Autumn Care of Myrtle Grove: Feeding Tube Jeopardy - NC
The declaration meant inspectors believed the facility's failure had already caused, or was likely to cause, serious injury or death.
A jejunostomy tube, called a j-tube, is not a standard feeding tube. Unlike a gastrostomy tube that delivers nutrition directly into the stomach, a j-tube bypasses the stomach entirely and feeds into the small intestine. The placement requires surgery. When one becomes dislodged, the tract through the abdominal wall begins to close within hours. Attempting to push the tube back in without surgical guidance risks perforating the intestine, introducing infection, or delivering nutrition directly into the abdominal cavity instead of the bowel. The consequences can include sepsis and death.
The inspection report does not describe what a nurse at Autumn Care of Myrtle Grove did when the tube came out. It does not name the resident, describe their condition, or say whether they were harmed. What the report makes clear is that what happened was serious enough to trigger the facility's immediate jeopardy designation on April 24, 2025, and serious enough that managers spent the following two days pulling every nurse in the building into mandatory retraining before inspectors would agree to lift it.
The facility sits on Carolina Beach Road in the southern part of Wilmington, a stretch of commercial corridor that runs toward the coast. The building serves residents who, in many cases, depend entirely on staff for their most basic medical needs. A resident on a j-tube cannot eat by mouth. They cannot self-monitor their tube. They rely on nurses to recognize when something has gone wrong and to respond correctly.
The immediate jeopardy removal process, documented in the inspection report dated April 24, 2025, reads like a checklist of everything the facility had apparently failed to ensure before the incident occurred. Inspectors reviewed sign-in sheets for in-services conducted on April 23 and April 24, the two days following the triggering event. Those sessions covered the facility's own Gastrostomy Tube Reinsertion Policy, which addresses j-tubes specifically, including what to do when one becomes dislodged, the requirement to notify the physician immediately, the prohibition against attempting reinsertion at the facility, the risks involved in any reinsertion attempt, and the requirement to send the resident to the hospital for surgical reinsertion.
That this policy existed before the incident is implicit in the record. Nurses were not being taught something new. They were being retested on something the facility had already written down and, apparently, not adequately communicated or enforced.
Staff interviews confirmed the retraining. Nurses told inspectors they had completed education on gastrostomy tubes and j-tubes and had taken a quiz on what to do if a jejunostomy tube became dislodged. The Director of Nursing told inspectors at 12:22 p.m. on April 24 that all nurses, including new hires and agency nurses, would be required to pass the validation quiz before being considered competent on feeding tube protocols.
The inspectors reviewed the completed quizzes. They found no concerns.
The immediate jeopardy was formally lifted the following day, April 25, 2025.
That sequence matters. The jeopardy was declared on April 24. The retraining had already begun on April 23, the day before the inspection concluded. That means someone at the facility knew, before inspectors arrived or shortly after they did, that a serious breakdown had occurred and that nurses did not have a shared, reliable understanding of what to do when a j-tube came out. The retraining was not an afterthought. It was a scramble.
The inspection report does not say how many nurses were retrained. It says 100 percent of nurses, including agency staff, were required to complete the education and pass the quiz. In a nursing home that uses agency nurses, that number can shift from shift to shift. The Director of Nursing's statement that new hires and agency nurses would also be required to pass the quiz going forward suggests the facility recognized that its prior onboarding process had not reliably covered this material.
The audit conducted as part of the immediate jeopardy removal process reviewed 100 percent of residents with feeding tubes. Inspectors confirmed that no other residents at the facility had j-tubes. That finding mattered: it meant the immediate jeopardy was contained to one resident's situation rather than a systemic risk spread across multiple patients with the same device.
But containment is not exoneration. A j-tube is not an obscure piece of equipment that nurses might reasonably be expected to encounter rarely. It is a standard intervention for residents who cannot tolerate gastric feeding, including those with gastroparesis, Crohn's disease, or other conditions affecting the stomach. Any skilled nursing facility that accepts residents on enteral nutrition should be able to demonstrate, before an incident occurs, that its nursing staff knows what to do when a tube is dislodged.
The record does not show that Autumn Care of Myrtle Grove could demonstrate that before April 23, 2025.
What the record shows is a facility that identified a gap in staff knowledge only after something went wrong with a resident who depended on a feeding tube to survive, then moved quickly to close that gap under the pressure of an active immediate jeopardy citation. The Director of Nursing made commitments. Inspectors reviewed quizzes and found them satisfactory. The paperwork was completed.
The resident who was at the center of this is not named in the inspection report. Their outcome is not described. Whether they were transported to a hospital in time, whether the tube was successfully reinserted, whether they experienced complications, none of that is in the record that was made public. What is in the record is the designation inspectors assigned to what happened to them: immediate jeopardy to resident health or safety, the category reserved for situations where the failure of care has already caused serious harm or carries a high likelihood of doing so.
The facility's immediate jeopardy removal date was validated as April 25, 2025. The inspection was completed that same day.
Somewhere in Wilmington, a resident who cannot eat without a tube running into their small intestine is still living in that building.
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.
The declaration meant inspectors believed the facility's failure had already caused, or was likely to cause, serious injury or death.
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.