Maple Manor Care Center

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 3 of 14 sampled residents (Resident #3, #11, and #32). Failure to review and revise the care plan as the needs change for the resident limited the ability of staff to communicate care needs and ensure continuity of care for each resident.Findings include:

Review of the facility policy titled Care Plans, Comprehensive Person-Centered occurred on 09/10/25. The revised policy, dated March 2025, stated, . Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. -Observation on the afternoon of 09/08/25 showed facility staff changed Resident #32's brief and left his/her pants down and around the ankles and covered with a blanket. On 09/09/25 at 3:39 p.m.,

observation showed the resident lying in bed without pants and covered with a blanket.

Review of Resident #32's medical record occurred on all days of survey. The current care plan failed to identify no pants while in bed.

During an interview on 09/10/25 at 8:41 a.m., an administrative nurse (#1) confirmed the care plan lacked Resident #32's choice of having pants removed while lying in bed. -Review of Resident #3's medical record occurred on all days of survey. A code status form, signed and dated by the resident on 03/22/25, showed do not resuscitate (DNR). A physician's order, dated 05/30/25, and the resident's electronic health record (EHR) identification ribbon identified DNR. The current care plan identified a full code status.

During an interview on 09/09/25 at 3:18 p.m., an administrative staff member (#2) confirmed facility staff failed to revise Resident #3's care plan when the code status changed to DNR. - Review of Resident #11's medical record occurred on all days of survey. The physician's orders included Seroquel (an antipsychotic medication) started on 05/09/25. The care plan lacked a problem, goal, or interventions related to the use of an antipsychotic medication.

During an interview on 09/10/2025 at 11:55 a.m. an administrative nurse (#1) confirmed staff failed to revise Resident #11's care plan to reflect the use of an antipsychotic medication.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Manor Care Center

1116 9th Ave Langdon, ND 58249

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 2 of 3 sampled residents (Residents #3 and #5) observed during medication pass. Failure to disinfect the rubber seal of insulin pens increases the risk of infection to residents and failure to follow manufacturer instructions for eye drop administration may impede

the effectiveness of the eye drops. Findings include:

Residents Affected - Few

Review of the facility policy titled Insulin Administration occurred on 09/10/25. This policy, dated May 2025, stated, . Pull off the pen cap. Wipe the rubber seal with an alcohol swab.

Information found at https://www.drugs.com/pro/pataday-once-daily-relief.html, revised 08/14/25, stated, .

Pataday (treatment for dry eyes) . Package Insert/Prescribing Info [information] . if using other ophthalmic products while using this product, wait at least 5 minutes between each product . -Observation on 09/09/25 at 9:14 a.m. showed a nurse (#4) administered Pataday eye drops to both of Resident #5's eyes. At 9:16 a.m. (two minutes later) the nurse administered Xiidra eyedrops (treatment for dry eyes) to both eyes. The nurse (#4) failed to wait at least five minutes between administering two different eye products.

During an interview on 09/10/25 at 12:45 p.m., an administrative staff member (#2) agreed the nurse should wait at least five minutes between administration of two eye drops. -Observation on 09/10/25 at 8:09 a.m. showed a nurse (#3) prepared an insulin pen for Resident #3. The nurse failed to wipe the rubber seal with an alcohol swab before applying the needle to the insulin pen.

During an interview on the afternoon of 09/10/25, an administrative nurse (#1) confirmed she expected staff to wipe the rubber seal of an insulin pen with an alcohol swab before applying the needle.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Manor Care Center

1116 9th Ave Langdon, ND 58249

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited MAPLE MANOR CARE CENTER in LANGDON, ND for a deficiency under regulatory tag F-F0688 during a standard health inspection conducted on 2025-09-10.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of MAPLE MANOR CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-24.

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, and staff interview, the facility failed to properly utilize assistive devices for 1 of 4 sampled residents (Resident #16) reviewed for falls. Failure to properly use a bed and chair alarm placed

the resident at risk for falls. Findings include:Review of Resident #16's medical record occurred on all days of survey. Diagnosis included dementia and anxiety. The current care plan stated, . I am at risk for falls .

