Maple Manor Care Center: 9 Care Deficiencies - ND
Federal inspectors found the facility failed to revise comprehensive care plans for three residents as their conditions and preferences changed, limiting staff's ability to provide consistent care.
The most serious oversight involved a resident whose resuscitation status changed from full code to do-not-resuscitate in March. The resident signed the DNR form on March 22, and a physician's order dated May 30 confirmed the change. Yet the care plan still identified full code status when inspectors arrived in September.
An administrative staff member confirmed during interviews that facility staff failed to revise the resident's care plan when the code status changed to DNR.
For another resident, staff began administering Seroquel, an antipsychotic medication, in May. The care plan contained no problem, goal, or interventions related to the use of this powerful psychiatric drug.
During a September 10 interview, an administrative nurse confirmed staff failed to revise the care plan to reflect the antipsychotic medication use.
The third case involved the resident who preferred to remain without pants while in bed. Inspectors observed staff changing the resident's brief on the afternoon of September 8, leaving pants down around the ankles and covering the person with a blanket.
The next day at 3:39 p.m., inspectors again observed the resident lying in bed without pants, covered with a blanket.
Nobody had documented this preference in the care plan.
An administrative nurse acknowledged during a September 10 interview that the care plan lacked information about the resident's choice to have pants removed while lying in bed.
The facility'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."
Care plans serve as roadmaps for staff, detailing each resident's specific needs, preferences, and medical requirements. When plans become outdated, staff may provide inappropriate care or miss critical interventions.
The DNR oversight represented the most dangerous gap. In a medical emergency, staff consulting an outdated care plan might attempt resuscitation on a resident who explicitly chose against it. The resident had signed the DNR form six months before the inspection, with physician confirmation following two months later.
The antipsychotic medication gap created different risks. Seroquel carries significant side effects for elderly residents, including increased fall risk and potential cardiac complications. Without proper care plan documentation, staff might not monitor for these adverse effects or implement necessary safety precautions.
Federal regulations require facilities to develop comprehensive care plans within seven days of resident assessments and revise them as conditions change. The goal is ensuring all staff members understand each resident's current needs and provide consistent care across shifts.
At Maple Manor, the breakdown occurred at the revision stage. Staff recognized changes in resident conditions and preferences but failed to update the formal care plans that guide daily care decisions.
The administrative nurse interviewed by inspectors acknowledged all three failures during separate conversations on September 9 and 10.
Inspectors classified the violations as causing minimal harm or potential for actual harm to few residents. However, the systematic failure to update care plans suggests broader problems with the facility's documentation and communication systems.
The facility must now develop a plan of correction addressing how staff will identify changes in resident conditions and ensure timely care plan revisions. The plan must demonstrate how Maple Manor will prevent similar oversights that leave residents vulnerable to inappropriate or inadequate care.
For the resident without pants, staff will continue accommodating this preference. But now they must document it properly so all caregivers understand this choice represents comfort, not neglect.
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.
The most serious oversight involved a resident whose resuscitation status changed from full code to do-not-resuscitate in March.
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.