Autumn Care of Myrtle Grove: Transfer Form Failures - NC
The patient, identified in inspection records only as Resident #1, had suffered a stroke and could not speak. He had no capacity to fill in the gaps himself.
Inspectors from the Centers for Medicare and Medicaid Services documented the failure during an April 2025 survey of the 5725 Carolina Beach Road facility. What they found was not a clerical oversight. It was a two-page hospital transfer form with entire sections left blank, and a nurse who walked off her shift and never came back to finish it.
Resident #1 had been admitted to the facility with a stroke, difficulty swallowing, and a complete absence of speech. Because he could not eat by mouth, a jejunostomy tube, a surgically placed feeding tube that delivers nutrition and medication directly into the small intestine, had been ordered for him. He was severely cognitively impaired and required someone else to make decisions on his behalf.
On January 25, 2025, the tube came out.
The Director of Nursing received a call from the floor nurse that afternoon and directed staff to contact the on-call provider and send the resident to the hospital. That part happened. What did not happen was the paperwork.
The transfer form that went with Resident #1 to the hospital listed his name, date of birth, admission date, and the reason for transfer: a pulled-out feeding tube. It noted that his responsible party had been notified. Page two had some risk alert boxes checked, including flags for aspiration risk and high fall risk, and listed his diet as enteral feeding.
Everything else was missing. His code status was not listed. His relevant diagnoses were not listed. His functional status was not listed. The sections for respiratory support, current medications, medical devices, isolation precautions, and vital signs were all blank. The form was not signed. It was not dated.
For a man who could not speak for himself, that form was the only way the hospital would know what it was dealing with.
The nurse assigned to Resident #1 that day, identified as Nurse #1, later told inspectors she had been managing an unusually heavy patient load. The residents she was responsible for that shift required intensive monitoring, including patients with tracheostomy tubes, feeding tubes, and open wounds. She acknowledged she had not completed the transfer documentation before leaving.
The Director of Nursing called her multiple times. Nurse #1 never returned to the facility.
"She never came back," the DON told inspectors during an interview on April 23, 2025. The DON said she had expected the nursing staff's documentation to be complete and accurate. She offered no explanation for why the form was not completed by another staff member before the resident was transported, or why the facility did not reconstruct the missing information and transmit it to the hospital after the fact.
Nurse #1, in her own interview, confirmed the calls came in. She said she never went back.
The deficiency was cited at a level of minimal harm or potential for actual harm, the lowest tier on the federal harm scale. CMS noted only one resident was reviewed for hospital transfers.
What the citation does not capture is the particular vulnerability of the person at the center of it. Resident #1 could not correct the record. He could not tell an emergency room nurse what medications he was on, whether he had a do-not-resuscitate order, or what his breathing had been like before the tube came out. He arrived at the hospital dependent on a form that told them almost nothing.
The nurse who was supposed to fill it out had already gone home.
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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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 patient, identified in inspection records only as Resident #1, had suffered a stroke and could not speak.
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.