Mary Gran Nursing Center: Broken Wheelchair Fall - NC
The wheelchair's left brake couldn't grip its bald tire.
Resident #3 underwent open reduction internal fixation surgery on March 28 to repair his fractured left femur. Hospital records confirmed he had suffered a proximal femoral shaft fracture from the fall at Mary Gran Nursing Center.
But four months later, federal inspectors found the same broken wheelchair sitting next to the resident's bed.
The wheelchair's two large back tires were worn completely flat with peeling black rubber tread. The right brake worked, but the left brake still wouldn't lock, allowing the tire to slide backward even when engaged. The resident confirmed it was his wheelchair but couldn't remember if staff had given him a different one after his March fall.
The Director of Nursing told inspectors the root cause of the March 14 incident was clear: faulty wheelchair equipment. The left brake couldn't lock because of the worn tire tread, causing the wheelchair to slide back and forcing the nursing assistant to lower the resident to the floor to prevent injury.
"Resident #3's old wheelchair should not have been in his room to use on 08/05/25, and should have been discarded, and a properly functioning wheelchair put in its place," the Director of Nursing told inspectors.
Both the Director of Nursing and Administrator said they immediately removed the broken wheelchair after the March fall and replaced it with a new one. They expected all wheelchairs in the facility to be checked monthly for proper brake and tire function.
In this case, they missed.
"They both stated they had no idea how Resident #3's old wheelchair showed up in his room on 08/05/25," inspectors wrote.
The facility's own policies require monthly wheelchair inspections to ensure brakes and tires function properly. The Administrator and Director of Nursing acknowledged this standard wasn't met for Resident #3's wheelchair.
Medical Director #1 examined the resident on March 27, three days after the fall, and ordered him sent to the local emergency department for further evaluation and treatment. A nurse practitioner had already ordered a two-view x-ray of his left hip.
The resident spent two weeks recovering from surgery before returning to the nursing home. His fractured femur required internal hardware to heal properly.
Federal inspectors classified the violation as causing actual harm to few residents. The facility failed to ensure residents received care free from accident hazards and that necessary equipment functioned safely.
The broken wheelchair represented a systemic failure in equipment maintenance and safety protocols. Despite policies requiring monthly inspections, staff allowed a wheelchair with completely worn tires and non-functioning brakes to remain in service.
The facility's leadership expressed surprise that the dangerous equipment had returned to active use. Their admission that they "had no idea" how the broken wheelchair reappeared in the resident's room four months after causing his hip fracture suggests gaps in equipment tracking and disposal procedures.
The resident's case illustrates how equipment failures can cascade into serious injuries requiring hospitalization and surgery. A functioning brake system would have prevented the wheelchair from sliding during the transfer attempt.
The nursing assistant's decision to lower the resident to the floor likely prevented a more severe fall from standing height. However, the controlled descent still resulted in a fracture requiring surgical repair with metal hardware.
Mary Gran Nursing Center's wheelchair maintenance protocols failed to protect residents from preventable accidents. The facility's own staff identified the equipment failure as the direct cause of the resident's injury, yet the same dangerous wheelchair remained accessible to vulnerable residents months later.
The inspection occurred following a complaint about conditions at the facility. Federal regulators found the wheelchair violation represented actual harm to residents, not just the potential for injury.
Equipment safety violations in nursing homes often reflect broader systemic problems with maintenance, oversight, and staff training. When facilities fail to follow their own safety protocols, residents pay the price through preventable injuries and hospitalizations.
Resident #3's hip fracture required weeks of recovery and permanent surgical hardware. The broken wheelchair that caused his injury sat waiting in his room for the next transfer attempt.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mary Gran Nursing Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Mary Gran Nursing Center in Clinton, NC was cited for violations during a health inspection on August 14, 2025.
The wheelchair's left brake couldn't grip its bald tire.
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.