Maple Manor Care Center: 9 Safety Deficiencies - ND
The outdated plan told staff to perform full resuscitation efforts on the resident, directly contradicting both the resident's written wishes and physician's orders that clearly stated DNR status as of May 30th.
Federal inspectors discovered the error during a September complaint investigation that revealed systematic failures to update care plans for three residents. The violations limited staff's ability to communicate essential care needs and ensure proper treatment continuity.
Administrative staff member confirmed during interviews that facility workers had failed to revise the resident's care plan when the resuscitation status changed months earlier.
A second resident presented a different documentation problem. Staff had been removing the person's pants while in bed and covering them with a blanket, a practice inspectors observed on two consecutive days in September. On September 8th, workers changed the resident's brief but left their pants down around their ankles. The following day at 3:39 p.m., inspectors found the same resident lying in bed without pants, covered only by a blanket.
The facility's care plan contained no mention of this arrangement.
An administrative nurse acknowledged during questioning that the care plan failed to document the resident's preference for having pants removed while lying in bed. This omission meant incoming staff had no written guidance about the resident's specific comfort needs.
The third case involved medication oversight. A resident had been prescribed Seroquel, an antipsychotic medication, starting May 9th. Yet the care plan contained no problem identification, treatment goals, or intervention strategies related to the powerful psychiatric drug.
Antipsychotic medications require careful monitoring and specific care protocols due to their significant side effects and regulatory restrictions in nursing home settings. The same administrative nurse confirmed that staff had failed to update the resident's care plan to reflect the antipsychotic medication use.
Maple Manor's own policy, revised in March 2025, explicitly states that "assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change."
The policy violations affected three of the 14 residents whose records inspectors reviewed during the September investigation.
Care plans serve as the primary communication tool between nursing shifts, ensuring that all staff members understand each resident's current medical status, treatment preferences, and specific needs. When these documents remain outdated, incoming workers may provide inappropriate care or miss critical safety measures.
The resuscitation order error posed the most serious risk. Emergency situations require split-second decisions, and staff typically rely on care plan documentation to guide their response. Had the resident experienced a medical crisis, workers following the outdated full-code instructions would have performed unwanted resuscitation efforts against the person's explicit wishes.
The medication documentation gap created different risks. Antipsychotic drugs can cause dangerous interactions with other medications, require specific monitoring for side effects, and need careful behavioral tracking to assess effectiveness. Without proper care plan documentation, staff lacked guidance on how to safely administer the medication and monitor the resident's response.
The facility's failure to document the pants removal preference, while less medically critical, reflected the same systematic breakdown in care plan maintenance. Such oversights can lead to confusion during shift changes, potentially causing distress for residents who expect consistent care routines.
Federal regulations require nursing homes to maintain current, comprehensive care plans that reflect each resident's evolving needs and preferences. The plans must be developed within seven days of admission and regularly updated as conditions change.
Inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few residents. The facility now faces federal oversight to correct the documentation failures and ensure care plans accurately reflect current resident status and treatment requirements.
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.
Federal inspectors discovered the error during a September complaint investigation that revealed systematic failures to update care plans for three residents.
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.