Autumn Care of Myrtle Grove: Record Falsification - NC
The resident's family caught it first. They told the nurse they didn't think he was supposed to get insulin, and she realized in that moment she had made the error. The blood sugar reading was right there: 103. The physician's order was explicit — no sliding scale coverage for any reading below 150. She had drawn up the insulin anyway, distracted after three nursing aides approached her at the medication cart with problems between the blood sugar check and the injection.
She told inspectors she documented zero units on the Medication Administration Record because she had signed in error. The correct entry, she acknowledged, would have shown two units given at 11:00 AM.
The Director of Nursing said she learned about the medication error from the nurse that same day. She said she had not known the documentation was wrong until inspectors asked about it during an interview on April 23, nearly three months after it happened.
That was the same day inspectors were also asking about a different patient, a different error, and the same nurse.
Earlier that morning of January 25, the nurse had been assigned to a group of high-acuity residents, the kind who require closer monitoring: residents with tracheostomy tubes, feeding tubes, wounds. One of them, a man with a surgically placed jejunostomy tube that delivered nutrition and medications directly into his small intestine, had pulled the tube out. It wasn't the first time. The SBAR form the nurse began filling out noted he had a history of pulling and tugging at it.
The j-tube coming out was a serious enough event that someone called 911. The resident was transferred to a hospital. The responsible party was notified at 12:51 PM. The on-call provider was reached at 1:12 PM. The nurse signed the form at 12:51 PM.
And then she left.
The SBAR form she left behind was four pages long and mostly blank. The primary diagnosis wasn't filled in. The medication alerts section, which specifically asks about anticoagulants, was empty. The resident was on apixaban, a blood thinner, twice a day. His vital signs weren't recorded. His pulse oximetry wasn't recorded. The sections covering his mental status, functional status, respiratory evaluation, cardiovascular evaluation, abdominal and gastrointestinal evaluation, skin condition, pain, and neurological status were all left blank. There was a checkbox at the top of each section to mark it as not clinically applicable. None of them were checked.
The Director of Nursing called the nurse multiple times and asked her to return to the facility to finish the paperwork. She never came back.
The medication record for that same resident told its own story. It showed the nurse had administered four medications, including Eliquis, the brand name for apixaban, during the 7:00 AM to 11:00 AM medication pass. The nurse told inspectors that wasn't true. She said she must have checked the medications off when she pulled them from the cart, before she ever gave them. She said she did not administer those medications to the resident on January 25.
The j-tube had been the delivery route for all of them. By the time the medications were supposed to be given, or were recorded as given, the tube was already causing problems. The resident had pulled it out twice that day. Whether any of those four medications actually reached him that morning, the record cannot confirm.
The nurse, when interviewed by phone on April 23, was direct about what happened with the diabetic resident. She remembered his blood sugar being in the low 90s or around 100. She remembered the aides interrupting her. She remembered drawing up the two units. She remembered the family's reaction. She said she should have documented what she actually did.
The Director of Nursing, interviewed separately, said she expected nursing documentation to be complete and accurate. She said the nurse should not have given sliding scale insulin at a blood sugar below 150. She said education would be provided on accurate documentation.
Both errors trace back to the same shift, the same nurse, the same morning. One resident left by ambulance with a partially completed transfer form and a medication record that may not reflect what he actually received. Another resident received a medication he wasn't supposed to get, and the record was left showing he received nothing.
Federal inspectors rated the harm level as minimal for both findings. The facility's plan of correction was not included in the inspection report reviewed.
The Director of Nursing's calls went unanswered. The paperwork stayed incomplete. The insulin was already in.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
The resident's family caught it first.
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.