Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Manor Care Center during CMS and state inspections, most recent first.
The facility failed to provide effective pain management for two residents with significant pain needs. One resident on hospice with contractures had repeated pain during morning care, but PRN morphine was rarely used before care. Another resident with diabetic neuropathy and a foot ulcer had severe, near-constant pain and showed clear distress during dressing changes, yet PRN oxycodone was not consistently timed before the procedure and the provider was not notified about the increased pain.
Dietary manager qualifications were not met when the facility failed to ensure its dietary manager had completed the required certification or equivalent national food service management credential. The job description listed specific minimum requirements, but the dietary manager confirmed she had not completed the certified dietary manager course or other required education.
The facility failed to ensure the Medical Director actively participated on the QA committee for 3 of 4 quarters. The QAPI policy required the Medical Director to serve on the committee and for the committee to meet at least quarterly, but attendance records showed the Medical Director attended only one meeting and missed multiple others. An administrative staff member stated he attended one meeting by phone, was unable to attend other meetings, and read the notes on rounds instead.
Bare-hand contact with ready-to-eat food and food-contact surfaces occurred in the north dining room when a dietary staff member touched a breakfast sandwich plate, handled grapes with a bare hand, and touched her face and face mask while dishing and passing plates. Two dietary staff members also touched the tops of dishes and/or reheated plates with bare thumbs, despite facility policies stating meals should be served without touching prepared food.
A nurse and CNAs failed to follow infection control practices during medication administration and resident care for residents with wounds, an indwelling catheter, and MDROs. A nurse placed meds on an uncleaned overbed table and returned insulin pens and an eye drop container to the med cart without sanitizing them, while CNAs kept soiled gloves on during clean tasks, handled a walkie talkie without sanitizing it, emptied a catheter bag and rinsed the container, and continued care after removing wound dressings without changing gloves or performing hand hygiene.
Failure to provide a resident with the ordered hand positioning device. A resident with hemiplegia and hemiparesis after a stroke had a care plan directing staff to place a rolled washcloth in the contracted right hand at night and when in bed during the day. Survey observations found the resident in bed without the washcloth, and a CNA stated she forgot to put it in. When the CNA opened the hand, the resident grimaced in pain and a small open area was noted on the palm.
Care plans were not revised to reflect current resident status for three residents. One resident's care plan did not note a preference to remain without pants while in bed, another resident's plan still listed full code despite DNR status in the record, and a third resident's plan did not address Seroquel use. Staff confirmed the care plans were not updated to match the residents' current needs and orders.
Failure to follow medication administration standards was observed for two residents during med pass. An RN gave Pataday eye drops and then Xiidra eye drops to a resident only two minutes later, instead of waiting at least five minutes between ophthalmic products. In a separate event, an RN prepared an insulin pen for another resident without wiping the rubber seal with an alcohol swab before attaching the needle, contrary to facility policy.
A resident with dementia and anxiety was identified as high risk for falls and had silent bed and chair alarms listed in the care plan and MDS. Surveyors observed the alarms unplugged and not functioning, and an administrative nurse confirmed they were unplugged and expected staff to ensure they were functional.
The facility failed to serve food at palatable temperatures on two survey days. A resident complained about cold food, and observations showed food temperatures below the facility's standard of 140°F. A three-bean vegetable dish was served at 72.5°F, and other meals were also below the required temperature. An administrative staff member confirmed the expectation for food to be served at acceptable temperatures.
The facility failed to adhere to its food storage policy, resulting in multiple food items in the main kitchen being found without labels or open dates. This included items in the walk-in refrigerator, freezer, and dry storage. An administrative staff member confirmed the expectation for proper labeling and dating, which was not followed.
The facility failed to maintain the dignity and personal hygiene of two residents. A resident's urinary catheter leg bag was repeatedly observed uncovered, contrary to facility policy. Another resident was frequently seen with an unshaven face, soiled shirt, and food debris, despite staff interactions. An administrative nurse confirmed these deficiencies, highlighting a lack of adherence to care standards.
The facility failed to follow professional standards in diabetes management for two residents. One resident's elevated blood glucose levels were not reported to the provider as required, and another resident received insulin without proper pen priming and administration time. These actions were confirmed by administrative staff.
A resident with weakness and dementia was not provided adequate supervision during a transfer, as CNAs inconsistently used one or two staff members despite care plan instructions. Observations showed a CNA assisting the resident with one staff member, even when the resident was shaky. Interviews revealed confusion among CNAs about the required assistance, and an administrative nurse noted that a nurse should assess the need for additional staff.
