Autumn Care of Myrtle Grove: Fall Hazard Violation - NC
The fall happened on June 25, 2025. The resident, identified in inspection records as Resident 11, had severe dementia, poor safety awareness, and a habit of wandering independently through the facility. She could not be expected to call for help before moving around. She walked into the lift. She fell.
The equipment had a designated storage location: a utility room, down the hall, not in use by anyone at that moment. A nurse aide, identified in the report as Nurse Aide 3, had left it in the hallway instead.
The unit manager told inspectors that she had provided one-to-one education to Nurse Aide 3 after the fall, covering proper storage and the reason it mattered. The Director of Nursing confirmed the same story during a separate interview on August 21: the lifts were to be stored when not in use, staff had received training on fall hazards, and this resident, specifically, was known to ambulate independently on the 600-hall with a history of falls behind her.
The facility's own interdisciplinary note, written on July 2 and documenting the June 25 incident, described the intervention as "one to one staff education in regard to maintaining egress of the hallway." Egress: a continuous, unobstructed pathway.
The lift had been the obstruction.
Federal inspectors cited the facility under F0689, the federal tag covering accident hazards and supervision. The deficiency was rated at the level of minimal harm or potential for actual harm, affecting few residents. It was a complaint inspection, conducted August 21.
Resident 11's vital signs and neurological checks were stable after the fall, according to the report. She continued to wander through the facility. She continued to have occasional periods of agitation. She continued to have poor safety awareness and impulsivity, which the nursing staff acknowledged meant she would not stop herself before walking into something left in her path.
The inspection report does not say how long the lift had been sitting in the hallway before she tripped on it. It does not say whether anyone walked past it in the time between when Nurse Aide 3 left it there and when Resident 11 hit it. What it says is that everyone interviewed, the nurse who cared for the resident, the unit manager, the Director of Nursing, knew exactly where the lifts were supposed to go when they weren't being used. The utility room. Not the hallway.
Mechanical lifts are large, heavy pieces of equipment used to transfer residents who cannot move on their own. They sit low to the ground on wheeled bases and extend upward. For a person without dementia, one left in a hallway is an inconvenience to walk around. For a resident with severe dementia who wanders independently and cannot reliably assess her own safety, it is something else.
The unit manager's response after the fall was a conversation with one employee. The Director of Nursing pointed to training that staff had already received. The facility's note from July described the pathway requirement and moved on.
Resident 11, the inspection report notes, remained at baseline after the fall and continued to wander as she had before.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Care of Myrtle Grove from 2025-08-21 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.
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Last verified: October 11, 2026 · Our methodology
Autumn Care of Myrtle Grove in Wilmington, NC was cited for violations during a health inspection on August 21, 2025.
The fall happened on June 25, 2025.
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.