Marian Manor: Marshmallow Choking Triggers Immediate Jeopardy - ND
The resident, identified in inspection records only as Resident #3, had a documented diagnosis of dysphagia, a condition that makes swallowing dangerous. His care plan spelled out the risk in plain language: he was at risk of aspiration and choking. His diet had been formally ordered as mechanically altered, Level 6 soft and bite-sized, a classification that limits food pieces to no larger than 1.5 centimeters for adults. Regular marshmallows are chewy, sticky, and according to the International Dysphagia Diet Standardisation Framework, a choking risk by definition. They can adhere to the roof of the mouth, the teeth, or the cheeks, and fall into the airway.
Nobody had removed them.
On February 17, 2026, at 11:30 in the morning, staff heard a loud crash coming from Resident #3's room. They responded immediately and found him face-down on the floor next to his wheelchair. When they suctioned him for excess secretions, they pulled out small white pieces of material that looked like marshmallow.
He was hospitalized.
Federal inspectors, who arrived at Marian Manor Healthcare Center in Glen Ullin, North Dakota for a survey conducted on May 28 and June 3, 2026, reviewed the facility's own investigation report from the day of the incident. Two administrative nurses confirmed during an interview on May 26 that the resident had eaten regular-sized marshmallows, not miniature ones, before the choking episode. The survey team consulted with the State Survey Agency and determined that an immediate jeopardy situation had existed on the day of the incident. Immediate jeopardy is the most serious classification federal inspectors can assign, reserved for situations where a facility's failures have caused, or are likely to cause, serious injury or death.
The immediate jeopardy finding was specific: staff had failed to remove snack items that were inconsistent with Resident #3's mechanically altered diet order from his room. That failure resulted in a choking episode and a hospitalization.
What inspectors found when they dug deeper was a quality oversight system that had never been designed to catch this kind of problem in the first place.
Marian Manor operates a Quality Assurance and Performance Improvement committee, known as QAPI, which is responsible for monitoring care and launching formal improvement projects when problems are identified. The facility's own QAPI policy, reviewed by inspectors on May 28, described a program built around resident-centered care and individualized plans. It stated that the committee assures monitoring activities cover all types of services and categories of care. It stated that Performance Improvement Projects, or PIPs, are chosen based on their importance and meaningfulness in relation to the scope of services provided.
After a resident on a restricted diet choked on a food item that is explicitly listed as a choking hazard in the international clinical framework governing his diet classification, no Performance Improvement Project was launched. Not one focused on diet accuracy. Not one examining how snack items in residents' rooms are monitored against their dietary orders. Nothing.
An administrative nurse, identified in the report as Nurse #2, told inspectors on May 28 that in the past, the QAPI committee had monitored food temperatures. Not diet accuracy. Temperatures.
The dietary supervisor, identified as Supervisor #6, confirmed the same thing during a separate interview eleven minutes later: the dietary QAPI process did not include diet accuracy.
This is the gap that inspectors documented. The facility had a system for measuring whether food arrived warm enough. It had no system for measuring whether the food, or the snacks sitting on a resident's bedside table, matched what that resident was medically permitted to eat.
The IDDSI framework that governs Resident #3's diet classification is not obscure. It is the international standard, maintained at iddsi.org, and the April 2026 version reviewed by inspectors during the survey lists marshmallows by name under chewy textures that pose a choking risk. The framework explains the mechanism: chewy foods become sticky and can fall into the airway. For a person with dysphagia, that is not a theoretical concern. It is the clinical reason the diet restriction exists.
Resident #3's care plan documented his dysphagia diagnosis. It documented his aspiration and choking risk. It specified his diet level. The information was there. What was not there was anyone checking whether what he had access to matched what his care plan required.
The inspection report does not describe what happened to Resident #3 after his hospitalization. It does not say how long he was hospitalized, whether he recovered fully, or what his condition was at the time of the survey three months later. The record goes quiet after the moment he was found on the floor.
What the record does show is the timeline. The choking incident happened on February 17. The facility completed an investigation report. That investigation was available for inspectors to review. And yet when inspectors asked about the QAPI response, the answer was that diet accuracy had never been part of what the committee monitored. The investigation happened. The improvement project did not.
The facility's QAPI policy states that PIPs are chosen based on their importance and meaningfulness. A resident on a medically ordered restricted diet choking on a food explicitly identified as a choking hazard for people with his condition, collapsing to the floor, requiring suctioning, and being hospitalized, did not trigger one.
Inspectors cited the immediate jeopardy finding under the federal tag F689, which covers accidents and supervision. The citation notes that the harm level was minimal or potential for actual harm, a designation that applies to the broader QAPI failure finding, not to the choking incident itself, which was already classified at the immediate jeopardy level.
Marian Manor is a small facility in a small town. Glen Ullin has a population of just over 700 people. For many residents of rural nursing homes like this one, the facility is not a choice made from a list of options. It is the option.
The marshmallows were on his table. His care plan said he was at risk of choking. The dietary quality process had never been built to connect those two facts. On the morning of February 17, Resident #3 went from finishing his lunch to lying face-down on the floor, and the people who suctioned him pulled white pieces out of his airway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marian Manor Healthcare Center from 2026-06-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
MARIAN MANOR HEALTHCARE CENTER in GLEN ULLIN, ND was cited for immediate jeopardy violations during a health inspection on June 3, 2026.
The resident, identified in inspection records only as Resident #3, had a documented diagnosis of dysphagia, a condition that makes swallowing dangerous.
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.