A resident with dementia requiring assistance with toileting was not adequately supported, leading to saturated and leaking incontinent products. Observations and record reviews showed multiple instances where staff failed to assist the resident every three hours as expected, with gaps of up to 12 hours. An administrative staff member confirmed the expectation for toileting assistance every 2-3 hours, which was not met.
Inadequate Pain Management During Care and Dressing Changes
Penalty
Summary
The facility failed to develop and provide an effective pain management regimen for two residents who required pain control. One resident was on hospice for a terminal illness, had contractures to both legs, and had orders for scheduled morphine every 4 hours plus morphine every 1 hour as needed. During morning care, when staff rolled the resident and moved or spread the legs, the resident repeatedly stated that it hurt really bad. On another morning care observation, the resident again stated, Ouch. Hurts really bad when the legs were moved to apply a brief. Review of the MARs showed scheduled morphine was given, but the PRN morphine was administered only once during the review period, and staff did not effectively use the PRN medication before providing care. The second resident had diagnoses of diabetic neuropathy and a left foot ulcer, with a care plan addressing chronic pain and instructions to evaluate pain interventions and notify the provider of increased pain. The resident had intact cognition and reported pain rated 8 out of 10, almost constantly, affecting sleep and daily activities. During a dressing change to the left foot, the resident showed facial grimacing, muscle tension, under-the-breath vocal sounds, and head movement throughout the procedure. The resident stated that the same pain medication had been used since 2014 and that morphine had been given with dressing changes in the hospital. Review of the MARs showed PRN oxycodone was not consistently given before dressing changes, including being given after one dressing change, at the same time as another, and hours before another, and the record lacked evidence that the provider was notified about increased pain with dressing changes or that scheduled pain medication was considered.
Dietary Manager Lacked Required Qualifications
Penalty
Summary
The facility failed to ensure 1 of 1 dietary manager (#11) met the required qualifications to serve in that role. Review of the undated Dietary Manager job description showed minimum requirements including certification as a dietary manager, certification as a food service manager, similar national certification for food service management and safety from a national certifying body, or 2 or more years of experience as a director of food and nutrition services in a nursing facility setting with completion of a course of study in food safety and management by October 1, 2023. During an interview, the dietary manager (#11) confirmed she had not completed the certified dietary manager course, and the facility did not ensure she had completed the required education for a certified dietary manager, certified food service manager, or a national certification for food services management and safety from a national certifying body.
Medical Director Did Not Consistently Participate in QA Committee
Penalty
Summary
The facility failed to ensure the Medical Director actively participated on the Quality Assurance (QA) committee for 3 of 4 quarters, specifically July-September 2024, October-December 2024, and April-June 2025. Review of the facility QAPI policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, revised January 2025, showed that the Medical Director was required to serve on the committee and that the committee was to meet at least quarterly. Review of QA committee attendance records from July 2024 through June 2025 showed the Medical Director attended only one meeting, in January 2025. During interview, administrative staff member #11 stated the Medical Director attended the January 2025 meeting by telephone, was unable to attend the October 2024 and May 2025 meetings, and did not attend but read the notes on rounds; the interview did not address the third quarter of 2024.
Bare-Hand Contact With Ready-to-Eat Food and Plates
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food safety in 1 of 2 dining rooms, the north dining room, because dietary staff used bare hands when handling ready-to-eat food and food-contact surfaces. Facility policies reviewed on 09/10/25 stated that staff should minimize hand contact with food surfaces, serve meals without touching prepared food, and change gloves after touching hair or face with gloved hands. During observations, a dietary staff member placed a breakfast sandwich plate in the microwave and touched the top of the plate with a bare thumb, then removed the heated sandwich and plate, placed grapes on the plate while touching them with a bare hand, and again touched the top of the plate with a bare thumb while handing it to another staff member. Later that day, two dietary staff members touched the top of dishes and/or reheated plates with their bare thumbs. The same dietary staff member also touched her face and face mask with her bare hand while dishing and passing plates.
