Maple Manor Care Center: 9 Deficiencies Found - ND
The DNR discrepancy was one of three care planning failures federal inspectors documented during a September complaint investigation at the 58-bed facility. Inspectors found staff routinely failed to update written care plans when residents' conditions or preferences changed, creating gaps between what residents needed and what their official medical records directed.
Resident #3 had signed the DNR form on March 22. By May 30, a physician had entered the DNR order and the resident's electronic health record displayed a DNR identification ribbon. But the care plan still called for full resuscitation efforts.
An administrative staff member confirmed to inspectors on September 9 that facility staff had failed to revise the care plan when the resident's code status changed to DNR.
In a second case, inspectors observed unusual care practices that weren't documented anywhere in official records. On September 8, they watched staff change Resident #32's brief, then leave the person's pants down around their ankles and cover them with a blanket. The next day at 3:39 p.m., inspectors again observed the resident lying in bed without pants, covered only by a blanket.
The resident's care plan contained no mention of this preference or practice. An administrative nurse told inspectors on September 10 that the care plan failed to document the resident's choice to have pants removed while in bed.
A third resident started taking Seroquel, an antipsychotic medication, on May 9. The powerful psychiatric drug requires careful monitoring and specific care protocols. But Resident #11's care plan included no problem identification, treatment goals, or nursing interventions related to the antipsychotic use.
The same administrative nurse confirmed that staff had not revised the care plan to reflect the new medication when inspectors interviewed her on September 10.
Federal regulations require nursing homes to develop comprehensive care plans within seven days of assessing each resident, then continuously review and revise those plans as conditions change. The facility's own policy, revised in March, stated 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 the primary communication tool between nursing staff, doctors, and other caregivers. They outline each resident's specific medical needs, personal preferences, and required interventions. When plans don't reflect current conditions, staff may provide inappropriate care or miss critical safety measures.
The DNR case presented the most serious risk. Emergency responders and night staff rely on care plans during medical crises. If a resident with a documented preference against resuscitation suffered cardiac arrest, staff following an outdated full-code plan might perform unwanted chest compressions and other aggressive interventions.
Antipsychotic medications like Seroquel carry significant side effects for elderly residents, including increased fall risk, sedation, and potential heart complications. Without proper care plan documentation, nursing assistants and other staff might not recognize medication-related symptoms or take appropriate precautions.
The inspection occurred in response to a complaint, though federal records don't specify what prompted the investigation. Inspectors sampled 14 residents' records and found care planning deficiencies affecting three of them.
Maple Manor Care Center operates as part of North Dakota's network of rural nursing facilities serving small farming communities. The facility provides both long-term residential care and short-term rehabilitation services.
The care planning violations received a "minimal harm" rating, indicating inspectors found no evidence that residents suffered immediate injury from the documentation failures. However, the deficiencies created potential for harm if medical emergencies had occurred while outdated care plans remained in effect.
Federal regulations classify care planning as a fundamental requirement for nursing home participation in Medicare and Medicaid programs. Facilities must submit correction plans to continue receiving federal funding.
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 21, 2026 · Our methodology
Maple Manor Care Center in LANGDON, ND was cited for violations during a health inspection on September 10, 2025.
The DNR discrepancy was one of three care planning failures federal inspectors documented during a September complaint investigation at the 58-bed facility.
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.