Silent fall alarms on chair and bed. A Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] identified a bed and chair alarm used daily. A Fall Risk Evaluation, completed 08/23/24 identified a Fall Risk Score of 18 (High Risk of falls). Observations on all days of survey showed Resident #16's chair and bed alarm unplugged and not functioning. During an interview on 09/10/2025 at 8:44 a.m., an administrative nurse (#1) confirmed Resident #16's bed and chair alarm were unplugged, was not aware if the resident was able to unplug the alarms, and expected staff to ensure the alarms are functional.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Manor Care Center

1116 9th Ave Langdon, ND 58249

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident displayed facial grimacing, muscle tension, under-the-breath vocal sounds, and moved her head back and forth throughout the entire dressing change procedure. During an interview on the afternoon of 09/09/25, Resident #5 stated, I've been on the same pain med [medication (the resident referred to oxycodone)] since 2014. I keep asking for a different family [drug class] to see if that helps, and I wish it was like when I was in the hospital. They would give me morphine with dressing changes.Review of Resident #5's MAR/TARs for September 1-9, 2025 related to morning dressing changes identified the following:* 09/02/25, no PRN oxycodone administered. * 09/03/25, the PRN oxycodone administered 1 hour and 37 minutes after the dressing change.* 09/04/25, the PRN oxycodone administered at 6:57 a.m., the same time the dressing change signed out.* 09/08/25, the PRN oxycodone administered 3 hours and 37 minutes before the dressing change.The facility failed to implement measures to prevent and/or treat Resident #5's pain before it occurred to promote optimal pain control before dressing changes. The medical

record lacked evidence the facility notified Resident #5's provider related to increased pain with dressing changes or consider scheduled pain medications.During an interview on 09/10/25 at 3:51 p.m., an administrative nurse (#1) stated, We could do more [to help control Resident #4 and #5's pain].

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Manor Care Center

1116 9th Ave Langdon, ND 58249

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited MAPLE MANOR CARE CENTER in LANGDON, ND for a deficiency under regulatory tag F-F0801 during a standard health inspection conducted on 2025-09-10.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of MAPLE MANOR CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-24.

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observations and review of facility policy, the facility failed to serve food in accordance with professional standards for food safety in 1 of 2 dining rooms (north dining room). Failure to ensure no bare-hand contact with ready-to-eat food has the potential to result in a food borne illness. Findings include:

Review of the facility policy titled Kitchen and Service Kitchen Safe Practice Guidelines occurred on 09/10/25. This policy, dated 07/14/25, stated, . When handling clean dishes care will be taken to minimize hand contact with food surfaces. plates [will be touched] on the outside rim . Review of the facility policy titled Serving Meals occurred on 09/10/25. This policy, dated 07/13/25, stated, . Staff will serve meal without touching prepared food. Review of the facility policy titled Dietary Infection Control and Glove Usage occurred on 09/10/25. This policy, dated 07/14/25, stated, . Change Gloves after . touching hair or face with gloved hands. -Observations of food service showed the following:*On 09/09/25 at 7:45 a.m., a dietary staff member (#13) placed a plate with a breakfast sandwich on it in the microwave, touching the top of the plate with her bare right thumb. The staff member then removed the heated sandwich/plate from the microwave, placed grapes on the plate, touching them with her bare hand, and touched the top of the plate with her bare right thumb as she handed the plate to another staff member.*On 09/09/25 at 12:17 p.m., two dietary staff members (#13 and #14) touched the top of dished and/or reheated plates with their bare thumbs. The dietary staff member (#13) also touched her face and face mask with her bare hand as she dished and passed plates.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Maple Manor Care Center

1116 9th Ave Langdon, ND 58249

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited MAPLE MANOR CARE CENTER in LANGDON, ND for a deficiency under regulatory tag F-F0868 during a standard health inspection conducted on 2025-09-10.

Category: Administration Deficiencies

The facility was found deficient in the following area: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of MAPLE MANOR CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-24.

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

adjusting the resident's clothing and bedding. After the observation, when asked if CNAs typically remove Resident #4's dressings, a nurse (#7) stated, She [CNA #6] normally does not do that [remove dressings]. I didn't say anything as she already touched them.During an interview on the afternoon of 09/10/25, an administrative staff member (#2) stated she expected staff to place medications on a clean surface, sanitize items after use and before placing them back into the medication cart, change gloves and perform hand hygiene between clean and dirty tasks, and nurses to remove dressings from resident wounds.

Event ID:

Facility ID:

If continuation sheet