Maple Manor: Infection Control Failures - ND
The oversight was part of a broader pattern of neglect discovered during a September complaint investigation. Federal inspectors found the facility failed to maintain current care plans for three residents, creating gaps that could compromise their safety and treatment.
Resident #32 preferred lying in bed without pants. On September 8, inspectors watched staff change the resident's brief, leave their pants around their ankles, and cover them with a blanket. The next afternoon, inspectors found the same resident lying in bed without pants, again covered only by a blanket.
The care plan said nothing about this preference.
Administrative nurse #1 confirmed during an interview that staff had never updated the resident's care plan to document their choice of removing pants while in bed. The omission meant new staff or substitute workers wouldn't know this was the resident's preference, not a care oversight.
More critically, the facility maintained incorrect life-or-death information for Resident #3. The resident signed a do-not-resuscitate order on March 22. A physician's order from May 30 confirmed the DNR status, and the resident's electronic health record displayed a DNR identification ribbon.
But the care plan still listed the resident as "full code."
For more than four months, anyone consulting the care plan would have received wrong instructions about whether to perform CPR if the resident stopped breathing or their heart stopped beating. Administrative staff member #2 acknowledged that facility staff had failed to revise the care plan when the resident's code status changed to DNR.
The third case involved medication oversight. Resident #11 began taking Seroquel, an antipsychotic medication, on May 9. Antipsychotic drugs carry serious risks for elderly patients, including increased mortality, and require careful monitoring and documentation.
The care plan contained no problem identification, treatment goals, or interventions related to the antipsychotic medication use. Administrative nurse #1 confirmed staff never revised the care plan to reflect the new medication, despite it being prescribed four months before the inspection.
Federal regulations require nursing homes to develop comprehensive care plans within seven days of assessment and revise them as residents' conditions or preferences change. The facility's own policy, revised in March, stated that assessments are ongoing and care plans must be revised as information about residents changes.
These weren't minor paperwork errors. Care plans serve as the primary communication tool between shifts, departments, and substitute staff. When a respiratory therapist arrives for an emergency, they consult the care plan to determine whether to perform life-saving measures. When a new aide starts a shift, they check the care plan to understand each resident's specific needs and preferences.
Without accurate information, staff cannot provide appropriate care. A substitute nurse might attempt resuscitation on a resident who specifically chose DNR status. An aide unfamiliar with Resident #32 might struggle to understand why the person was found without pants, potentially causing embarrassment or unnecessary intervention.
The antipsychotic medication gap created additional risks. These drugs require monitoring for side effects including drowsiness, confusion, and movement disorders. Without care plan documentation, staff might not recognize medication-related changes in the resident's condition or know to watch for specific complications.
Inspectors found these violations affected few residents but carried potential for actual harm. The facility's failure to maintain current care plans limited staff ability to communicate care needs and ensure continuity of care.
The inspection occurred in response to a complaint, suggesting someone noticed problems serious enough to report to state authorities. The specific nature of that complaint wasn't detailed in the inspection report.
Maple Manor Care Center operates at 1116 9th Avenue in Langdon, a town of roughly 2,000 people in northeastern North Dakota. The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs.
For Resident #3, the months-long gap between signing a DNR order and having it reflected in the care plan represented a fundamental breakdown in communication that could have had irreversible consequences.
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: August 5, 2026 · Our methodology
Maple Manor Care Center in LANGDON, ND was cited for violations during a health inspection on September 10, 2025.
The oversight was part of a broader pattern of neglect discovered during a September complaint investigation.
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.