Infection Control Lapses During Medication Administration and Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards during medication administration and resident care for 2 of 14 sampled residents. Review of CDC guidance stated that enhanced barrier precautions involve gown and glove use during high-contact resident care for residents with wounds or indwelling medical devices, and that hand hygiene, cleaning and disinfection of environmental surfaces, proper handling of indwelling medical devices, and wound care are critical. Resident #5’s record showed enhanced barrier precautions related to an open left foot wound. During observation, a nurse prepared the resident’s oral medications, insulin pens, and eye drops, applied PPE outside the room, entered the room, and placed the medications on the overbed table without a barrier or disinfecting the table. After administering the medications, the nurse removed PPE, carried the insulin pens and the container holding one eye drop bottle out of the room, and returned them to the medication cart without sanitizing them. Resident #4’s record showed enhanced barrier precautions for multiple open wounds, an indwelling catheter, and MDROs. During observed care, CNAs provided perineal care, but one CNA kept soiled gloves on while opening the nightstand to apply skin barrier cream, and another CNA repeatedly reached into her pocket to answer a walkie talkie while wearing the same gloves and did not sanitize the device before leaving the room. Later, one CNA emptied the catheter bag and used water from the bathroom sink to rinse the toilet, while another CNA used the toilet sprayer to rinse the urine container. During wound care, a CNA removed soiled dressings from multiple wounds, folded a soiled foot dressing and handed it to a nurse, then failed to remove gloves, perform hand hygiene, or apply clean gloves before adjusting the resident’s clothing and bedding. An administrative staff member stated that medications should be placed on a clean surface, items should be sanitized before returning to the medication cart, gloves and hand hygiene should be changed between clean and dirty tasks, and nurses should remove dressings from resident wounds.
Failure to Provide Ordered Hand Positioning Device
Penalty
Summary
The facility failed to ensure that a resident with contractures received the necessary device to maintain range of motion and hand positioning. Resident #29 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right side, and the care plan directed staff to place a rolled-up washcloth in the resident’s right hand at night and when in bed during the day. On observation throughout the survey, the resident’s right hand was noted to be contracted in a gripped position, and on the afternoon of 09/09/25 and 09/10/25 the resident was observed in bed without the rolled washcloth in place. During interview, a CNA stated staff were able to open the resident’s right hand but it hurt her, said she forgot to put the washcloth in, then returned to the room, opened the hand, observed the resident grimace in pain, and placed the rolled washcloth in the resident’s right hand. The CNA also noticed a small open area on the resident’s palm. An administrative nurse stated she expected staff to place the rolled washcloth in the resident’s hand whenever she was assisted to bed.
Care Plans Not Updated to Reflect Current Resident Status
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for 3 of 14 sampled residents to reflect current resident status. Review of the facility policy titled Care Plans, Comprehensive Person-Centered showed that assessments are ongoing and care plans are revised as information about residents and their conditions change. Survey observations and record review found that Resident #32 was observed with pants down around the ankles after brief changes and later lying in bed without pants, yet the current care plan did not identify the resident's preference for no pants while in bed. An administrative nurse confirmed the care plan lacked this information. Resident #3's record showed a code status form signed by the resident indicating DNR, along with a physician's order and EHR identification ribbon reflecting DNR, but the current care plan still identified full code status. An administrative staff member confirmed the care plan was not revised when the code status changed. Resident #11's physician orders included Seroquel, an antipsychotic medication started on 05/09/25, but the care plan did not include a problem, goal, or interventions related to antipsychotic use. An administrative nurse confirmed the care plan was not revised to reflect the medication.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to follow professional standards of practice for 2 of 3 sampled residents observed during medication pass. For Resident #5, a nurse administered Pataday eye drops to both eyes and then, two minutes later, administered Xiidra eye drops to both eyes without waiting at least five minutes between the two ophthalmic products, as required by the referenced prescribing information. For Resident #3, a nurse prepared an insulin pen but did not wipe the rubber seal with an alcohol swab before applying the needle, contrary to the facility’s insulin administration policy. An administrative staff member and an administrative nurse both confirmed the expected practice for the eye drops and insulin pen preparation.
Unplugged Bed and Chair Alarms for Resident at High Fall Risk
Penalty
Summary
The facility failed to properly utilize assistive devices for one resident reviewed for falls. The resident had diagnoses of dementia and anxiety, and the care plan identified the resident as at risk for falls with silent fall alarms on the chair and bed. A quarterly MDS identified daily use of a bed and chair alarm, and a fall risk evaluation completed on 08/23/24 identified a fall risk score of 18, indicating high risk for falls. During observations on all days of survey, the resident's chair and bed alarm were found unplugged and not functioning. During an interview on 09/10/2025 at 8:44 a.m., an administrative nurse confirmed the alarms were unplugged, was not aware whether the resident could unplug them, and expected staff to ensure the alarms were functional.
