Maple Manor Care Center: Food Safety Violations - ND
The contradiction between what Resident #3 wanted and what their care plan directed represents one of three cases where the nursing home failed to update critical medical instructions, according to a September complaint inspection.
Administrative staff member #2 confirmed during a September 9 interview that facility staff failed to revise the resident's care plan when their code status changed to do not resuscitate. The resident had signed the DNR form on March 22. A physician's order from May 30 and the resident's electronic health record both identified the DNR status, but the care plan still showed full code.
The care plan failures extended beyond life-and-death decisions.
Resident #32 preferred lying in bed without pants, a choice staff accommodated but never documented in official care instructions. Inspectors observed staff changing the resident's brief on September 8, leaving pants down around the ankles and covering them with a blanket. The next day at 3:39 p.m., inspectors again found the resident in bed without pants, covered by a blanket.
Administrative nurse #1 confirmed during a September 10 interview that the care plan failed to identify the resident's choice to have pants removed while in bed.
A third resident received antipsychotic medication for four months without any care plan documentation addressing the powerful drug's use. Resident #11 started taking Seroquel on May 9, but the care plan contained no problem identification, treatment goals, or intervention strategies related to the antipsychotic medication.
The same administrative nurse acknowledged staff failed to revise Resident #11's care plan to reflect the antipsychotic medication use.
Federal regulations require nursing homes to develop comprehensive care plans within seven days of assessment and revise them as residents' conditions change. The facility's own policy, updated in March, states that assessments are ongoing and care plans must be revised as information about residents changes.
The inspection found care plan deficiencies affected three of 14 residents whose records were reviewed.
Outdated care plans create communication breakdowns among staff and compromise continuity of care, inspectors noted. When care instructions don't match residents' current needs or preferences, staff may provide inappropriate treatment or miss important interventions.
The DNR case illustrates the most serious potential consequence. If Resident #3 experienced cardiac arrest, staff following the outdated care plan would attempt resuscitation against the resident's documented wishes. The resident had made their preference clear through signed paperwork, physician orders, and electronic health record updates, but the care plan team never incorporated this life-altering decision.
For Resident #11, the missing antipsychotic documentation meant staff lacked formal guidance for monitoring side effects, drug interactions, or behavioral changes associated with Seroquel. Antipsychotic medications carry significant risks for elderly patients, including increased mortality rates and movement disorders.
Even seemingly minor oversights like Resident #32's clothing preference reflect broader communication failures. When personal choices aren't documented, different staff members may handle situations inconsistently, creating confusion and potentially distressing residents who expect their preferences to be honored.
The facility policy emphasizes person-centered care planning, but the inspection revealed a gap between written procedures and actual practice. Care plan teams failed to incorporate significant changes documented elsewhere in medical records, from medication additions to fundamental decisions about end-of-life care.
Administrative staff acknowledged each failure during interviews, confirming that care plan revisions lagged behind residents' changing needs and preferences. The inspection classified the violations as minimal harm with potential for actual harm, affecting few residents.
The documentation failures spanned months. Resident #3's DNR request went unincorporated for at least four months between the March signature and September inspection. Resident #11's antipsychotic medication remained undocumented for four months after the May prescription start date.
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 resident had signed the DNR form on March 22.
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.