step every time.
The unit manager said she usually checked. The nurse said she did not recall. The lab came and went.
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 27, 2026 · Our methodology
Autumn Care of Myrtle Grove in Wilmington, NC was cited for violations during a health inspection on April 24, 2025.
The culture would have shown whether the antibiotic she was taking was actually working against the specific bacteria causing her infection.
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.