Deficiency in Serving Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve foods at palatable temperatures on two of the three days of the survey, specifically on July 8 and 9, 2024. According to the facility's policy, hot food items should be served at a temperature of at least 140 degrees Fahrenheit to ensure good flavor and prevent foodborne illnesses. However, observations during the survey revealed that food temperatures were below this standard. On July 8, a resident expressed dissatisfaction, stating that the food was always cold. During the noon meal observation on the same day, a three-bean vegetable dish was served at 72.5 degrees Fahrenheit. On July 9, during the evening meal, the temperatures of macaroni and cheese, mashed potatoes, and green peas were recorded at 132, 139, and 95 degrees Fahrenheit, respectively. An administrative staff member acknowledged that the expectation was for food to be served at acceptable temperatures.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to store food in a sanitary manner in its main kitchen, as observed during a survey. The facility's policy requires that opened or prepared foods be placed in enclosed containers, dated, and labeled. However, during an inspection of the walk-in refrigerator, several food items were found without identifying labels or open dates. These included containers of taco sauce, a brick of cream cheese, bowls of desserts, a bag of sliced strawberries, bags of shredded cheese, and a jar of peach preserves. Additionally, a tray of fruits contained a spoiled orange, and a tray of fruit juice containers was found sitting in spilled juice with dark, sticky spots. Further inspection of the walk-in freezer revealed bags of frozen potato tots, french fries, and omelet patties without labels or open dates. The dry storage area contained open bags of pudding mix and croutons without open dates. An administrative staff member confirmed that the expectation was for staff to label and date food items when opened and to discard any food items that were not identifiable. This lack of adherence to food storage policies has the potential to affect food quality and safety.
Failure to Maintain Resident Dignity and Personal Hygiene
Penalty
Summary
The facility failed to provide care that promotes dignity and enhances the quality of life for two residents requiring assistance with activities of daily living. Resident #8's urinary catheter leg bag was observed exposed and uncovered on multiple occasions, despite the facility's policy requiring such bags to be covered to maintain the resident's dignity. This was confirmed by an administrative nurse who stated that staff are expected to cover the catheter leg bags at all times. Resident #14 was frequently observed with an unshaven face, a soiled shirt, and food debris on his face, indicating a lack of personal hygiene care. Despite multiple interactions with staff, the resident's shirt was not changed, and his face was not adequately cleaned. An administrative nurse confirmed that Resident #14 often had a soiled shirt or dirty face and that staff were expected to address these issues. The facility's failure to maintain the residents' personal hygiene and dignity was evident through these repeated observations.
Failure to Follow Professional Standards in Diabetes Management
Penalty
Summary
The facility failed to adhere to professional standards of practice in two separate instances involving residents with diabetes. In the first instance, a resident with Type 2 Diabetes Mellitus had a physician's order to notify the provider if blood glucose levels exceeded 400 mg/dL or fell below 70 mg/dL. Despite recorded blood glucose levels of 445 mg/dL and 436 mg/dL on two separate occasions, the facility did not document any notification to the resident's provider about these elevated levels. An administrative nurse confirmed that the staff failed to notify the provider, which could have placed the resident at risk for delayed treatment and adverse health events. In the second instance, the facility did not follow its policy for insulin administration. During an observation, a medication aide prepared an insulin pen for a resident without priming it, which is necessary to remove air bubbles and ensure accurate dosing. The aide also failed to wait the required length of time after administering the insulin before removing the needle. An administrative staff member confirmed that the staff did not follow the established procedure for insulin administration, potentially leading to the resident receiving an inaccurate dose.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents during a gait belt transfer for a resident diagnosed with weakness and dementia. The resident's care plan indicated that transfers should be assisted by one or two staff members, depending on the resident's condition. A physical therapy note also recommended using two staff members if the resident appeared shaky. However, during an observation, a CNA assisted the resident with a transfer using only one staff member, despite the resident showing signs of shakiness and unsteadiness. Interviews with CNAs revealed inconsistencies in the understanding and implementation of the transfer assistance required for the resident. One CNA stated they always used one assist because they were instructed to do so, while another CNA mentioned using two staff members only sometimes, depending on the resident's condition. An administrative nurse indicated that the decision for the number of staff required for a transfer should be assessed by a nurse, highlighting a lack of proper supervision and delegation in the facility.
Inadequate Toileting Assistance for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate toileting assistance for a resident diagnosed with dementia, who required staff assistance with toileting. The care plan indicated that the resident needed assistance from one staff member for toilet use. However, observations revealed that the resident was not assisted in a timely manner, resulting in the resident's incontinent product becoming saturated and leaking urine through their clothing. This was observed on two separate occasions, highlighting a pattern of inadequate toileting assistance. A review of the resident's toileting record from June 9th to July 9th, 2024, showed 56 instances where staff did not assist the resident with toileting every three hours as expected. The log indicated gaps ranging from 3.5 to 12 hours between toileting assistance. An administrative staff member confirmed that the expectation was for staff to assist residents with toileting every 2-3 hours, which was not adhered to in this case.
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What surveyors actually found near you
We read the 5 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Langdon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pembilier Nursing Center | 23.6 mi | ★★★★★ | 5 | 0 |
| Wedgewood Manor | 34.1 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Park River | 38.5 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.