Maple Manor: Pain Management Harm Found - 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 oversight involved Resident #3, whose care plan contradicted explicit instructions about life-saving measures. The resident signed a DNR form on March 22. A physician's order dated May 30 confirmed the do-not-resuscitate status, and the resident's electronic health record displayed a DNR identification ribbon.
But the care plan still identified full code status when inspectors arrived in September.
An administrative staff member confirmed during a September 9 interview that facility staff had failed to revise the resident's care plan when the code status changed months earlier.
Inspectors also documented care planning failures for two other residents with very different needs.
Resident #32 preferred to lie in bed without pants, a personal choice that staff accommodated but never documented. On September 8, inspectors observed facility staff changing the resident's brief, then leaving pants down around the ankles and covering the person with a blanket. The next day at 3:39 p.m., they observed the resident lying in bed without pants, again covered with a blanket.
The care plan made no mention of this preference.
"The care plan lacked Resident #32's choice of having pants removed while lying in bed," an administrative nurse confirmed during a September 10 interview.
For Resident #11, staff had started an antipsychotic medication called Seroquel on May 9 but never updated the care plan to reflect this significant addition to the treatment regimen.
The care plan contained no problem identification, goals, or interventions related to the antipsychotic medication use. The same administrative nurse who spoke about Resident #32 confirmed staff had failed to revise this care plan as well.
Federal regulations require nursing homes to develop complete care plans within seven days of comprehensive assessments and to review and revise them as residents' 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."
The disconnect between policy and practice affected residents with vastly different care needs. One faced potential confusion about life-saving measures in an emergency. Another's comfort preferences went undocumented. A third's psychiatric medication remained invisible in the formal care planning process.
Care plans serve as the central communication tool for nursing home staff across all shifts and departments. When they contain outdated or missing information, night shift workers might not know about medication changes, emergency responders might receive conflicting instructions, and new staff members lack guidance about individual resident preferences.
The inspection found these planning failures despite the facility's written commitment to ongoing assessment and plan revision.
Resident #3's case proved particularly concerning because DNR orders represent some of the most critical information in a care plan. The five-month gap between signing the DNR form and updating the care plan meant staff were operating under potentially life-altering misinformation.
The resident had clearly communicated wishes about end-of-life care in March, obtained physician confirmation in May, and had the DNR status reflected in the electronic health record. Yet the care plan that guided daily decision-making still called for full resuscitation efforts.
Administrative staff acknowledged each failure during inspector interviews, confirming systemic breakdowns in the care planning process rather than isolated oversights.
The inspection classified these violations as causing minimal harm or potential for actual harm to residents, but the implications extended beyond immediate physical consequences to fundamental questions about whether residents' documented wishes and medical needs were being properly communicated to their caregivers.
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 signed a 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.