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Complaint Investigation

Mary Gran Nursing Center

August 14, 2025 · Clinton, NC · 120 Southwood Drive
Citations 8
CMS Rating 1/5
Beds 212
Provider ID 345218
Healthcare Facility
Mary Gran Nursing Center
Clinton, NC  ·  View full profile →
Inspection Summary

Mary Gran Nursing Center in Clinton, NC — inspection on August 14, 2025.

Found 8 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Federal health inspectors cited Mary Gran Nursing Center in Clinton, NC for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-08-14.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of Mary Gran Nursing Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-01.

Federal health inspectors cited Mary Gran Nursing Center in Clinton, NC for a deficiency under regulatory tag F-F0580 during a standard health inspection conducted on 2025-08-14.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 8 deficiencies cited during this inspection of Mary Gran Nursing Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-01.

Federal health inspectors cited Mary Gran Nursing Center in Clinton, NC for a deficiency under regulatory tag F-F0600 during a standard health inspection conducted on 2025-08-14.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 8 deficiencies cited during this inspection of Mary Gran Nursing Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-01.

Federal health inspectors cited Mary Gran Nursing Center in Clinton, NC for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-14.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 8 deficiencies cited during this inspection of Mary Gran Nursing Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-01.

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NP #1 with new orders of two view x-ray of left hip. On 03/27/25 Medical Director #1 completed a physical assessment on Resident #3 with new orders given to send Resident #3 to local emergency department for further evaluation and treatment. On 03/27/25 hospital records indicated Resident #3 had a left hip fracture of the proximal femoral shaft. On 03/28/25 Resident #3 underwent open reduction internal fixation (ORIF) of his left femur. An observation was conducted on 08/05/25 at 12:20 PM of Resident #3's wheelchair located next to his bed. Resident #3 confirmed the wheelchair next to his bed was his.

The wheelchair's two large back tires were worn flat and peeling black rubber tread.

The right brake worked well, but the left tire brake did not lock on tire allowing the tire to slide backwards when in the locked position.

The resident stated he could not remember if they gave him a different one or not after the 03/27/25 fall. An interview was conducted on 08/04/25 at 3:00 PM with the Director of Nursing (DON).

The DON stated that the root cause for Resident #3's fall on 03/14/25 was a faulty wheelchair where the left brake didn't lock due to the worn tire tread, causing the wheelchair to slide back resulting in NA #1 having to lower the resident to the floor.

An interview and follow-up wheelchair observation with the Administrator and Director of Nursing were conducted on 08/05/25 at 12:45 PM.

They confirmed that on 03/14/25 Resident #3 was lowered to the floor because his wheelchair slid back, due to worn tires, and the left brake lock did not grab the bald tire, which was a wheelchair equipment failure.

The DON stated 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 DON and Administrator expected Resident #3's wheelchair to have been replaced, and all wheelchairs in facility checked monthly and for brakes and tires to function properly, which in Resident #3's case, they missed.

The Administrator and DON said they immediately removed Resident #3's wheelchair from his room after the 03/14/25 fall and replaced it with a new one.

They both stated they had no idea how Resident #3's old wheelchair showed up in his room on 08/05/25.

Facility ID:

Federal health inspectors cited Mary Gran Nursing Center in Clinton, NC for a deficiency under regulatory tag F-F0726 during a standard health inspection conducted on 2025-08-14.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 8 deficiencies cited during this inspection of Mary Gran Nursing Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-01.

Federal health inspectors cited Mary Gran Nursing Center in Clinton, NC for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-14.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of Mary Gran Nursing Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-01.

Federal health inspectors cited Mary Gran Nursing Center in Clinton, NC for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-14.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of Mary Gran Nursing Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-01.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Clinton, NC, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Mary Gran Nursing Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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