Autumn Care of Myrtle Grove: Immediate Jeopardy Feeding Tube - NC
At Autumn Care of Myrtle Grove, a nursing facility on Carolina Beach Road in Wilmington, federal inspectors found in April that staff did not know what to do if that happened.
The inspection, conducted on April 24, 2025, resulted in a citation at the most serious level the federal government assigns: immediate jeopardy to resident health or safety. That designation means inspectors determined the facility's failure placed residents at risk of serious injury, serious harm, serious impairment, or death. It is not a routine finding. Facilities that receive it are required to act immediately to remove the danger before inspectors will close out the citation.
The specific failure involved jejunostomy tubes, a type of enteral feeding device that a relatively small number of nursing home residents require. Unlike a standard gastrostomy tube, which enters the stomach through the abdominal wall, a j-tube is routed past the stomach and into the jejunum, the middle section of the small intestine. They are used when a resident cannot tolerate feeding into the stomach, often due to conditions affecting gastric motility, reflux, or aspiration risk. Their placement is surgical. Their dislodgement is a medical emergency.
What inspectors found was that licensed nursing staff at the facility had not been properly trained on what to do if one of these tubes became dislodged. The gap wasn't a matter of a policy buried in a binder. It was a gap in what nurses actually knew and could actually do if they walked into a room and found a j-tube had come out.
The facility's director of nursing acknowledged the problem on April 24 at 12:22 in the afternoon.
By then, the facility was already in the process of trying to fix it. In-service education sessions had been conducted with nurses on April 23 and April 24, covering enteral feeding tubes, j-tube specifics, and the steps staff should take if a jejunostomy tube becomes dislodged, including the critical piece: notifying a physician immediately. An education sign was posted. Staff were interviewed by inspectors and confirmed they had received the training. Inspectors reviewed the sign-in sheets.
The director of nursing told inspectors that starting April 24, she or the assistant director of nursing would personally review all new admissions during the Clinical Morning Meeting, held Monday through Friday, to identify any incoming resident who had a j-tube. Weekend admissions would be reviewed as well. The purpose was to make sure that every licensed nurse on staff would know, before that resident arrived, that a j-tube was present and what the protocol required if it came out.
Inspectors also verified that at the time of the inspection, the resident whose situation had triggered the citation was the only resident in the facility with a j-tube.
The immediate jeopardy was formally removed on April 25, 2025, one day after the inspection concluded. CMS validated that removal date.
That a citation reaches the immediate jeopardy level before a facility acts is, by definition, a statement about what didn't happen beforehand. Nursing homes admitting residents with j-tubes are admitting residents with a device that requires specific, practiced knowledge to manage safely. A tube that comes out at two in the morning, on a weekend, handled by a nurse who has never been told what makes a j-tube different from any other feeding tube, is a resident in danger.
The inspection report does not describe what happened to the resident who had the j-tube, or how the deficiency was originally identified. It does not say whether the tube became dislodged, or whether the gap in staff knowledge was caught before any harm occurred. The report documents what inspectors found when they arrived, and what the facility did once they found it.
What the record shows is that as of the inspection date, the training had not happened until inspectors were present to require it. The new oversight protocol, in which the director of nursing would personally flag j-tube admissions each morning, did not exist until the afternoon of April 24.
Autumn Care of Myrtle Grove is a Medicare and Medicaid certified facility. Immediate jeopardy citations are among the most serious findings in the federal inspection system and are published in CMS databases accessible to families researching care options. The citation and the facility's plan of correction become part of the public record.
For the resident on Carolina Beach Road who depended on that tube to eat, the margin between a staff member who knew what to do and one who didn't was the margin that mattered.
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 immediate jeopardy violations during a health inspection on April 24, 2025.
That designation means inspectors determined the facility's failure placed residents at risk of serious injury, serious harm, serious impairment, 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.