Maple Manor Care Center: 9 Care Deficiencies - ND
Federal inspectors found the facility failed to update care plans for three residents during a September complaint investigation, creating gaps that "limited the ability of staff to communicate care needs and ensure continuity of care."
The most serious lapse involved Resident #3, whose care plan still called for full resuscitation efforts despite the resident signing a DNR form on March 22. A physician's order from May 30 confirmed the do-not-resuscitate status, and the resident's electronic health record displayed a DNR identification ribbon. But the care plan never changed.
An administrative staff member confirmed during a September 9 interview that facility staff failed to revise the resident's care plan when the code status changed to DNR.
Inspectors also discovered care plan failures affecting daily comfort and medication safety. Resident #32 preferred lying in bed without pants, but staff never documented this choice in the care plan. On September 8, inspectors observed facility staff changing the resident's brief, then leaving pants down around the ankles and covering the resident with a blanket. The next day at 3:39 p.m., inspectors found the resident lying in bed without pants, again covered with a blanket.
An administrative nurse confirmed on September 10 that the care plan failed to identify the resident's preference for having pants removed while in bed.
The third resident affected, Resident #11, began taking Seroquel in May. The antipsychotic medication requires careful monitoring and specific care protocols, but staff never added any problems, goals, or interventions related to the drug use in the resident's care plan.
The same administrative nurse who acknowledged the pants documentation failure also confirmed staff failed to revise Resident #11's care plan to reflect the antipsychotic medication started four months earlier.
Federal regulations require nursing homes to develop complete care plans within seven days of comprehensive assessments and revise them as residents' conditions change. Maple Manor's own policy, revised in March, states that "assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change."
The inspection occurred following a complaint. Inspectors reviewed 14 residents' records and found care plan failures affecting three of them.
Care plans serve as roadmaps for daily care, communicating each resident's specific needs, preferences, and medical requirements to nursing staff, doctors, and other caregivers. When plans contain outdated or missing information, staff may provide inappropriate care or miss critical interventions.
The DNR documentation failure posed the most immediate risk. In medical emergencies, staff rely on care plans to make split-second decisions about life-saving measures. Wrong resuscitation orders could force unwanted medical interventions on a resident who specifically chose comfort care over aggressive treatment.
Antipsychotic medications like Seroquel require monitoring for serious side effects including movement disorders, metabolic changes, and increased fall risk in elderly patients. Without care plan documentation, staff might miss warning signs or fail to implement necessary safety measures.
The facility received a minimal harm citation, indicating inspectors found the violations created potential for harm but no residents suffered actual injury. However, the failures affected multiple aspects of care across several months.
Maple Manor Care Center operates at 1116 9th Avenue in Langdon, a rural community in northeastern North Dakota near the Canadian border. The facility must submit a correction plan to continue participating in Medicare and Medicaid programs.
The inspection report does not indicate how long the care plan discrepancies existed before inspectors discovered them or whether the facility has experienced similar documentation problems in the past.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maple Manor Care Center from 2025-09-10 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
Maple Manor Care Center in LANGDON, ND was cited for violations during a health inspection on September 10, 2025.
A physician's order from May 30 confirmed the do-not-resuscitate status, and the resident's electronic health record displayed a DNR identification ribbon.
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.